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Reflective functioning (RF), as conceptualized by Fonagy (1991; Fonagy and Target 1997), is the capacity to make sense of what might be expectable transactional behavior between people based on their motivations, affective states, or developmental stages.1 The term is a concise way of referring to a patient's process of thinking about his own thoughts, feelings, and behavior. RF is an ego capacity that may or may not improve with psychodynamic psychotherapy as patients internalize the therapist's mode of thinking. As patients' predominant defenses change from projecting or externalizing conflicts to assessments that are more realistic, one would expect reflective capacity to improve. An important research question is, Does RF improve as a result of symptomatic change, or is improved RF necessary for that change to occur? Do patients with greater reflective capacity do better in psychotherapies in general? Broader utilization of this set of measures in standard clinical trials will help unravel this.
Limited data have been accumulated in this regard. Levy et al. (2006), in a randomized controlled trial (RCT) of 90 patients with borderline personality disorder treated either with dialectical behavioral therapy (DBT), transference-focused psychotherapy (TFP), or supportive psychotherapy (ST), found significantly greater change in RF in the TFP condition relative to the other groups.
Bouchard et al. (2008) have demonstrated that low RF scores on 73 Adult Attachment Interviews predicted the presence of Axis I or II disorders. Does an increase in RF then correlate with a diminution of Axis I symptomatology? A cogent research strategy might examine changes in patients' reflective capacities over the course of psychotherapeutic or