A Longitudinal Analysis of Reflective Functioning and Its Association With Psychotherapy Outcome in Patients With Depressive and Anxiety Disorders

The ability to mentalize has been discussed as potential change mechanism in psychotherapy. Reflective functioning (RF) offers an empirical framework for the assessment of mentalization in therapy sessions. In the present study, we assessed RF longitudinally and examined its association with symptomatic distress, symptom severity of depression and anxiety, and interpersonal problems over the course of treatment. Thirty-seven patients diagnosed with depression or anxiety disorders received 25 +/- 3 sessions of integrative cognitive-behavioral therapy (CBT) in an outpatient setting. The observer-rated in-session Reflective Functioning Scale (RFS) was applied to transcripts of therapy Sessions 1, 8, 16, and 24. The effects of RF were investigated both within and between patients using hierarchical linear modeling. RF significantly increased over the course of treatment, and this improvement in RF was significantly associated with depressive symptoms. This means that after a session where patients positively deviated from their own average RF during treatment, they reported lower depression severity. In post hoc analyses, we found a significant interaction effect of the within- and between-patient RF effects on interpersonal problems. Patients with overall higher levels of RF and with positive deviations from their own average RF over the course of treatment tended to have less interpersonal problems during psychotherapy. The present study contributes to the preliminary evidence that changes in RF may serve as a common factor in psychotherapy in contrast to being a specific factor in psychodynamic therapies. More longitudinal studies are necessary to gain a better understanding of RF as a change mechanism in psychotherapy. Public Significance Statement The present study suggests that the capacity to perceive and understand oneself and others (mentalization) improves over the course of cognitive-behavioral therapy in patients with depressive and anxiety disorders. Further, mentalization is associated with psychotherapy outcome: after a session where patients positively deviated from their own average ability to mentalize, they reported lower depression severity; patients with overall higher levels of mentalizing over the course of treatment and with positive deviations from their own average ability to mentalize, tended to have less interpersonal problems during psychotherapy. It may thus be beneficial for practitioners to find ways of improving their patients' ability to mentalize over the course of treatment and thereby interpersonal problems (possibly also other psychotherapy outcomes).