title: Reflective functioning as predictor of working alliance and outcome in the treatment of depression.
abstract: OBJECTIVE
  Although considerable attention has been paid to the concept of mentalization in psychotherapy, there is little research on mentalization as predictor of psychotherapy process and outcome. Using data from a randomized controlled trial of cognitive-behavioral therapy and interpersonal psychotherapy for depression, we studied mentalization in 85 outpatients with major depressive disorder (MDD) according to the Diagnostic and Statistical Manual of Mental Disorders. It was hypothesized that patients showing lower capacity for mentalization would experience poorer quality of alliance and worse outcome.
  
  
  METHODS
  Depressive symptoms were measured each session using the Beck Depression Inventory-II. Mentalization was measured as reflective functioning (RF) on a slightly shortened version of the Adult Attachment Interview. A measure of depression-specific reflective functioning (DSRF), measuring mentalization about depressive symptoms, was also used. The Working Alliance Inventory-Short Form Revised was completed after each session by both therapist and patient. Longitudinal multilevel modeling was used to analyze data.
  
  
  RESULTS
  The patients had on average very low RF (M = 2.62, SD = 1.22). Lower pretreatment RF/DSRF predicted significantly lower therapist-rated working alliance during treatment. RF did not affect patient-rated alliance, but lower DSRF predicted lower patient-rated alliance across treatment. Patients with higher RF/DSRF had better outcomes on self-rated depression.
  
  
  CONCLUSIONS
  The findings showed lower than normal capacity for mentalization in patients with MDD. Lower RF/DSRF predicted worse treatment outcome. More research is needed to understand how RF affects psychotherapy response and how RF is affected after recovery from depression.
authors.affiliation: Department of Behavioural Research and Learning, Linkoping University.
authors.forename: Annika
authors.initials: A
authors.lastname: Ekeblad
authors.affiliation: Department of Behavioural Research and Learning, Linkoping University.
authors.forename: Fredrik
authors.identifier: 0000-0002-2486-6859
authors.initials: F
authors.lastname: Falkenström
authors.affiliation: Department of Behavioural Research and Learning, Linkoping University.
authors.forename: Rolf
authors.initials: R
authors.lastname: Holmqvist
mesh_terms: D000328:Adult; D015928:Cognitive Behavioral Therapy / Q000379:methods*; D003865:Major Depressive Disorder / Q000628:therapy; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care; D009629:Person-Centered Psychotherapy / Q000379:methods*; D011369:Professional-Patient Relations; D056345:Theory of Mind