Child Abuse & Neglect 95 (2019) 104065

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Child Abuse & Neglect

journal homepage: www.elsevier.com/locate/chiabuneg

Research article

The protective role of mentalizing: Reflective functioning as a

T
mediator between child maltreatment, psychopathology and
parental attitude in expecting parents
⁎
Berthelot Nicolasa,d,e,f,g, , Lemieux Roxannea,d,f, Garon-Bissonnette Juliab,d,f,g,
Lacharité Carlb,d,g, Muzik Mariac,h
a
Department of Nursing Sciences, Université du Québec à Trois-Rivières, Canada
b
Department of Psychology, Université du Québec à Trois-Rivières, Canada
c
Department of Psychiatry, University of Michigan, United States
d
Centre d’études interdisciplinaires sur le développement de l’enfant et la famille, Canada
e
CERVO Brain Research Center, Canada
f
Interdisciplinary Research Center on Intimate Relationship Problems and Sexual Abuse, Canada
g
Groupe de recherche et d’intervention auprès de l’enfant vulnérable et négligé, Canada
h
Center for Human Growth & Development, University of Michigan, United States

A R T IC LE I N F O ABS TRA CT

Keywords: Background: Childhood maltreatment impacts parenting and has intergenerational consequences.
Child maltreatment It is therefore crucial to identify clinically responsive resilience-promoting factors in pregnant
Reflective function women and expecting men with history of childhood maltreatment. Mentalization, or reflective
Pregnancy functioning, appears as a promising concept to understand risk and resilience in the face of
Mental health
childhood maltreatment.
Antenatal attachment
Objective: This study evaluated the multivariate relationship between exposure to childhood
maltreatment, reflective functioning, psychological symptoms and parental attitude in expecting
parents.
Methods: Two hundred and thirty-five pregnant women and 66 expecting fathers completed self-
report assessment measures of childhood trauma, reflective functioning, depression, post-trau-
matic stress disorder, parental sense of competence and antenatal attachment. Twenty-eight
percent (n = 85) of the community sample reported personal histories of childhood maltreat-
ment.
Results: Structural equation modeling indicated that reflective functioning (a) partially mediated
the association between childhood maltreatment and psychological symptoms during pregnancy
and (b) independently predicted participants’ perception of parental competence and psycholo-
gical investment toward the unborn child.
Conclusion: Overall, this study provides empirical evidence of the protective role of reflective
functioning during the prenatal period in parents with histories of childhood maltreatment.

⁎
Corresponding author at: Université du Québec à Trois-Rivières, Department of Nursing sciences, PO Box 500, Trois-Rivières, Québec, Canada.
E-mail address: Nicolas.berthelot@uqtr.ca (N. Berthelot).

https://doi.org/10.1016/j.chiabu.2019.104065
Received 12 April 2019; Received in revised form 19 June 2019; Accepted 24 June 2019
0145-2134/ © 2019 Elsevier Ltd. All rights reserved.
N. Berthelot, et al. Child Abuse & Neglect 95 (2019) 104065

1. Introduction

Child maltreatment (CM) has definite and long-lasting consequences on mental health (Afifi et al., 2014; Green et al., 2010). In
the long term, CM is particularly associated with depressive symptoms (Nelson, Klumparendt, Doebler, & Ehring, 2017; Sexton,
Hamilton, McGinnis, Rosenblum, & Muzik, 2015) and post-traumatic stress disorder (Dias, Sales, Mooren, Mota-Cardoso, & Kleber,
2017; Seng et al., 2013). Multiple evidence confirms that CM impacts parenting (Morelen, Rosenblum, & Muzik, 2018) and has
intergenerational consequences as offspring of maltreated parents are particularly likely to show, early on, risk factors for psycho-
pathology such as neurobiological anomalies (Buss et al., 2017) and disorganized attachment (Berthelot et al., 2015). In the face of
the consistent amount of evidence linking CM to poor psychological outcomes, it is argued that scientific research should identify
clinically responsive mechanisms through which CM leads to symptoms and difficulties in parenting (Shonkoff, 2016). Such studies
would be helpful in the design of future clinical research addressing these mechanisms to alleviate the negative effects of CM and
interrupt their intergenerational transmission.

1.1. Mentalization and childhood adversity

Mentalization is defined as the ability to perceive and interpret human behaviors in terms of intentional mental states such as
feelings, wishes, goals or desires (Fonagy, Gergely, Jurist, & Target, 2002). It is a developmentally acquired ability that primarily
emerges from attachment relationships during which the child is treated as someone with his/her own mind and experiences sensitive
caregiving that is modulated by the caregivers’ continuous attempts to understand his/her mental states. Through such sensitive
attachment relationships, the child discovers his/her own mind and cultivates an understanding of the psychological world. Across
development, other experiences may support the development of mentalization, including significant relationships with peers, tea-
chers or other adults (Luyten, Nijssens, Fonagy, & Mayes, 2017). Since mentalization contributes to a sense that others and oneself are
understandable and predictable, this ability is crucial for affective regulation and the development of a coherent self (Fonagy et al.,
2002; Morel & Papouchis, 2015).
Mentalization is operationalized in research through the metric called reflective functioning (RF). RF was initially evaluated using
a coding protocol applied to the Adult Attachment Interview (Fonagy, Target, Steele, & Steele, 1998), a semi-structured interview
aiming to elicit narratives about the self and relationships with attachment figures during childhood (George, Kaplan, & Main, 1985).
The Reflective Functioning Questionnaire (RFQ) was recently developed to provide a measure of mentalizing that is easier and faster
to administer (Fonagy et al., 2016). The instrument assesses two types of impairments in RF, namely hypermentalization and hy-
pomentalization. Hypermentalization is observed when a person is overly certain about his/her mental states or those of others, while
in reality, mental states are rather opaque and can only be inferred. Conversely, hypomentalization is observed when one perceives
mental states as being completely opaque and accordingly unapproachable. Mentalization is a multifacet construct and other
measures have been developed to assess RF in relation to specific domains including parenting (Pajulo et al., 2018; Slade, 2005) and
trauma (Berthelot, Ensink, & Normandin, 2013a,b; Ensink, Berthelot, Bernazzani, Normandin, & Fonagy, 2014).
In the last decades, the concept of mentalization evolved as a particularly attractive theory to understand risk and resilience
trajectories in the face of CM. From a developmental perspective, it is assumed that CM leads to mental health problems in part
through an early deleterious effect on the development of the child’s reflective functions (Allen, 2013; Fonagy & Target, 1997). CM is
alleged to disrupt the development of RF during childhood through various pathways (Ensink et al., 2014). For instance, parents who
show maltreating behaviors typically fail to consider their child’s perspective and are likely to discourage the expression of emotions
and disallow an environment where their child can explore his/her inner world safely (Allen, Fonagy, & Bateman, 2008; Allen, 2013;
Fonagy & Luyten, 2009). Even when the parent is not the abuser, a general context encouraging mentalization may be unlikely in
families concerned with CM considering recent evidence showing that non-abusive mothers of sexually abused children have lower
parental RF than mothers of non-abused children (Ensink, Begin, Normandin, Godbout, & Fonagy, 2017). In such contexts, the child
experiences unbearable mental states brought on by the trauma that are not contained, not reflected upon and not understood by the
caregiver. The child’s mind is consequently left alone which in turn may lead to psychological withdrawal as a solution, ultimately
compromising mentalization (Fonagy & Bateman, 2016). A similar pathway may unfold when the parent is unpredictably frightening
or abusive and the child cannot reliably depend on the parent’s emotional comfort. Alternatively, CM may also interfere with RF
through neurobiological processes. Indeed, early adversity was shown to lead to structural and functional changes in brain regions
involved in mentalization (Luyten & Fonagy, 2015). There is evidence from human and animal models that chronic stress leads to
alterations in brain structures crucial for mentalization and affective regulation, such as the amygdala, which is involved in de-
termining the emotional valence of stimuli (Tottenham & Sheridan, 2009) and the ventromedial prefrontal cortex (Morey, Haswell,
Hooper, & De Bellis, 2016; Thomaes et al., 2010), which is important for affectively oriented mentalization.
Despite the strong theoretical basis suggesting that CM hinders the development of RF, most evidence of a negative association
between CM and mentalization emerged very recently from samples of children (Ensink et al., 2017; Tessier, Normandin, Ensink, &
Fonagy, 2016) and adolescents (Quek et al., 2017). Scientific studies have yielded inconsistent results regarding the association
between trauma and RF in adult populations. Two studies in community samples of women with histories of childhood maltreatment
that evaluated RF using interviews about parenting in one’s own childhood (Adult Attachment Interview; AAI) or towards one’s own
child (Parent Development Interview; PDI) did not observe clear deficits in RF (Ensink et al., 2014; Stacks et al., 2014). In patients
with axis-I disorders, a similar lack of association between CM and affect-centered mentalization (i.e. the ability to identify, reflect
on, express, and regulate one’s emotions, and to differentiate between one’s own and another person’s emotional state) was recently
observed (Herrmann et al., 2018). In contrast, several other studies in clinical samples did report significant associations between

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histories of CM and lower RF or parental RF. The sample composition in these studies ranged from patients with personality disorders
(Brune, Walden, Edel, & Dimaggio, 2016; Chiesa & Fonagy, 2014), patients with non-affective psychosis (Weijers et al., 2018) and a
sample of substance abusing mothers (Hakansson, Watten, Soderstrom, Skarderud, & Oie, 2018). All these studies reporting RF-
trauma linkages did not control for potentially confounding variables typically associated with RF, such as education or income, and
consisted of samples of patients with severe psychiatric disorders, potentially introducing bias. Thus, more studies using community
samples may be beneficial to further clarify the theoretical model linking CM to poor mentalization in adult populations. In addition,
since none of these studies used the RFQ, we know very little on the relationship between CM and the two principal types of
impairments in RF, namely hypomentalization and hypermentalization.

1.2. Mentalization and psychopathology in the context of child maltreatment

Adults who develop good mentalization abilities despite exposure to adverse life events may be the most resilient (Fonagy &
Bateman, 2016). Indeed, mentalization is crucial to the elaboration of a coherent narrative about trauma (Ensink & Normandin,
2011), which is essential for recovery (Deblinger, Mannarino, Cohen, Runyon, & Steer, 2011). In contrast, a recent study showed that
impairments in mentalization among adolescents who experienced childhood traumatic experiences were associated with affect
dysregulation, which in turn predicted psychopathology (Belvederi Murri et al., 2017). A limited number of studies with adult clinical
populations showed that RF mediates the association between CM and severe psychiatric problems such as borderline symptoma-
tology (Chiesa & Fonagy, 2014) and negative psychotic symptoms (Weijers et al., 2018). Again, most evidence of a mediating role of
RF between CM and less severe psychopathologies come from recent studies with children (Ensink, Begin, Normandin, & Fonagy,
2016, 2017) or adolescents (Belvederi Murri et al., 2017, Quek et al., 2017). Further studies are thus needed to evaluate whether RF
mediates the relationship between CM and psychological symptoms in adults from the community who are more likely than psy-
chiatric patients to have benefited from other resilience-promoting factors.

1.3. Mentalization and parenting in parents exposed to childhood maltreatment

Reflective functioning is suggested to be crucial for parenting as sensitive caregiving requires parents to imagine the child’s
experience and be mindful of their own affects and their impact on the relationship with the child (Ensink, Normandin, Plamondon,
Berthelot, & Fonagy, 2016). The role of mentalization for the parent-infant relationship was recently confirmed by a meta-analysis
showing that parental mentalization is a better predictor of mother-infant secure attachment than parental sensitivity (Zeegers,
Colonnesi, Stams, & Meins, 2017).
RF may be particularly important in periods of acute stress, such as the transition to parenthood, where the level of adaptation
required is enormous and during which time the parent undergoes a substantial reorganization of his/her identity. The multiple
challenges associated with pregnancy and parenting may be particularly intense for adults who were exposed to CM. Indeed, ex-
pecting a child may resurrect unresolved attachment traumas (Raphael-Leff, 2010) which compromise mental health, prenatal at-
tachment and perception of parental competence during pregnancy (Berthelot, Lemieux, Garon-Bissonnette, & Muzik, In press) as
well as postnatal mother-infant attachment (Berthelot et al., 2015; Huth-Bocks, Muzik, Beeghly, Earls, & Stacks, 2014). A study with
pregnant women with and without exposure to child abuse showed that those women who had good levels of mentalization about
their history of abuse (labeled trauma-specific reflective functioning) experienced more positive and less negative affects towards
their baby and motherhood and were more satisfied in their romantic relationships compared to those mothers with low levels of
trauma-specific mentalization (Ensink et al., 2014). Mentalization about trauma also prospectively predicted mother-infant attach-
ment at 18-months postpartum (Berthelot et al., 2015). However, we still know little about the role of more general mentalization
abilities during the critical period of pregnancy in women and men exposed to CM. A focus on mentalization may be particularly
useful for timely detection of subgroups of parents with a history of CM who are the most likely to transmit risk trajectories associated
with abuse or neglect.

1.4. The present study

A first objective of this paper was to contribute to the literature on the link between CM and the development of RF among a non-
clinical community sample. As highlighted prior, this is a less studied population compared to samples comprised of psychiatrically ill
participants. For this study, we chose an instrument (RFQ) measuring two distinct problems in terms of reflective functions, namely
hypermentalization and hypomentalization, and we evaluated the association between CM and both types of impairments. A second
objective was to evaluate whether RF mediates the association between CM and psychological symptoms (depressive and post-
traumatic stress). As previously discussed, studies with adult populations mainly focused on more severe psychiatric disorders.
Finally, given the protective role of mentalization during the transition to parenthood (particularly for those who had been mal-
treated as children), we chose a sample of expecting parents (mothers and fathers) for this study and evaluated whether RF con-
tributed to parental attitudes (parenting sense of competence and prenatal attachment) over the effect of other sociodemographic risk
factors.
The relevance of studying mentalization as a mechanism in trajectories of risk and resilience following CM is further supported by
the fact that this ability can be improved through therapeutic interventions. Indeed, numerous mentalization-based treatments
benefit from empirical support for various disorders (Balestrieri, Zuanon, Pellizzari, Zappoli-Thyrion, & Ciano, 2015; Bateman &
Fonagy, 2008; Hauber, Boon, & Vermeiren, 2017; Lof, Clinton, Kaldo, & Ryden, 2018; Robinson et al., 2016). Mentalization-based

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interventions were also shown efficient in prenatally (Pajulo, Pajulo, Jussila, & Ekholm, 2016) and postnatally (Byrne et al., 2018;
Camoirano, 2017; Sadler et al., 2013) supporting parenting in high risk samples.

2. Methods

Adults awaiting a child were recruited between September 2015 and September 2018 during prenatal classes offered to the
general population by a large university hospital. The research project was briefly explained. Participants wishing to participate in
the research first completed, on site, a short set of questionnaires, including sociodemographic information and the Childhood
Trauma Questionnaire (CTQ; see below). Participants were again contacted by the research team during the third trimester of
pregnancy. Women and men who agreed to participate to the complete research protocol received, by mail or electronically, a set of
self-report questionnaires assessing RF, mental health, parental confidence and prenatal attachment (see below). Participants were no
different from those who refused to participate in terms of CM (respectively 30% and 28% were exposed to CM), χ2(1,
N = 701) = 1.52, p = .70. Inclusion criteria were being 17 years old or older and not suffering from a severe psychiatric disorder
(e.g. psychosis). The study received ethical approval from the Comité d’éthique de la recherche avec des êtres humaines de
l’Université du Québec à Trois-Rivières (CER-15-210-07.02) and the Comité d’éthique de la recherche du Centre Intégré Universitaire
de Santé et de Services Sociaux de la Mauricie-et-du-Centre-du-Québec (CER2014-027-00).

2.1. Participants

The total sample comprised 301 participants (78% women). Women ranged in age from 17 to 45 years old (M = 28.45,
SD = 4.49) and men from 22 to 40 years old (M = 29.53, SD = 4.06). The majority of women (89.4%) were primiparous. Of the 66
fathers, 45 (68%) were partners of participating women. The vast majority of the sample (95%) was Caucasian, French-speaking and
in common-law relationships or married. In terms of education, 87% had some post-secondary education and 40% had university
degrees. Eighty-six percent were employed. Around a quarter (23%) had annual family income of less than 35 000$, the low-income
cut-off for a family with one child in Canada, whereas the average annual family income was between 65 000$ and 74 999$. Overall,
this community sample was predominantly in common-law relationship, highly educated and financially well resourced, and should
be considered low-risk.
Classification of participants into the two groups (CM vs no trauma) was obtained by consensus agreement between two in-
dependent clinical psychologists with expertise in trauma evaluations using all available information, including the Childhood
Trauma Questionnaire (Bernstein et al., 2003), a self-developed screening instrument on interpersonal traumas (Lemieux & Berthelot,
2019), and a personalized interview assessing participants’ relationship with both parents. Overall, 28.3% (n = 85) of the sample
reported having been exposed to at least one type of CM. Women (29.5%) and men (23.9%) had been similarly exposed to CM, χ2(1,
N = 301) = 0.81, p = .37. Overall, 27 participants (9%) reported physical abuse, 25 (8.3%) sexual abuse, 63 (20.9%) emotional
abuse, 46 (15.3%) physical neglect and 20 (6.6%) emotional neglect. Of those participants with CM histories, more than half (53%)
had experienced multiple traumas (defined as the exposure to more than one type of maltreatment), whereas the remainder (47%)
had experienced a single type of maltreatment.

2.2. Measures

2.2.1. Sociodemographics
To control for potentially confounding variables, we developed a socio-demographic risk index based on extensively researched
risk factors for poor psychological outcomes during pregnancy. Using such indices, that capture the complex phenomena of cumu-
lative risk, is suggested to be a better strategy than considering each variable independently (Moore, Vandivere, & Redd, 2006). Our
index, from 0 to 4, was calculated by summing binary scores (absent vs present) on four recognized risk factors: not having a high-
school diploma, being under the low-income cut-off for a family with one child, being a parent younger than 20 years old and having
been involved with the criminal justice system.

2.2.2. Childhood trauma questionnaire

Childhood trauma was assessed using the French version (Lacharité, Deshaulniers, & St-Laurent, 2002) of the Childhood Trauma
Questionnaire (CTQ-28; (Bernstein et al., 2003). The 28-item self-reported measure examines five types of childhood trauma: phy-
sical, psychological and sexual abuse as well as physical and psychological neglect. Responses to each item are rated on a 5-point
Likert scale, ranging from 0 (never true) to 5 (always true). Higher scores reflect more severe exposure to childhood abuse and neglect.
Cut-offs were validated for each subscale (physical abuse ≥ 8, psychological abuse ≥ 10, sexual abuse ≥ 8, physical neglect ≥ 8 and
psychological neglect ≥ 15) (Walker et al., 1999). The CTQ-28 shows a good validity across diverse clinical and general populations
(Bernstein et al., 2003). The Cronbach’s alpha for the CTQ in this study was of 0.82.

2.2.3. Edinburgh postnatal depression scale

Prenatal depressive symptoms were assessed using the French version of the Edinburgh Postnatal Depression Scale (EPDS) (Cox,
Holden, & Sagovsky, 1987), a 10-item self-reported measure using a variable 4-point Likert scale. First designed to assess postnatal
depression, the EPDS has shown good reliability and validity when used to measure prenatal depressive symptoms (Adouard,
Glangeaud-Freudenthal, & Golse, 2005; Cox & Holden, 2003). A meta-analysis reported that convergent validity was good and

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internal consistency was satisfactory (median ∝ = .84) (Tsai et al., 2013). The French version shows similar validity indices (good
internal consistency and convergent reliability with the DSM-IV) (Adouard et al., 2005). The Cronbach’s alpha for the EPDS in this
study was of 0.85.

2.2.4. PTSD checklist for DSM-5

Post-traumatic stress symptoms were assessed using the validated French version (Ashbaugh, Houle-Johnson, Herbert, El-Hage, &
Brunet, 2016) of the PTSD Checklist for DSM-5 (PCL-5) (Wilkins, Lang, & Norman, 2011). This 20-item self-reported questionnaire was
based on the PTSD diagnostic criteria of the DSM-5. Responses were rated on a 5-point Likert scale ranging from 0 (not at all) to 4
(always). Total score was obtained by adding each item. Both the French and the English versions have good reliability (internal
consistency, temporal stability, test-retest) and convergent validity (Ashbaugh et al., 2016; Wilkins et al., 2011). The Cronbach’s
alpha for the PCL-5 in this study was of 0.93.

2.2.5. Maternal confidence questionnaire

Parental confidence was assessed using the French version of the Maternal Confidence Questionnaire (Parker & Zahr, 1985). The
MCQ is a 14-item self-reported questionnaire that can be administered to both men and women. Responses are rated on a 5-point
frequency Likert scale, from 1 (never) to 5 (always). A higher score reflects a higher degree of perceived confidence regarding parental
aptitudes. Examples of items are “I will know when my baby will want me to play with him/her”, “I will be able to tell when my baby
is sick” and “Being a parent will be demanding and unrewarding” (reversed item). A good content validity for both men and women
was reported (Zahr & Cole, 1991) and a literature review revealed good construct validity and internal consistencies in over twenty
studies (mean ∝ = .89) (Badr, 2005). The Cronbach’s alpha for the MCQ in this study was of 0.74.

2.2.6. Maternal/Paternal antenatal attachment scale

To assess prenatal attachment, the maternal and paternal versions of the Antenatal Attachment Scales (MAAS, PAAS) (Condon,
1993) were used. The MAAS and the PAAS are designed to assess psychological investment toward the unborn child and commitment
to the pregnancy. Higher scores reflect greater investment and commitment. The maternal version of the self-reported questionnaire
includes 19 items while the paternal version has 16 items, evaluated on a variable 5-point Likert scale. For the current study, the total
scores were converted to z-scores and were subsequently combined into a single scale of prenatal attachment. The instruments have
two subscales. The Quality subscale measures the strength of the emotional bond towards the fetus and the frequency of thoughts and
behaviors reflecting a positive investment towards the fetus [ex. “Over the past two weeks, my feelings about the baby inside me have
been…” (positive-negative)]. The Preoccupation subscale assesses the time spent in attachment mode [ex. “Over the past two weeks,
when I have spoken about or thought about the baby inside me, I got emotional feelings which were…” (strong-weak)]. Both versions
(maternal and paternal) have good psychometric properties (Condon, 1993). The Cronbach’s alpha for the MAAS in this study was of
0.68.

2.2.7. Reflective functioning questionnaire

The complete 54-item French version of the Reflective Functioning Questionnaire (RFQ) (Fonagy et al., 2016) was used to
evaluate participants’ capacity to think about themselves and others in terms of mental states. Responses are rated on a 7-point Likert
scale from 1 (completely disagree) to 7 (completely agree). A median-scoring method is used to obtain two subscales (Certainty and
Uncertainty) reflecting distinct impairments in understanding the interplay between internal states and behaviors (Fonagy et al.,
2016). First, the Certainty scale indicates hypermentalizing, meaning that the participant assumes being excessively knowledgeable
about his mental states and those of others, going far beyond the available evidence (Badoud et al., 2015). The 26 items used for the
Certainty scale are rescored so that the original responses ranging from 1 to 7 are scored 3, 2, 1, 0, 0, 0, 0. In this way, low agreement
on these items is indicative of hypermentalization, while moderate agreement reflects adequate levels of certainty about mental
states. Conversely, the Uncertainty scale refers to hypomentalizing, meaning that the participant shows a complete lack of knowledge
about mental states and mainly relies on concrete thinking (Badoud et al., 2015). The 26 items measuring Uncertainty are also
rescored with the median-scoring method: original responses (from 1 to 7) are scored 0, 0, 0, 0, 1, 2, 3, meaning that low to moderate
agreement with the items reflect adequate understanding that mental states are opaque, while high levels of agreement reveal a
complete lack of knowledge about one’s own and others’ mental states. The original English version of the instrument (Fonagy et al.,
2016) and a shorter version of the questionnaire in French showed good psychometric properties (Badoud et al., 2015; Fonagy et al.,
2016). The RFQ demonstrated good internal consistencies in this study (α = .84 for the Uncertainty scale and α = .84 for the
Certainty scale).

2.3. Statistical analysis

Pearson’s correlations between study’s variables were first conducted. Group differences were next evaluated using ANCOVAs
controlling for sociodemographic risk. Structural equation modeling (SEM) was finally performed with AMOS 24.0, using maximum
likelihood parameter estimates. SEM was used to examine the adequacy of a theoretical model in which CM (CTQ total score) was the
exogenous variable, whereas psychological symptoms, parental confidence and prenatal attachment were the endogenous variables,
and RF and the sociodemographic risk index were added as mediators. The latent variable “psychological symptoms” was estimated
through depressive and PTSD symptoms. The latent variable “reflective function” was estimated through the two subscales of the RFQ
(i.e. Certainty about mental states and Uncertainty about mental states). Adequacy of model fit was assessed through several indices:

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Table 1
Correlations, means and standard deviations of study variables.
Measures Mean SD 1 2 3 4 5 6

CTQ total score 35.16 9.27

RF Certainty 26.32 12.34 −.15*
RF Uncertainty 9.19 8.40 .15* −.39**
Sociodemographic risk 0.39 0.67 .24** −.10 .24**
PTSD 8.48 4.82 .18** −.25** .23** .08
Dissociation 9.97 11.53 .40** −.25** .26** .12 .61**
Depression 16.42 8.75 .18** −.19** .26** .06 .32** .43**

a nonstatistically significant chi-square value, a CFI value of 0.90 or higher, and a RMSEA value below 0.06 with a RMSEA 90%
confidence interval ranging from 0 to .08 (Hu & Bentler, 1999). A ratio of chi-square to degrees of freedom (χ2/df) was also used
because chi-square tests are sensitive to sample size (Kline, 2011). Satisfactory fit is observed when values are less than 5 and
considered ideal when the value is around 3 (Ullman, 2001). The SEM was next performed with women only to rule out the pos-
sibility that the results were inflated by the inclusion of partners in the analyses.

3. Results

Correlations between variables are presented in Table 1. ANCOVAs controlling for sociodemographic risk showed that partici-
pants exposed to CM had significantly higher scores on the Uncertainty scale of the RFQ (M = 10.59, SE = 0.88) than participants not
exposed to trauma (M = 7.96, SE = 0.54), F(1, 290) = 6.29, p = .01, η2p = .02, and only marginally significant (p = .10) lower scores
on the Certainty scale of the RFQ (M = 24.79, SE = 1.38) than participants not exposed to trauma (M = 27.47, SE = 0.85), F(1,
290) = 2.68, p = .10, partial η2p = .009.
Given expected and significant associations between the variables proposed in the theoretical model, we next ran a structural
analysis model (Fig. 1). The sociodemographic risk index was not included in the final model since it was not significantly associated
with the endogenous variables. Results revealed a good data fit: χ2(11, N = 301) = 23.62, p = .01, Ratio χ2/df = 2.15, CFI = 0.97,
NFI = .94, RMSEA = .06 with 90% CI [.026, .096]. A significant, but small size association was observed between CM and RF. CM
predicted psychological symptoms and RF indirectly mediated this association. Only RF, but not psychopathology, significantly
predicted parental confidence and antenatal attachment. Furthermore, indices of model fit were also satisfactory when analyses were
restricted to women only, χ2(11, N = 234) = 28.69, p = .003, Ratio χ2/df = 2.61, CFI = 0.95, NFI = .92, RMSEA = .08 with 90%
CI [.046, .121].

4. Discussion

The present study evaluated the associations between CM, RF, prenatal attachment and parental mental health and sense of
competence in a community sample of expecting parents. Specifically, we explored whether CM is associated with impairments in RF
(hypomentalization and hypermentalization), which in turn predict poor mental health, low levels of parental sense of competence
and weak prenatal attachment in this sample. Overall, we found confirmation for the theoretical model demonstrating that RF
indirectly mediated the association between CM and psychological symptoms and was predictive of parental attitudes during
pregnancy.

Fig. 1. Structural equation model of childhood maltreatment, impairments in reflective functioning, psychological symptoms and parental attitudes
during the prenatal period.
Note. * p < .05 *** p < .001. RF = Reflective functions.

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The finding that CM is associated with impaired RF is noteworthy considering the inconsistent amount of evidence linking
childhood adversity and mentalization in adult samples from the community. Interestingly, CM was particularly associated with
hypomentalization and was not significantly predictive of hypermentalization when controlling for sociodemographic risk factors.
This suggests that adults with histories of CM are particularly likely to display a general tendency to avoid thinking in mental states
terms and to assume that they can’t reasonably know why others and they act in certain ways. Adults exposed to CM may have
developed this tendency to avoid being in touch with the mean intentions of their maltreating attachment figures and to avoid facing
alone intense affects and frightening thoughts (Allen, 2013; Fonagy et al., 2002). Yet, the size of the association between CM and RF
impairments was relatively small in the present study. This contrasts with what was observed in samples of sexually abused children
(Ensink et al., 2017; Tessier et al., 2016), adolescents (Quek et al., 2017) and adults with borderline personality disorders (Chiesa &
Fonagy, 2014); in all these studies there was a larger association between CM and RF. This suggests that mentalization capacities are
not drastically impaired in adults from the community exposed to CM. One possibility is that mentalization capacities are particularly
challenged in the aftermath of CM but continue to develop by different routes throughout development. Indeed, it is possible that
most participants exposed to childhood maltreatment in our relatively low risk sample ultimately benefited from other opportunities
(such as a positive relationship with a non-abusive parent, another member of the family, a therapist, a teacher or a romantic partner)
that contributed to lifting the barriers of epistemic mistrust engendered by past traumas and regaining a sense of curiosity about their
inner world and that of others. This would imply that mentalization is relatively robust in the face of CM when such adverse
environments are counterbalanced by positive and caring relationships. This hypothesis is supported by a recent study showing the
protective role of adaptive experiences during childhood for parental RF in parents exposed to CM (Hakansson et al., 2018). Another
possibility is that CM particularly alters mentalization in affectively hot (i.e., highly emotionally laden) contexts, and that the self-
report format of the instrument used to assess RF in the current study does not efficiently capture the nuanced impacts of trauma on
mentalization. Indeed, the RFQ may be considered a somewhat low-stress task and possibly predominantly captures the cognitive
component of mentalization and does not tap into its affective component as much as other assessment measures of RF such as
attachment interviews or interactional measures. Finally, it is also possible that exposure to CM does not adversely impact menta-
lization capacity as a whole, but only mentalization related to trauma. This hypothesis is supported by previous studies showing that
pregnant women with histories of childhood abuse do not exhibit a general inhibition of mentalization but show significant unique
impairments in mentalizing specifically around the experience of trauma (Berthelot et al., 2015; Ensink et al., 2014). Further studies
should evaluate the respective role of RF and trauma-specific RF in predicting psychopathology and parenting in adults with histories
of CM.
This study is among the first to demonstrate, in a community sample of adults, that the relationship between CM and psycho-
logical symptoms is indirectly mediated by mentalization abilities. Our study extends previous findings with children and adolescents
which showed that RF mediated the association between childhood sexual abuse and dissociation (Ensink et al., 2017) and CM and
depression (Belvederi Murri et al., 2017; Ensink et al., 2016, 2017) and adds to the ambiguous literature regarding the association
between mentalization and non-severe psychiatric disorders (Katznelson, 2014). Our findings suggest that psychopathology may not
be the direct consequence of trauma, but a result of not having developed resilience-promoting abilities (Fonagy & Bateman, 2016).
Belvederi Murri et al. (2017) observed that, in adolescents, the depressogenic effect of CM is largely explained by affective
dysregulation. In the present study, both hypermentalization and hypomentalization were correlated with depressive symptoms and
may differentially contribute to poor emotion regulation. In the first case, individuals who over-interpret their mental states and
those of others are at higher risk of misinterpreting others’ intentions and may lack the cognitive flexibility to reconsider their
perception. When negative affect is experienced, which is common in survivors of CM, individuals who hypermentalize may project
their own negative affects on others and be unaware of their misattribution. This results in depressogenic interactions, as the person
subjectively experiences that negative affects generate negative responses. On the other hand, Ensink et al. (2017) argue that people
who refuse to engage in mentalization are deprived of the cognitive ability to understand the source of their negative emotions and to
reframe the negative affects and perceptions regarding themselves, which in turn increases emotional dysregulation and the risk of
developing depressive symptoms. Our theoretical model assumes that poor mentalization, either hyper- or hypomentalization, is the
source of depressive symptoms in the aftermath of trauma. However, this relation is probably bidirectional, in that depression may
undermine mentalization as well through its adverse effects on cognition and relationships (Allen et al., 2008; Fischer-Kern et al.,
2013).
As expected, PTSD was similarly associated with hypermentalization and hypomentalization. Individuals who hypermentalize are
highly sensitive to social cues during interactions and are likely to interpret ambiguous situations as threats (Sharp & Vanwoerden,
2015), which may reactivate previous experiences of interpersonal traumas and trigger affective dysregulation at the core of PTSD.
On the other hand, in the absence of mentalization, the person functions at the level of psychic equivalence, where mental states are
perceived as corresponding to external reality (Fonagy, 1995). Thus, when one experiences trauma-related thoughts, sensations and
emotions, these mental states are not connected to their source and are perceived as the result of a real and active threat.
Results add to the literature on trauma, RF and parenting. While a previous study reported that psychopathology is predictive of
parental attitudes in expecting parents (Berthelot et al., In press), the present findings suggests that this association is mediated by
impairments in RF, as mentalization was the only predictor of prenatal attachment and parental sense of competence in our model.
These findings are noteworthy since most studies on the role of RF for sensitive parenting focused on the postnatal period where
problems can already be observed in the offspring of parents who experienced CM and have limited RF (Berthelot et al., 2015; Huth-
Bocks et al., 2014). Early detection of subgroups of parents with histories of CM who are most at risk to experience significant
difficulties during the postnatal period will lead to delivering timely interventions that will focus on the mechanisms of risk. Hence,
perception of parental confidence and prenatal attachment are predictive of postnatal involvement (Siddiqui & Hagglof, 2000) and

7
N. Berthelot, et al. Child Abuse & Neglect 95 (2019) 104065

our model suggests that supporting RF in parents exposed to CM may contribute to “create space for the baby” (Narayan, Bucio,
Rivera, & Lieberman, 2016), resulting in a more positive psychological investment in the pregnancy, parenthood and the baby to
come.
Findings of this study should be interpreted in the light of some limitations. First, our research is based on theoretical and
historical grounds, and was correlational in nature. Thus, the suggested direction between the variables cannot be assured. However,
previous writings suggest that deficits in RF are likely to constitute a vulnerability trait, rather than a consequence of psychological
disorders (Katznelson, 2014). Another limit was that mental health was assessed using self-report instruments rather than clinical
interviews, which might have produced a response bias. Finally, the assessment of trauma was retrospective which could have led to a
recall bias. However, critical analyses of retrospective reports suggest that such presumed biases do not systematically affect the
association between childhood maltreatment and later outcomes (Brewin, Andrews, & Gotlib, 1993; Reuben et al., 2016).
Intervening postpartum with parent-infant dyads may already be a step too late (Berthelot, Lemieux, & Lacharité, 2018) since
intergenerational repercussions of CM can be observed shortly after birth (Buss et al., 2017). The results of the study support the
implementation of interventions that would help expecting parents gain awareness of their internal working models and psycho-
logical functioning before the birth of their child. Recently, two prenatal programs aiming to strengthen reflective functions were
specifically developed for trauma survivors: the Perinatal Child-Parent Psychotherapy for Pregnant Women with Childhood Trauma
(P-CPP) (Narayan et al., 2016) and Supporting the Transition to and Engagement in Parenthood (STEP) (Berthelot et al., 2018). The
P-CPP is an adaptation of the Perinatal Child-Parent Psychotherapy and aims to strengthen pregnant women’s emotional attunement,
reflective processing and sense of bonding with the baby. This psychotherapy uses trauma-informed interpretations and other
treatment modalities to allow processing of trauma-related memories before the birth of the child. STEP is a prenatal group ac-
companiment program for expecting parents exposed to childhood interpersonal traumas. This program uses different treatment
modalities to strengthen mentalization about the self and parenthood, and mentalization of trauma (Berthelot et al., 2018). STEP is
divided into three sections, addressing (1) the experience of pregnancy, (2) the influence of past benevolent and traumatic experi-
ences on current emotional experiences and functioning, (3) and the relationship with the baby. Further studies should evaluate
whether these prenatal interventions improve parenting through their effects on parental mentalization.

Acknowledgement

This work was supported by the Fonds de recherche du Québec Société et Culture [grant number 2018-NP-204630]

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