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Therapist Reflective Functioning, Therapist


Attachment Style and Therapist Effectiveness

Article in Administration and Policy in Mental Health and Mental Health Services Research · January 2017
DOI: 10.1007/s10488-017-0790-5

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Adm Policy Ment Health
DOI 10.1007/s10488-017-0790-5

ORIGINAL PAPER

Therapist Reflective Functioning, Therapist Attachment Style


and Therapist Effectiveness
John Cologon1 · Robert D. Schweitzer1 · Robert King1 · Tobias Nolte2 

© Springer Science+Business Media New York 2017

Abstract  This study investigated the relationship between Therapist Reflective Functioning, Attachment
two therapist attributes (reflective functioning and attach- and Effectiveness
ment style) and client outcome. Twenty-five therapists
treated a total of 1001 clients. Therapists were assessed The findings of large scale naturalistic studies (Saxon and
for reflective functioning and attachment style using the Barkham 2012) suggest that differences between therapists
Adult Attachment Interview and the Experiences in Close contribute to psychotherapy outcome. While the propor-
Relationships Scale. Clinical outcome was measured using tion of outcome attributable to therapist differences (6–8%)
the Outcome Questionnaire (OQ-45). Data were analysed is not large, it is potentially important. If we can optimise
using hierarchical linear modelling. Results indicated that the therapist contribution to outcome, there is potential to
therapist reflective functioning predicted therapist effective- lift overall therapy outcomes. At a time when it is increas-
ness, whereas attachment style did not. However, there was ingly clear that the contribution of the specific form of psy-
evidence of an interaction between therapist attachment chotherapy is minor (cf. Wampold 2001), it is important
style and therapist reflective functioning. Secure attach- to understand other variables that we have the potential to
ment compensated somewhat for low reflective functioning control and optimise.
and high reflective functioning compensated for insecure Current research suggests that many therapist factors
attachment. Possible implications for the selection of ther- have little, if any, impact on client outcomes. Previously
apy training candidates and therapist training are discussed. researched factors include therapist gender, theoretical ori-
entation, experience, education and training (Baldwin and
Keywords  Mentalization · Reflective functioning · Imel 2013; Lambert 2013a). These findings suggest that
Attachment · Psychotherapy outcome · Adult attachment any therapist factors which do contribute to client outcome
interview · Therapist effectiveness · OQ-45 · Therapist are not acquired through training or experience. It is pos-
factors sible that the factors which differentiate between therapists
are personality characteristics that are not amenable to
change through training or experience. However, it is also
possible that these personality factors have not been the
focus of training, or may not be salient when therapists are
This study was conducted as part of the Ph.D. of the primary
acquiring experience.
author. The current study aimed to investigate two variables
that have some face validity as characteristics that might
* John Cologon contribute to therapist effectiveness. One variable, thera-
john@jcologon.com
pist reflective functioning, should contribute to therapist
1
Queensland University of Technology, Brisbane, Australia capacity to understand and empathise with a client. The
2
Research Department of Clinical, Educational and Health
other variable, therapist attachment, should contribute to
Psychology, The Anna Freud Centre, University College the therapist’s ability to enter into a supportive and stable
London, London, UK relationship with the client. As outlined below, current

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literature indicates that these variables are relevant to inter- functioning frequently involves holding in mind multiple,
personal functioning. It has been argued that they also be concurrent points of view. For example, a therapist may
relevant to client outcomes in psychotherapy. However, to concurrently track both the probable mental processes of
our knowledge these factors have not been investigated as the client, and their own reactions within a session. Thus,
predictors of therapist effectiveness. reflective functioning bears close relationships to constructs
such as theory of mind, mind-mindedness, metacognition,
Therapist Attachment and Effectiveness psychological mindedness, mind reading, and perspective
taking (Allen 2006; Choi-Kain and Gunderson 2008; Fon-
Attachment is a complex construct with biological and psy- agy 2015). It is also a component of empathy, which has
chological components. It is thought to be central to human long been considered an important component of therapist
social functioning. Developmentally, attachment refers effectiveness (Rogers 1957/2007).
to the bond between parents and children, which forms a Reflective functioning is seen to play a key role in the
template for subsequent intimate relationships. Difficulties development of attachment security. In Fonagy’s evolving
in early attachment are thought to have enduring implica- conceptualisation, attachment and reflective functioning
tions for subsequent relationships (Mikulincer and Shaver are seen as “loosely coupled” (Fonagy and Bateman 2006,
2007). The term ‘attachment style’ refers to a characteris- p. 420). Reflecting this coupling, securely attached children
tic orientation to the other person in interpersonal relation- have been observed to develop reflective capacities earlier
ships. Attachment style is thought to have origins in early than children who are less securely attached (Fonagy and
attachment relationships with parents or other key figures Bateman 2006). This finding has been interpreted to mean
(Brumbaugh and Fraley 2007). that the development of reflective functioning contrib-
Attachment style is broadly categorised as secure or utes to the development of secure attachment. It has been
insecure. Secure attachment is characterised by a confident hypothesised that this occurs in part through interpersonal
and optimistic orientation to others. By contrast, insecure processes that underpin the development of epistemic
attachment is characterised by a fearful, avoidant or over- trust, a capacity for openness to benign others as a source
dependent orientation towards others (Mikulincer and of knowledge about the world (Fonagy 1998; Nolte et  al.
Shaver 2007). Reliable measures of attachment style have 2011).
been developed, as a result of which a substantial body of
empirical research has demonstrated that attachment style The Interface Between Attachment and Reflective
is a predictor of the trajectory of adult relationships (Fraley Functioning
et al. 2000). It is therefore reasonable to expect that thera-
pist attachment style may affect the quality of the therapeu- It has been argued that childhood secure attachment is
tic relationship. facilitated by parental reflective functioning. For example,
It has been proposed that therapists with a secure attach- a mother’s ability to treat their child as a mental agent has
ment style may achieve better client outcomes than inse- been found to predict the attachment status of their child
curely attached therapists, due to the impact of attachment (Fonagy et al. 1991). In addition, reflective functioning has
style on variables such as the therapeutic alliance (Black been found to mediate the relationship between experiences
et  al. 2005; Sauer et  al. 2003) and countertransference of abuse and the development of borderline personality
(Mohr et  al. 2005). It has also been argued that effective disorder. Persons with a history of abuse and low reflec-
therapists need to provide a secure base for the client (Far- tive functioning are most at risk of developing the disorder
ber et  al. 2009). Securely attached therapists may be bet- (Fonagy et al. 1996).
ter able to establish this base than insecurely attached The transgenerational mechanism described above may
therapists. have application beyond the parent–child relationship.
Given the centrality of the dyadic relationship to the pro-
Reflective Functioning and Therapist Effectiveness cess of therapy, it is possible that a parallel process occurs
in psychotherapy. A therapist with high mentalizing capaci-
Reflective functioning (or mentalization) refers to the ties may be better able to create the secure and reflective
ability to conceptualise, identify, and understand mental interpersonal space that allows for therapeutic change.
states in the self and others. It involves both cognitive and This proposition is consistent with Fonagy and Bateman’s
affective aspects. Reflective functioning also requires an (2006) argument that the therapist’s capacity to “keep the
understanding of the complex relationships between fac- patient’s mind in mind” is major mechanism of change in
tors which constitute human motivation, and which predict psychotherapy (Fonagy and Bateman 2006, p. 415).
human behaviour. These factors include conflicting desires, Given this potential parallel between parenting and psy-
goals, and other intentional mental states. Reflective chotherapy (Farber et  al. 2009), it can be theorized that

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reflective functioning plays a part in effective therapy. In varied from 4 to 219, with a mean of 38.84 clients per ther-
addition, it has been argued that mentalizing mediates the apist (SD = 57.84).
relationship between the therapist’s internal working model
and the attachment processes of the patient within the ther- Clients
apeutic relationship (Holmes 2011). One of the key roles
of the therapist is thus to use their own reflective function- Data from 1001 clients were included in this study. Clients
ing to develop the patient’s reflective functioning. (Fonagy were included in the study on the condition that they had
and Bateman 2006). Therapists who have a greater capacity attended more than one therapy session, and had completed
for reflective functioning should have a greater capacity to a standard outcome measure on at least two occasions. Cli-
facilitate this process. ents ranged in age from 18 to 64  years, with a mean age
Reflective functioning has been researched from the per- of 33.7 years (SD = 11.3). The gender balance in the client
spective of multiple paradigms, using varied tools. Some of group was 67% females to 33% males. The main presenting
these measures focus on cognitive aspects, whereas others problems were depression and anxiety, with a smaller pro-
tap affective processes (Choi-Kain and Gunderson 2008; portion of clients citing relationship difficulties, PTSD, and
Ensink and Mayes 2010; Fonagy et al. 2011). However, as drug or alcohol issues.
with attachment, this research has mainly been focussed
on the reflective functioning of parents and psychotherapy
clients. There remains a paucity of research investigating Materials
therapist reflective functioning in relation to therapeutic
effectiveness. Measures for Assessing Therapists

Adult Attachment Interview (AAI)


The Present Study
The AAI (George et  al. 1985), was scored as a measure
The current study examines the relationship between key
of reflective functioning. The AAI is a semi-structured
therapist variables and therapy effectiveness. Specifically,
interview which explores an adult’s early childhood expe-
the current study investigates the relationship between ther-
riences and the perceived impact of these experiences on
apist reflective functioning and psychotherapeutic effec-
later development. Reflective functioning is assessed using
tiveness. We also aim to examine the relationship between
a coding scheme developed by Fonagy et  al. (1998). This
therapist attachment security and therapist effectiveness,
scoring reflects the extent to which the interviewee is able
and any potential relationship between these two predictors.
to mentalize, or reflect from differing viewpoints, on the
material presented in the interview. Reflective functioning
is scored on an 11-point scale, with possible scores ranging
Method from −1 (rejection of reflective functioning) to 9 (excep-
tional reflective functioning) A score of 5 reflects “ordinary
Participants reflective functioning” (Fonagy et al. 1998).
The Reflective Functioning scale is reported to have
Therapists inter-rater reliability in the order of .70–.75 (Fonagy et al.
1991). The inter-rater reliability depends on the training of
Twenty-five therapists (4 males, 21 females) participated in raters, who are required to be trained to demonstrate inter-
the study. The therapists included 16 students participating rater reliability of at least .70 with pre-existing test-AAIs.
in postgraduate courses, and 9 therapists working at a uni- The AAIs with therapists were conducted by the first
versity counselling centre. Therapists ranged in age from author. Interviews were transcribed according to the proto-
24 to 56 years, with a mean age of 41. 9 years (SD = 9.7). col set out in the AAI manual and then coded for reflective
Years of experience ranged from 0 to 30, with a mean of functioning by two trained coders who had been certified as
7.3 years (SD = 7.7). Eleven of the therapists reported their reliable.
primary therapeutic orientation as psychodynamic. A fur-
ther six therapists indicated a commitment to Acceptance Experiences in Close Relationships Scale (ECR)
and Commitment Therapy (ACT). The next most preva-
lent orientation was integrative (four therapists), followed The ECR (ECR: Brennan et  al. 1998) is a 36-item self-
by humanistic/client-centred (two therapists). One thera- report measure of attachment style. The scale was devel-
pist indicated CBT as their primary orientation, and one oped through factor analysis of 60 self-report measures of
therapist ticked “other”. The number of clients per therapist attachment. The developers selected two sets of 18 items,

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which loaded most strongly on each of the two underly- observations are missing for some persons across the waves
ing factors: attachment anxiety and attachment avoidance. of data collection. Thirdly, hierarchical linear models can
Items are rated on a 7-point Likert scale. Internal consist- also accommodate situations in which the time of data col-
ency for the anxiety subscale is reported as .94 and for the lection varies across persons. Fourthly, hierarchical linear
avoidance subscale as .91. Test–retest reliability for the models can handle missing data across levels of dependent
anxiety subscales is reported as .90 and for the avoidance variables and allow for within-subjects and/or between-
subscale as .91 (Fraley et al. 2000). As is common practice subjects heterogeneity. Fifthly, hierarchical linear models
(Mikulincer and Shaver 2007), the wording of items was explicitly model the covariance structure of the data and
modified to make the scale more relevant to the context. allow time to be treated as a fixed or random effect. Finally,
The words “romantic partner” were replaced with “peo- hierarchical linear models do not require the assumption of
ple”, “someone”, and “people I’m close to” as appropri- sphericity (Bryk and Raudenbush 1988, 1992; Todd et  al.
ate, to make the scale more relevant to the therapy context 2005). The analysis was completed using the software pro-
rather than the romantic one. Where such a wording would gram HLM, version 7.22a.
not have made sense, the word “partner” was retained, but The data were analysed twice, using HLM (Bryk and
the word “romantic” was dropped. Raudenbush 1992). Initially, a 3-level model was used, in
which therapy sessions were nested within clients, who
Measure for Assessing Client Outcome were nested within therapists. To examine the possibility of
differences between clinics, a 4-level model was also run,
Outcome Questionnaire 45 (OQ‑45) in which therapy sessions were nested within clients who
were nested within therapists who were nested within clin-
The OQ-45 (Lambert et  al. 2004) is a 45-item self-report ics. Since the results of the 4-level model were essentially
measure designed to track changes over the course of psy- the same as the results of the 3-level model (i.e., the same
chotherapy. Items are scored on a 5-point Likert scale, rang- variables were significant or non-significant at the same
ing from 0 = never to 4 = almost always. The instrument level of significance), it was concluded that differences
yields three subscales: Subjective Distress (SD), Interper- between clinics were not important and that the 3-level
sonal Relations (IR), and Social Role (SR). Test–retest reli- model was more parsimonious. Hence, the results of the
ability is reported to be r = .84, and internal consistency is 3-level model are reported here.
reportedly .93 (Doerfler et al. 2002). The OQ-45 is reported
to correlate with several other self-report measures, such Results Descriptive Statistics
as the Beck Depression Inventory. It has been found to be
responsive to changes over time as a result of psychother- Means, standard deviations, and ranges for the variables
apy (Vermeersch et al. 2000). analysed are reported in Table 1, below.
Correlations between the therapist level variables are
Data Collection Procedures given in Table 2, below.

Following ethical approval from the Human Research Eth- Normality


ics Committee of QUT, informed consent was obtained
from participating therapists. Therapists were interviewed The dependent variable in this study was the OQ-45 score.
using the procedure specified in the AAI protocol. Follow- OQ-45 scores for the study had a kurtosis of .02, a stand-
ing the interview, the therapists were asked to complete the ard error of kurtosis of .07, skewness of .04 and standard
ECR. Those therapists for whom client OQ-45 data was not error of skewness of .02. The distribution of the OQ-45
already available were then given client information sheets, was examined for conformity to the normal distribution by
client consent forms, and instructions for collecting the the maximum likelihood method. The procedure yielded
OQ-45 data from their clients after each therapy session. a χ2 of 31.6 (df = 8, p < .001), a Shapiro–Wilk statistic of
.99 (p < .001), and a Kolmogorov–Smirnov statistic of .02
Data Analysis (Lillefors p = .007). It was therefore concluded that the
sample was sufficiently normal for the analysis proposed.
Data were analysed using hierarchical linear modelling
(HLM). HLM was chosen for multiple reasons. Firstly, Inter‑Rater Reliability
HLM deals satisfactorily with the dependency between
clusters in longitudinal and cross-sectional data that Since the main predictor variables for this study are based
involves hierarchical properties. Secondly, hierarchical lin- on coding of the AAI for reflective functioning by trained
ear models have the capacity to clarify trends even when and accredited raters, it was important to assess inter-rater

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reliability. For reflective functioning, this was done in sev- previous research, were expected not to contribute signifi-
eral ways: using the intraclass correlation coefficient (ICC); cantly to therapist effectiveness, was analysed. The predic-
using Krippendorf’s alpha; and using Lin’s concordance. tors in this model were therapist gender, age, and orienta-
For reflective functioning, the ICC was .73, Krippendorf’s tion (type of therapy practiced). As expected, none of these
alpha was .79, and Lin’s concordance was .71. factors contributed significantly to the explanation of thera-
pist effectiveness. A comparison of this model with the
Fully Unconditional Model and Unconditional Growth unconditional model was non-significant (χ2 = 6.993, df = 8,
Model p > .500). This indicates that adding therapist gender, age,
and orientation did not improve the adequacy of the model.
The results for the fully unconditional model and the Therefore, these variables were discarded for subsequent
unconditional growth model are presented in Tables  3 analyses.
and 4. Therapists saw clients for widely differing numbers
of sessions. Hence it was considered important to test the
Preliminary Analyses effect of number of sessions on outcome. When number of
sessions was added to the unconditional model, the effect
Before exploring the predictors central to the current study, on outcome was non-significant (p = .230). Hence, number
a conditional model involving factors which, on the basis of of sessions was excluded from further analyses.

Table 1  Descriptive statistics Variable Name N Mean SD Minimum Maximum

Level one (therapy sessions) Session 4760 5.25 5.62 2 43


OQ-45 4760 77.60 23.83 8 164
Level two (clients) Initial severity 1001 80.39 23.30 10 153
No of sessions 1001 4.76 4.71 2.00 43.00
Level three (therapists) Therapist age 25 37.88 10.77 24 56
ECR anxiety 25 3.47 0.69 2.11 5.00
ECR avoidance 25 3.75 0.82 1.78 5.22
Reflective functioning (RF) 25 6.12 1.09 4 7.5

Table 2  Correlations between Age No. of clients ECR avoidance ECR anxiety RF Years of
therapist variables experi-
ence

Age 1.000
No. of clients 0.261 1.000
ECR avoidance −0.169 0.261 1.000
ECR anxiety −0.010 −0.262 0.220 1.000
RF −0.314 −0.185 0.057 0.091 1.000
Years of experience 0.712 0.464 0.135 −0.041 −0.363 1.000

Table 3  HLM results for the fully unconditional model


Fixed effects Coefficient SE t-ratio df p

OQ intercept (γ000) 76.82 0.84 91.24 24 <.001


Random effects SD Variance χ2 df p

Session (level 1) error variance (e) 13.60 184.92


Client (level 2) unexplained variance (r0) 19.94 397.63 9975.34 945 <.001
Therapist (level 3) unexplained variance (u00) 1.55 2.40 41.58 24 .014

HLM model: OQtij = γ000 + r0ij + u00j + etij

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Table 4  HLM results for the unconditional growth model


Fixed effects Coefficient SE t-ratio df p

OQ intercept (γ000) 77.46 0.89 86.91 3738 <.001


OQ slope (γ100) −0.84 0.30 −2.84 24 .009
Random effects SD Variance χ2 df p

Session (level 1) error variance (e) 13.30 176.72


Client (level 2) unexplained OQ slope variance (r1) 4.57 20.84 2339.23 945 <.001
Therapist (level 3) unexplained OQ Slope Variance (U10) 0.65 0.42 130.97 24 <.001

HLM model: OQtij = γ000 + γ100*SESS_Ttij+r1ij*SESS_Ttij + u10jSESS_Ttij + etij

Initial severity of client disturbance was considered There was a significant fixed effect for reflective function-
likely to affect outcome. Therefore, initial severity was ing (p < .001). The addition of reflective functioning to the
added to the unconditional model as a level two predictor. model provided a markedly significant improvement over
Initial severity had a significant effect both on the level of the previous model (χ2 = 12.46303, df = 1, p < .001).  The
the intercept for outcome (p < .001) and also on the slope effects of reflective functioning and attachment on therapist
(p < .001). It will be noted that the effect on slope was in effectiveness are detailed in Table 6, below.
the direction that more severe clients had greater improve- The findings support the relationship between capacity
ment, presumably because they had more room to improve. for reflective functioning and therapist effectiveness.
A comparison of this model with the unconditional The trajectories for clients of therapists with low,
model yielded the following model comparison statistics: medium, and high reflective functioning are presented in
χ2 = 1351.14953, df = 2, p < .001, indicating that the addi- Fig.  1. The high reflective functioning group consists of
tion of initial severity as a predictor significantly improved those therapists with a score of 7 or higher. The medium
the model. Hence, initial severity was retained as a level reflective functioning group contains therapists scoring
two predictor in subsequent analyses. Results of this analy- higher than 5 and lower than 7. The low reflective func-
sis are presented in Table 5. tioning group consists of therapists scoring 5 or lower
(i.e. lower than “normal reflective functioning”). It is evi-
dent from the slopes that symptom severity decreased
Reflective Functioning and Therapist Effectiveness significantly over time for clients of therapists in the high
reflective functioning group. In other words, these thera-
The study aimed to examine the relationship between pists were effective. The level of symptoms for clients of
capacity for reflective functioning, as measured by the therapists with medium levels of reflective functioning also
reflective functioning scale, and therapist effectiveness. decreased over time, but to a lesser extent than for those of

Table 5  HLM growth model taking account of average initial severity of client per therapist
Fixed effects Coefficient SE t-ratio df p

OQ intercept (γ000) 77.87 0.89 86.74 3738 <.001


OQ slope (γ100) −2.05 0.60 −3.40 24 .002
OQ slope per initial severity score (γ110) −0.20 0.02 −11.57 944 <.001
Random effects SD Variance χ2 df p

Session (level 1) error variance (e) 19.87 394.69


Client (level 2) unexplained OQ slope variance (r1) 3.49 12.16 2571.84 944 <.001
Therapist (level 3) unexplained OQ slope variance (u10) 2.40 5.75 155.20 24 <.001

HLM model: OQtij = γ000 + γ100*SESS_Ttij + γ110*SESS_Ttij*INITSEVij + r1ij*SESS_Ttij + u10j*SESS_Ttij + etij

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high reflective functioning therapists. Low reflective func- Interaction Between Reflective Functioning
tioning therapists had negligible effect on client symptoms. and Attachment

Estimation of Effect Size Although attachment did not have a significant direct effect
on therapist effectiveness in the initial analysis, when inter-
Estimates of variance accounted for are problematic in actions were examined, a significant interaction between
multilevel models (McCoach 2010; Widman 2011). It attachment and reflective functioning was found, in terms
is not possible to calculate a direct equivalent to ­R2 for of their effect on therapist effectiveness. Inclusion of the
multilevel models. The most widely used method of esti- interaction term also resulted in significance for attachment
mating the variance accounted for, proportional reduc- anxiety, which was not significant when the interaction
tion in variance (Bryk and Raudenbush 1992), suggests term was not included. Details of the interaction are pre-
that 70.5% of the variance in therapist effectiveness is sented in Table 7, below.
accounted for by reflective functioning. The nature of the interaction was examined by taking a
median split of therapists on their ECR anxiety scores and
Attachment Style and Therapist Effectiveness plotting the relationship between RF and effectiveness for
the two groups. The resultant graph is presented below in
Attachment style did not make a significant contribution to Fig. 2.
the model as can be seen  in Table 6, below. The effectiveness scores on the vertical axis represent
aggregated slopes from client OQ trajectories, so the more

Fig. 1  OQ score trajectories for


clients of low, medium and high
RF therapists. Greater negative
slope means greater improve-
ment

Table 6  Effect of reflective functioning and attachment on therapist effectiveness


Fixed effects Coefficient SE t-ratio df p

OQ intercept (γ000) 76.77 0.86 89.43 968 <.001


OQ slope (γ100) −0.86 0.13 −6.88 21 <.001
RF (γ101) −0.45 0.11 −4.15 21 <.001
ECR avoidance (γ102) −0.03 0.18 −0.16 21 0.87
ECR anxiety (γ103) −0.27 0.18 −1.48 21 0.16
OQ slope per initial severity score (γ110) 0.80 0.02 52.78 968 <.001
Random effects SD Variance χ2 df p

Session (level 1) error variance (e) 13.09 171.56


Client (level 2) unexplained OQ slope variance (r1) 9.85 97.06 4644.22 968 <.001
Therapist (level 3) unexplained OQ slope variance (u10) 0.41 0.17 81.63 21 <.001

HLM model: OQtij = γ000 + γ100*SESS_Ttij + γ101*SESS_Ttij*RFj + γ102*SESS_Ttij*ECR_AVDj + γ103*SESS_Ttij*ECR_ANXj + γ110*SESS_Ttij*INI


TSEVij + r1ij*SESS_Ttij + u10j *SESS_Ttij + etij

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Table 7  Interaction between RF and attachment anxiety Reflective Functioning and Therapist Effectiveness


Coefficient SE t-ratio df p value
The findings support the significance of reflective function-
Reflective functioning 1.615328 0.520387 3.104 15 .007 ing for therapist effectiveness. Therapist reflective function-
ECR avoidance 0.000862 0.135746 0.006 15 .995 ing is thought to facilitate growth in the client’s reflective
ECR anxiety 4.011969 1.099564 3.649 15 .002 functioning. It is thus considered by some to be founda-
Interaction between −0.665152 0.166683 −3.991 15 .001 tional to the process of change in psychotherapy (Fonagy
ECR anxiety and RF
and Bateman 2006). Therapist reflective functioning may
HLM model: OQmtij = γ0000 + γ0001 + γ0100*INITSEVtij + γ1000*SESSIO therefore be considered a common factor across therapies.
Nmtij + γ1010*SESSIONmtij*RFij + γ1020*SESSIONmtij*RFXANXij + γ1030 The finding that therapist reflective functioning predicts
*SESSIONmtij*ECR_AVDij + γ1040*SESSIONmtij*ECR_ANXij + γ1100* therapist effectiveness further develops our understanding
SESSIONmtij*INITSEVtij + e0tij + r00ij + r10ij *SESSIONmtij + u000j + u100j
*SESSIONmtij + εmtij of the role of common factors in the process of psycho-
therapy (cf. Wampold 2001). The investigation of common
factors has become important in light of the results of a
recent meta-analysis of the effects of therapist competence
in, and adherence to, specific therapies. This analysis found
that the effect size for adherence was .02, and for compe-
tence was .07 (Webb 2012). Considering the importance
of reflective functioning in therapy, it is unsurprising that
therapists with higher reflective function (regardless of
orientation) are more able to facilitate growth in the reflec-
tive functioning of their clients. This is, to our knowledge,
the first empirical study to provide evidence that therapist
reflective functioning is an important factor in therapist
effectiveness. This result indicates that therapist reflective
functioning affects therapist effectiveness, independently of
Fig. 2  Relationship between RF and effectiveness for high and low their attachment representation.
attachment anxiety therapists The significant association between reflective func-
tioning and therapist effectiveness found in this study is
consistent with results reported in a study that used the
negative the value, the greater the effectiveness. Positive patient therapist form of the AAI (Diamond et  al. 2003).
values indicate deterioration rather than improvement. As That study, which used a case-study approach due to a very
can be seen from the graph, although higher RF leads to small sample size, involved the scoring of therapists’ reflec-
greater effectiveness for both high and low anxiety thera- tive functioning on the patient-therapist adult attachment
pists, the effect of RF on effectiveness is considerably interview (PT-AAI). In that study, whenever a therapist
greater for the therapists with high attachment anxiety than scored 4 or above for reflective functioning on the PT-AAI,
it is for those with low anxiety. Furthermore, for the thera- the client’s reflective functioning increased from pre-ther-
pists with the lowest RF, higher attachment anxiety reduces apy to post-therapy.
their effectiveness, whereas for therapists with higher RF, The results reported here also support results reported
higher attachment anxiety increases their effectiveness. in a study investigating therapist use of personal counsel-
ling (Rizq and Target 2010). That study found that thera-
pists “with higher levels of reflective functioning (who
Discussion were more likely to be secure/earned secure) appeared to
use their experience of being a client in therapy as a spring-
Consistent with previous findings (Baldwin and Imel 2013; board to understanding the more subtle and complex psy-
Lambert 2013a) this study showed that psychotherapy out- chological needs of their clients” (Rizq and Target 2010,
comes varied according to therapist. More importantly, this p. 476).
investigation identified therapist variables associated with The interaction between attachment anxiety and reflec-
client outcome. Therapists with higher reflective function- tive functioning in this study is consistent with the idea
ing capacities had significantly better client outcomes than that mentalizing provides a buffer that protects against
therapists with lower reflective functioning. Contrary to the harmful effects of attachment trauma in earlier life
expectation, therapists with higher attachment security did (Eagle et  al. 2009). Reflective functioning may indeed be
not have better client outcomes. indicative of a certain level of earned security. This study

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Adm Policy Ment Health

suggests that reflective functioning may not only protect, therapist availability, which means that it is unlikely that
but transform attachment anxiety from a negative to a assignment factors biased outcome. However, we can-
positive factor in terms of therapist effectiveness. Having not exclude the possibility that there was some intentional
high reflective functioning enabled therapists in this study assignment that could have confounded findings. We con-
who reported high levels of attachment anxiety to outper- trolled for those factors that we knew predicted outcome
form therapists with lower attachment anxiety, so that what but there may have been variables we did not measure that
might have been considered to be a setback was trans- confounded results.
formed into an asset. A second limitation derives from sample size. Although
The finding that reflective functioning predicts thera- this study found significant results, the number of therapists
pist effectiveness may also clarify the findings of a study constituting level three of the analysis was not large. This
in which psychotherapy students who demonstrated signs meant that we had insufficient power to detect small effects.
of emotional disturbance on self-report measures initially A study using a larger sample might find significant results
performed less effectively than their peers. However, after regarding attachment style.
training, their effectiveness improved so that it matched A further limitation derives from variability in the num-
their peers (O’Donovan and Dyck 2005). ber of clients seen by each therapist, which in this study
Assuming emotional disturbance to be similar to attach- ranged from 4 to 209. It could be argued that the small
ment anxiety (cf. Esbjorn et al. 2012), we might conclude numbers for some therapists increased the risk that the
that the effectiveness of trainee therapists who showed slope is not a reliable estimate of therapist effectiveness
signs of emotional disturbance would depend on their because small samples increase the risk that a particular
level of reflective functioning. If they lacked sufficient group of clients have atypical recovery trajectories. To the
reflective functioning to deal with their attachment anxi- extent that recovery prospects relate to initial severity, con-
ety, they might not be able to exploit their own develop- trolling for initial severity mitigates this problem to some
mental history in an interpersonally constructive way. extent. However, this study does not investigate the effec-
They might therefore perform relatively ineffectively as tiveness of each individual therapist, but factors predicting
therapists. However, if the process of training they under- the trend across therapists in terms of effectiveness. In that
went included elements which led to an improvement in process, the pooling of estimates from all the therapists
their level of reflective functioning, then their effectiveness means that the inclusion of therapists with lower numbers
might be expected to also improve. of clients helps to increase the power of the estimation of
The findings have implications for optimising therapeu- the effect of predictor variables, irrespective of the accu-
tic outcomes, the selection of therapy training candidates, racy of estimation at the individual therapist level (B. E.
and enhancing therapy training experiences. The findings Wampold 2012, personal communication). It would, how-
suggest that enhanced reflective functioning is important ever, be a problem if the number of clients per therapist
in determining the effectiveness of therapists. In select- varied in a systematic, non-random way that affected out-
ing candidates for training, consideration may be given to come. This does not appear to be the case, given that num-
selecting candidates who are able to demonstrate the req- ber of clients per therapist is non-significant as a predictor
uisite components of effective therapists. The findings also variable. Furthermore, the small and non-significant corre-
suggest that programs aimed at enhancing reflective func- lation between reflective functioning and number of clients
tioning may well contribute to therapist effectiveness. (r = −.185, p = .377) indicates that differences in numbers
It is not surprising that reflective functioning is relevant of clients have probably not contaminated the most signifi-
to effective therapy. It could be asserted with some justifi- cant result in this study, the connection between reflective
cation that reflective functioning is the core of what thera- functioning and therapist effectiveness. Nevertheless, the
pists do! “All therapy requires mentalizing on the part of possibility that variations in numbers of clients may have
the patient and the therapist” (Allen and Fonagy 2006, p. subtly affected the results in some way cannot be com-
xix). It is therefore intuitive that being able to understand pletely excluded.
the mental processes of oneself and others means being Finally, therapeutic intervention is a possible confound.
able to provide better therapy. We did not control for intervention and it is possible that
more reflective therapists used more effective interventions
and it was this, rather than their reflective functioning, that
Research Limitations resulted in better client outcomes. We think this unlikely
given the weight of evidence for broad equivalence of ther-
An important limitation of this study relates to the natu- apeutic interventions with high prevalence disorders (Lam-
ralistic design. Clients were not randomised to therapists. bert 2013b; Wampold 2001), but it cannot be excluded.
For the most part, assignment to therapist was based on

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Adm Policy Ment Health

Directions for Future Research Lutz et  al. 2007; Najavits and Strupp 1994; Okiishi et  al.
2003, 2006; Shapiro et  al. 1989).This growing body of
The findings of this study need replication, preferably with research indicates that differences in therapist effective-
a larger sample and ideally with clients randomly assigned ness are not explained by differences in the level of thera-
to therapists. If reflective functioning is an important ingre- pist experience, education or training. However, there has
dient in therapist effectiveness, then the extent to which been a gap in our knowledge regarding what makes ther-
training can enhance reflective functioning is a question apists effective. The findings from this study suggest that
that needs to be answered. If it can be shown that particu- one of the characteristics that make therapists effective is a
lar methods of training enhance reflective functioning, well-developed ability to mentalize. While not surprising,
this would have significant implications for the training of this has implications for our understanding of the thera-
psychotherapists. Steps in that direction have already been peutic process, and for the selection and training of thera-
taken by Canadian researchers, who report that a train- pists. Research into reflective functioning has suggested a
ing program did indeed increase the reflective functioning significant role for mentalizing in protecting people from
of student therapists (Ensink et  al. 2013). This interest- the effects of attachment trauma and overcoming childhood
ing research assessed reflective functioning using a video difficulties (Bateman et al. 2009). This paper suggests that
vignette system known as the Therapist Mental Activity people characterized by high levels of mentalizing and an
Scale (TMAS: Maheux et al. 2012). This scale is a revision understanding and integration of adverse experiences may
of the Countertransference Rating System (CRS: Norman- be among those who make good therapists.
din and Bouchard 1993). Although the authors state that the
Compliance with Ethical Standards 
scale, which derives from the French psychoanalytic tradi-
tion going back to Pierre Marty (Marty and Michel 1963)
Conflict of interest  No conflicts of interest were involved.
has been modified/to make it “fully compatible with Fon-
agy’s model” (Maheux et  al. 2012, p.  527), it is not clear Ethical Approval  All procedures performed in studies involving
how successful this revision has been in terms of the extent human participants were in accordance with the ethical standards of
to which this scale relates to the reflective functioning Human Research Ethics Committee of Queensland University of Tech-
nology and with the 1964 Helsinki declaration and its later amend-
scale. It is also therefore not clear how that research relates ments or comparable ethical standards, and were approved by the
to the research presented here. The only published com- Human Research Ethics Committee of QUT.
parison of the system on which this scale is based, known
at the time as the Mental States Rating System (MSRS),
found that they “share some aspect of a core mentalization
process and that each illuminates a specific component”
(Bouchard et al. 2008, p. 47). That comparison also found
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