Changes in Attachment Representation in Psychotherapy: Is Reflective Functioning the Crucial Factor?

Objectives: The study analyzed the interdependence of change in attachment representation and reflective functioning (RF) in psychotherapy. Methods: RF data from 63 female borderline personality disorder (BPD) patients were analyzed with respect to change of attachment representation (from insecure to secure and from unresolved to resolved) from three angles: (1) RF as a moderator variable, (2) RF as an outcome variable, and (3) RF changes over one year of treatment. Results: Patients who changed to a resolved attachment classification showed higher RF before treatment and at follow-up than patients who remained unresolved (RF = 3.0 vs. RF = 2.14, p = 0.039; and RF = 3.4 vs. RF = 2.36, p = 0.002). Similar results were found for changes from insecure to secure. Conclusion: A higher RF level before psychotherapy proved to be a moderator for change in attachment representation. Patients with unresolved attachment and low-level RF at the outset had the least chance for representational change during the first year of psychotherapy.