Two-Year Follow-Up and Changes in Reflective Functioning in Specialist and Nonspecialist Treatment Models for Personality Disorder

There is a growing body of studies linking impairments in mentalizing or reflective functioning (RF) with childhood adversity, the development of personality disorder (PD), and psychiatric morbidity. Fewer studies have investigated the purported role of changes in RF in relation to clinical outcome in treatments focusing on this capacity. Moreover, it is as yet unclear whether specialist and nonspecialist treatment models are equally effective in bringing about change in RF in conjunction with symptomatic improvement. This study aimed to investigate the association between changes in RF in 3 samples of individuals with PD treated in 2 specialist psychosocial programs (a mixed residential and community-based step-down program [RT-CBP] and a residential-only psychotherapy treatment program [RT]) and in an outpatient general psychiatric service over a 2-year period after intake into treatment. RF was assessed using the Reflective Functioning Scale scored on the Adult Attachment Interview, and clinical outcome was assessed in terms of psychiatric distress, social adjustment, and global functioning. Changes in RF were most marked in RT-CBP compared with RT and general psychiatric service. Changes in RF explained differences between treatment models for social and global adjustment outcomes, but not for disparities in psychiatric distress. A medium-intensity treatment approach to PD such as RT-CBP was more effective in improving RF and provided a balance between psychotherapy input and efforts at social integration, by bringing patients into closer contact with their social world.