Journal of Consulting and Clinical Psychology © 2015 American Psychological Association

2016, Vol. 84, No. 1, 67–78 0022-006X/16/$12.00 http://dx.doi.org/10.1037/ccp0000055

Reflective Functioning as Predictor of Working Alliance and Outcome in

the Treatment of Depression

Annika Ekeblad Fredrik Falkenström

Linköping University and Sundsvall Hospital, Västernorrland Linköping University and Uppsala University
County Council, Sweden

Rolf Holmqvist
Linköping University
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This document is copyrighted by the American Psychological Association or one of its allied publishers.

Aims: 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.
Method: 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. Conclu-
sions: 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.

What is the public health significance of this article?

This study shows that the capacity for mentalization, that is, the capacity for understanding humans
as being motivated by a more or less unobservable mental state (e.g., intentions, wishes, feelings,
thoughts), is important for getting optimal results from interpersonal psychotherapy and cognitive–
behavioral therapy in the treatment of depression. For depressed patients with severely restricted
mentalization, some adaption of treatment or some other treatment may be preferred.

Keywords: psychotherapy process, mentalization, reflective functioning, working alliance, major

depression

In recent years the concept of mentalization (Fonagy, Gergely, behavior in terms of underlying mental states, that is, thoughts,
Jurist, & Target, 2002) has attracted interest from both clinicians feelings, wishes, needs, and so forth, and can be seen as consisting
and researchers in the field of clinical psychology and psychother- of three dimensions: implicit versus explicit mentalization; men-
apy. Mentalization is defined as the capacity to understand human talization about self versus mentalization about other people; men-

This article was published Online First November 23, 2015.
Annika Ekeblad, Department of Behavioural Research and Learning,
Linköping University, and Psychiatric Clinic, Sundsvall Hospital, Västernorrland
County Council, Sweden; Fredrik Falkenström, Department of Behavioural Re-
search and Learning, Linköping University, and Center for Clinical Research
Sörmland, Uppsala University; Rolf Holmqvist, Department of Behavioural Re-
search and Learning, Linköping University.
The authors would like to thank all participating patients and thera-
pists: Without your work this trial would not have been possible. We
also want to thank the Psychiatric Clinic, Sundsvall Hospital, Väster-
norrland County Council, for making this research possible, together
with FoU Västernorrland, the Rehsam Fund, 2010/013, the L. J.
Boëthius Research Fund, Emil Andersson Research Fund, the Swedish
Research Council for Health, Working Life and Welfare (Grant 2013-
0203) and Vårstavi Foundation.
Correspondence concerning this article should be addressed to Annika
Ekeblad, Kristinagatan 8, S-87160 Härnösand Sweden. E-mail: annika
.ekeblad@lvn.se

67
 68 EKEBLAD, FALKENSTRÖM, AND HOLMQVIST
talization about thoughts versus mentalization about feelings
(Bateman & Fonagy, 2004). According to the theory developed by
Fonagy and his coworkers (Bateman & Fonagy, 2004; Fonagy et
al., 2002; Fonagy & Target, 2000; Target & Fonagy, 1996),
mentalization is developed in attachment relationships with care-
givers in infancy and onward. Attachment figures’ mirroring in-
fants’ mental states in a congruent (i.e., correct) and marked (i.e.,
showing that what is reflected is the infant’s mental state and not
the adult’s own experience) way is thought to promote develop-
ment of representations of mental states that can be used for
reflection.
Mentalization has been operationalized for research purposes as
reflective functioning (RF; Fonagy, Target, Steele, & Steele,
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1998). Conceptually, RF is defined as a continuum from an un-
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willingness to think in mental state terms at all or to avoid such
thinking actively or passively, through stages in which mental state
language is used but with no clear indication of reflectiveness, and
a bit higher up on the scale to basic demonstrations of mentaliza-
tion such as a capacity to distinguish internal from external reality,
or the limitations of direct knowledge of mental states. On the
highest end of the scale, RF ratings show more-developed in-
stances of “playing with reality” (e.g., Fonagy & Target, 1996, p.
1), in which more-complex interactional sequences involving men-
tal states and behavior affecting each other are considered. Usually
RF ratings are done on transcribed Adult Attachment Interviews
(AAI; George, Kaplan, & Main, 1985). When rated from the AAI,
the RF score is interpreted as the person’s capacity to mentalize
in the context of attachment relationships actualized in the inter-
view. The RF scale has also been used to rate mentalization about
discrete symptoms and problems on the Panic-Specific Reflective
Functioning Interview (Rudden, Milrod, Target, Ackerman, &
Graf, 2006). In this interview, the RF scores are interpreted as the
capacity to understand psychiatric symptoms in terms of underly-
ing mental states.
Impaired RF has been hypothesized to be related to various
psychopathologies and to the development of the psychotherapy
process. For instance, deficient mentalization has been shown in
patients with borderline personality disorder (Fonagy et al., 2002;
Fonagy & Target, 2000), and partial deficits in mentalization have
also been related to other psychiatric conditions such as anorexia
nervosa (Skårderud, 2007a, 2007b, 2007c), panic disorder and
depression (Lemma, Target, & Fonagy, 2011; Luyten, Fonagy,
Lemma, & Target, 2012), obsessive– compulsive disorder (Kull-
gard, Persson, Möller, Falkenström, & Holmqvist, 2013), and
posttraumatic stress disorder (PTSD; Markowitz & Meehan,
2009). There is some research suggesting that in anxiety disorders
the general level of RF is not lowered but that mentalization
specific to the anxiety disorder symptoms is low (Kullgard et al.,
2013; Rudden et al., 2006).
Mentalization and Depression
The basic theoretical assumption of a mentalization-based ap-
proach to depression (Luyten et al., 2012) is that depressive
symptoms reflect responses to threats to attachment relations,
either because of (impending) separation, rejection, loss; (impend-
ing) failure experiences; or a combination of these. It is assumed
that threats to attachment relations result in feelings of abandon-
ment and/or shame, which lead to depressed mood and reduced
capacity for mentalization (Fonagy et al., 2002). Reduced mental-
ization may in turn make it harder to resolve, or even worsen, the
issues at hand, with the result that depressed mood may increase
further.
Some studies have shown lower RF on the AAI in depressed
patients than in nonclinical samples (Fischer-Kern et al., 2013,
2008). However, there are also studies showing close to normal RF
in depressed patient groups (Taubner, Kessler, Buchheim,
Kächele, & Staun, 2011). The patients in these studies differ in the
level of functioning and comorbidity, which may explain the
differences. The studies by Fischer-Kern et al. (2013, 2008) in-
clude severely comorbid patients (e.g., substance abusing and
psychotic inpatients), whereas the study by Taubner et al. (2011)
was based on patients who were stable enough to attend psycho-
analytic psychotherapy several times weekly.
The causal direction of a possible relationship between impaired
mentalization and depression is not established. It may be that
depression impairs the capacity for mentalization or that an im-
paired capacity to mentalize is a risk factor for developing depres-
sion. A third alternative is a bidirectional influence, in that depres-
sion lowers mentalization and lowered mentalization creates
interpersonal problems that exacerbates depression (Luyten et al.,
2012). Still another explanation would be that there is a third
variable, such as a general cognitive impairment due to depression
severity, that causes both worsening of the depression and im-
paired mentalization (Montag et al., 2010).
Mentalization and Psychotherapy Process/Outcome
Interestingly, the concepts of mentalization and working alliance
may be seen as having a common theoretical root. An article by
Sterba (1934) described the need for patients in psychotherapy to
develop an internal “split” between an observing and an experiencing
part. The idea of an “observing ego” is related to mentalization in the
sense that mentalizing requires the capacity to disengage from imme-
diate experience and reflect on it. In order to engage in the therapeutic
work the patient must also in a way separate between a cooperating
part of the mind (the alliance) and an experiencing that faces the
therapeutic challenges. Several contemporary authors have noted that
mentalization to some extent may be a prerequisite for effective use of
psychotherapy (Lemma et al., 2011; Taubner et al., 2011). The work
of psychotherapy may demand a capacity to reflect on mental states
and relationships, which implies that patients who are not used to, or
even actively resist, thinking in mental state terms may be at a
disadvantage when seeking psychotherapeutic help. In addition, be-
cause lower RF generally implies less-secure internal working models
of attachment (Fonagy, Steele, Steele, Moran, & Higgitt, 1991),
patients with lower RF may resist more-intimate or emotionally
intense aspects of the therapeutic relationship as well. It is also likely
that different kinds of psychotherapeutic interventions require more or
less mentalization from the patient.
There is little research on mentalization as a predictor of psy-
chotherapy outcome and/or process, and the results of the existing
studies are conflicting. A recent review (Katznelson, 2014) con-
cluded that “the evidence is inconclusive at best with regards to
how levels of RF are predictive of psychotherapeutic outcome” (p.
115). A study by Fonagy et al. (1996), using an early version of the
RF scale, investigated mentalization in inpatients at a London
 PATIENT REFLECTIVE FUNCTIONING AS PREDICTOR
hospital. Results showed that the only variable that predicted
outcome was attachment classification.
A small pilot study (n ⫽ 24) by Müller, Kaufhold, Overbeck,
and Grabhorn (2006) showed a significant and relatively strong
relationship between initial RF and psychotherapy outcome
(r ⫽ ⫺.46) for a mixed-diagnostic psychiatric sample (eating
disorders and depressive disorders). Patients with higher RF had
better outcome. This study used the Operationalized Psychody-
namic Diagnostic Interview (OPD Task Force, 2008) supple-
mented by five demand questions taken from the AAI to rate RF
in addition to the probe “Why do you think your father/mother/
partner behaved that way in this particular situation?” (Müller et
al., 2006, p. 488) after every relationship episode described. Be-
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cause the context for rating RF differs from those based on the
This document is copyrighted by the American Psychological Association or one of its allied publishers.
AAI, it may be that the RF ratings used in the study by Müller et
al. (2006) are not comparable to those for the RF as it is usually
scored. Another small study by Taubner et al. (2011) used RF
ratings on the full AAI to predict outcome for chronically de-
pressed patients in long-term psychoanalytic treatment. In this
study there was no statistically significant relationship between RF
and outcome. More studies comparing RF ratings on different
interviews are needed to find out in what ways RF is stable across
different types of interviews.
Empirical findings about associations between RF and the psycho-
therapy process are even sparser. Taubner et al. (2011) found a
moderate association between pretreatment RF and the early patient-
rated therapeutic alliance (r ⫽ .48, p ⫽ .07). There was also a trend
for high RF to predict improvement in alliance during treatment (d ⫽
.95, p ⫽ .08). There is thus clearly a need for further research on RF
as a predictor and/or moderator of process and outcome in psycho-
therapy. In the present study we tested the predictive power of RF
rated on the AAI on the working alliance and on outcome. In addition,
we tested the associations between a new measure, Depression-
Specific Reflective Functioning (DSRF; Falkenström, June 2010)
interview and psychotherapy process and outcome.
We hypothesized that patients with low RF/DSRF scores would
have more difficulties establishing a working alliance with their
therapists, because of their general difficulty in fulfilling a general
requirement of therapy, that is, reflecting on thoughts, feelings, and so
forth in their relationships. This could be expected to result in diffi-
culties complying with the therapeutic tasks of, for instance, cognitive
restructuring (which requires reflection on thoughts as separate from
external reality) in cognitive– behavioral therapy (CBT), or working
with affects or communication analysis used in interpersonal psycho-
therapy (IPT). In addition, insecure internal working models of at-
tachment associated with low RF might interfere more generally with
the formation of a productive therapeutic relationship. This would be
revealed by lower scores on working alliance measures in both
therapist and patient ratings. We also predicted that patients with
lower RF scores would show less improvement of symptoms during
treatment. Finally, we explored potential differences between treat-
ment types in how RF affects the working alliance and outcome.
Specifically, we anticipated that due to the intense focus on interper-
sonal relationships in IPT, the alliance and outcome in IPT would be
more adversely affected by lower RF than CBT. Because RF is likely
to be affected by general cognitive impairments in patients with
MDD, we wanted to also control for this possibility using tests of
cognitive functioning.
69
Method
Participants
The participant patients were all diagnosed with major depres-
sive disorder (MDD) by experienced psychiatrists and clinical
psychologists using the Structured Clinical Interview for DSM–IV
(SCID; First, Spitzer, Gibbon, & Williams, 2002). They had been
referred to the psychiatric clinic for treatment for depression. Most
of them came from primary care, but some came from the psychi-
atric clinic’s inpatient care and some from other units at the
psychiatric clinic. All patients had previously received treatment
for depression, most commonly medication in primary care, with
none or only partial response, and they were referred to the
psychiatric clinic for further treatment. The inclusion criteria were
age 18 to 65 and MDD diagnosis. Exclusion criteria were psycho-
sis, ongoing substance addiction, serious neuropsychiatric disor-
der, or active self-harm behavior. Ongoing medication was not an
exclusion criterion, but the recommendation was to avoid changes
in medication during therapy. To be included in the study the
patient had to accept random allocation to the therapy methods and
video filming of all sessions. A total of 96 patients were included
out of 99 who were asked to participate. Patients who met the
inclusion criteria were fully informed about the study and gave
their written consent. The study was approved by the Regional
Ethical Review Board in Linköping (2010/348 –31). The random-
ization procedure was done by a psychologist at the clinic not
otherwise involved in the project.
Therapists
All participating therapists worked on a regular basis at the
psychiatric clinic in Sundsvall. There were nine therapists provid-
ing IPT, with 4.9 as the mean number of patients treated. There
were 25 therapists providing CBT, treating on average 1.9 patients.
Training and Supervision
All therapists had basic training in psychotherapy and specialist
training in the treatment method they provided. During the trial the
therapists in both the IPT and the CBT arm had regular supervision
(once to twice a month) with trained supervisors in the respective
methods and were given the opportunity to attend more days of
training in their respective therapy forms.
Treatments
IPT was delivered according to the standard manual (Weissman,
Markowitz, & Klerman, 2000). In this trial, 14 sessions were used.
CBT was implemented according to the two principal manuals that
exist for CBT for depression (Beck, Rush, Shaw, & Emery, 1979;
Martell, Dimidjian, & Herman-Dunn, 2010). The CBT therapists
were proficient in both manuals and used them to different degrees
according to their clinical judgment. Some therapists also included
mindfulness-based interventions in their CBT treatment (Segal,
Williams, & Teasdale, 2013), again, according to clinical judg-
ment. This is how CBT is usually implemented in clinical practice
in psychiatric care in Sweden.
 70 EKEBLAD, FALKENSTRÖM, AND HOLMQVIST
Treatment adherence was assessed by rating Sessions 3 and 7
using the Collaborative Study Psychotherapy Rating Scale (Evans,
Piasecki, Kriss, & Hollon, 1984) from videotaped therapy ses-
sions. The IPT ratings were higher in IPT therapies than in CBT
therapies (2.20 vs. 1.33), F(1, 69) ⫽ 45.17, p ⬍ .001, and the CBT
ratings were higher in CBT therapies than in IPT therapies (2.33
vs. 1. 42), F(1, 69) ⫽ 52.95, p ⬍ .001. IPT therapists were more
adherent to IPT than to CBT (2.20 vs. 1.42), F(1, 33) ⫽ 9.06, p ⬍
.001, and CBT therapists were more adherent to CBT than to IPT
(2.33 vs. 1.33), F(1, 35) ⫽ 7.53, p ⬍ .001. Thus, IPT and CBT
could be distinguished as separate therapies.
Measures
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Beck Depression Inventory—II (BDI–II; Beck & Steer,
1996). The BDI–II is a widely used instrument to self-assess
depressive symptoms. The scale consists of 21 items, each item
rated from 0 to 3. The BDI–II has showed high reliability; capacity
to discriminate between depressed and nondepressed participants;
and improved concurrent, content, and structural validity (Wang &
Gorenstein, 2013). It was completed before each session.
Montgomery Åsberg Depression Rating Scale (MADRS;
Montgomery & Asberg, 1979). The MADRS is an observer-
rated depression scale where depression symptoms are assessed
using a clinical interview. The scale consists of 10 items where the
symptom severity is rated on a scale ranging from 0 to 6, resulting
in a total score of maximum 60, where higher scores indicate
more-severe depression. MADRS is especially designed to be
sensitive to change in symptom levels (Montgomery & Asberg,
1979). The scale has shown satisfactory internal consistency and
good psychometric properties (Holländare, Andersson, & Eng-
ström, 2010; Svanborg & Åsberg, 1994). The interview was made
before and after the treatment.
Working Alliance Inventory. The Working Alliance Inventory—
Short Form (WAI–S; Tracey & Kokotovic, 1989) for therapist-
rated, and revised short form (WAI-SR; Hatcher & Gillaspy, 2006)
for patient-rated working alliance were used. Both forms consist of
a 7-point Likert scale with four items designed to measure each of
the three aspects of the alliance (agreement on goals, tasks, and
emotional bonds), making a total of 12 items. The Working Alli-
ance Inventory is one of the more widely used measures of the
therapeutic alliance, and several studies have shown good reliabil-
ity and validity (Horvath & Greenberg, 1989, 1994; Samstag et al.,
2008). Swedish translations were used in the present study (Falk-
enström, Hatcher, & Holmqvist, 2015). The WAI was completed
after each session by the patient and the therapist independently
from each other. The largest factor analysis of the factor structure
of the patient-rated WAI showed that it was best represented by a
bifactor model with one general factor and two specific (“group”)
factors corresponding to the Task/Goal and Bond subscales, re-
spectively (Falkenström et al., 2015). However, because the spe-
cific factors contained little reliable variance, the recommendation
is to use the sum score of all items. Although based on a much
smaller sample, therapist-rated version produced a similar finding
(Tracey & Kokotovic, 1989).
Trail Making Test (TMT; Reitan, 1985). The TMT is a
neuropsychological test included in many test batteries. It provides
information on visual search, scanning, speed of processing, men-
tal flexibility, and executive functions. TMT–A assesses cognitive
processing speed, and TMT–B executive functions. The test is
easily completed, and participants are assessed on the basis of the
amount of time taken to finish it. The TMT is a commonly used
test and has good psychometric properties (Lim et al., 2013;
Tombaugh, Kozak, & Rees, 1999). In the present study the TMT
was used to control for the possibility that RF/DSRF are lowered
by general cognitive impairments due to depression.
Verbal Fluency in FAS form. FAS (based on the letters F, A,
and S used in the test) is an easily completed and sensitive
cognitive test assessing phonemic verbal fluency, and the used
result is the number of words beginning with each letter. The test
is used in many test batteries and has good psychometric properties
(Lim et al., 2013; Ruff, Light, Parker, & Levin, 1996; Tombaugh
et al., 1999). In the present study the FAS was used to control for
the possibility that RF/DSRF were affected by general verbal
fluency.
Adult Attachment Interview (AAI; George, Kaplan, &
Main, 1985). In this semistructured interview, respondents are
asked to describe their childhood attachment experiences and to
evaluate possible impacts of these experiences on their own per-
sonality and behavior. The interview is transcribed verbatim, and
the transcription is used to rate RF. In the present study a slightly
shortened version of the interview was used (Questions 1–11).
Because this version includes most of the so-called demand ques-
tions (Taubner et al., 2013), it is possible to use it for rating RF.
Reflective Functioning (Version 5; Fonagy et al., 1998).
The Reflective Functioning scale is usually used to rate mental-
ization on responses to the AAI. High RF is characterized by AAI
interview passages showing explicit mentalization, especially
when interview questions are posed to which a response without
any reflection on mental states would seem odd (so-called demand
questions; e.g., “Why do you think your parents behaved the way
they did during your childhood?”). The four overarching catego-
ries of responses that are scored as reflective functioning are
1. Understanding of the nature of mental states,
2. Explicit efforts to tease out mental states underlying
behavior,
3. Recognizing developmental aspects of mental states, and
4. Mental states in relation to the interviewer.
Scores are given to individual passages throughout the inter-
view, but in the end these are weighed together to create one final
RF score between ⫺1 and 9, where ⫺1 is negative or antireflective
RF, 5 is considered ordinary RF, and 9 is exceptional RF. The
Reflective Functioning scale has shown the expected one-factor
structure, good reliability, and stability over time (Taubner et al.,
2013).
Depression-Specific Reflective Functioning (Falkenström,
2010). Rudden et al. (2006) developed the Panic-Specific Re-
flective Functioning interview in order to test the hypothesis that in
specific Axis I disorders, mentalization in general may not be
impaired but there may still be specific mentalization deficits
around the understanding of a certain symptom area. In this trial
we included a Swedish version of this interview, adapted slightly
by Falkenström (2010) to be used with depression, therefore called
 PATIENT REFLECTIVE FUNCTIONING AS PREDICTOR
Depression-Specific Reflective Functioning (Depression-Specific
RF). The English version is in the Appendix. The interview was
scored using the original Reflective Functioning manual (Fonagy
et al., 1998). The Depression-Specific RF measure has not previ-
ously been subjected to reliability or validity tests.
Assessments were made at baseline by an external rater, after
Session 5 by the treating therapist or by the same external rater,
and at completion of therapy by the same external rater as at
baseline. Follow-up is planned after 12 months. Ratings of BDI–II
were made by the patient before every therapy session, and the
WAI–SR and WAI–S were scored after each session. The AAI and
Depression-Specific RF interviews were transcribed verbatim and
rated independently by two authors of this article. The more
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experienced rater (Fredrik Falkenström) was trained at the Anna
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Freud Centre and has shown reliability with the authors of the RF
scale.
Procedure
Patients were referred to the psychiatric clinic for treatment of
depression. The recruitment started in the fall of 2010 and ended
in November 2013. The patients who fulfilled the inclusion criteria
were asked about participation and were given a written informa-
tion sheet about the study with contact information. If patients
gave written informed consent to participate they were randomized
to either CBT or IPT, and therapy started. All therapy sessions
were videotaped in order to make treatment adherence assessment
possible.
Statistical Analyses
Data was analyzed using multilevel growth curve modeling
(Singer & Willet, 2003). With regard to depression severity, re-
peated measurements of the BDI–II were modeled using a random
intercepts and slopes model. Because differences in depression
level at treatment termination was of particular interest, the time
variable was centered on Session 14 (the last session according to
the research protocol). With time centered on the last session, the
random intercept represents end-of-treatment status with respect to
depression severity— estimated using available information from
all sessions. Depression end state is more reliably estimated this
way than by using observed BDI–II scores at the last session only.
The main effect of RF then represents the regression of end-state
depression on pretreatment RF. In addition to the main effect of
RF, the cross-level interactions with linear and quadratic time,
representing the effect of RF on change rate and change pattern
during treatment, were also tested.
When WAI scores were analyzed, time was instead centered on
the Session 1, because working alliance in the initial phase of
therapy is of particular importance theoretically (Horvath & Lu-
borsky, 1993). The main effect of pretreatment RF then represents
model-implied working alliance at the beginning of treatment,
estimated using all available information. As with the BDI–II,
cross-level interactions between pretreatment RF and time repre-
sent the effect of mentalization on the rate of change in working
alliance during treatment.
In all analyses, we were most interested in the main effects of
predictors. Still, if significant interactions exist with any of the
polynomials of time, these have to be modeled or else results may
71
be biased. On the other hand, including many nonsignificant
interactions would lead to less-reliable estimates and thus to a loss
of statistical power. Because of these considerations, a model
trimming approach was used, in which all predictors were first
entered as full factorial interactions with all polynomials of time.
If the highest order cross-level interaction was nonsignificant (e.g.,
the interaction between the predictor and the cubic term in a cubic
model), this interaction was removed and the model reestimated.
This procedure was repeated until either an interaction was found
statistically significant or all interaction terms for this predictor
were removed. So, if for instance the interaction with the cubic
term was nonsignificant, this was removed. If, upon reestimation,
the interaction with the quadratic term was significant, this was
retained together with the main effect and the lower order inter-
action with the linear term.
RF and DSRF were grand-mean-centered to facilitate interpre-
tation of intercepts. Analyses were made on the intention-to-treat
sample—that is, all patients who were randomized and came to
Session 1—with completer status entered as covariate (dummy-
coded with completer coded as “1” and dropout as “0”). All
multilevel models were analyzed with full maximum likelihood
estimation, using Stata (Version 13.1).
Results
Descriptive Statistics
The pretreatment characteristics of the study population (n ⫽
96) are presented in Table 1. The randomization seemed to be
successful except for the pretreatment MADRS scores, where the
IPT group had significantly higher scores than did the CBT group
(29.2 vs. 25.9, p ⬍ .05). Of the participants, 68.1% were on
antidepressant medication when referred to the trial but still ful-
filled the inclusion criteria for major depressive disorder. The
mean age was 34.2 years, there were 68.8% women in the sample
of participants, and 49.5% had at least one personality disorder
according to the Structured Clinical Interview for DSM–IV (2nd
ed.; SCID–II; First, Gibbon, Spitzer, Williams, & Benjamin,
1997). Pretreatment depression severity was in the moderate to
severe range (BDI–II M ⫽ 36.5, SD ⫽ 9.5; MADRS M ⫽ 27.5,
SD ⫽ 6.5). There was no difference in outcome between patients
getting antidepressants and those who did not (p ⫽ .74).
Interrater reliability for the two raters was tested using intraclass
correlation (ICC; two-way mixed model for the scores of a single
rater). For RF, ICC ⫽ .84, 95% confidence interval (CI) [.76, .89],
and for DSRF ICC ⫽ .83, 95% CI [.74, .89], indicating excellent
reliability. Ratings from the more experienced rater (Fredrik Falk-
enström) were used in the final analyses.1 In this study, 85 tran-
scripts of AAI and 79 DSRF interviews were available. Six pa-
tients were not interviewed, due to the interviewers’ sickness; two
pairs of interviews were impossible to use, due to language prob-
lems; two patients never showed up for the interviews; and for one
patient there were technical problems making the interviews im-
possible to transcribe. Six additional DSRF interviews could not be
used, some due to lost videotapes and some because they were
1
We also tested the same models using the mean of both raters or the
ratings of only the second rater, and results were roughly the same.
 72 EKEBLAD, FALKENSTRÖM, AND HOLMQVIST

Table 1
Pretreatment Characteristics of the Study Population

Variable Total sample (N ⫽ 96) CBT (n ⫽ 48) IPT (n ⫽ 48) Test value p

Mean age in years (SD) 34.2 (10.82) 32.0 (9.89) 36.5 (11.32) 2.08 .04
Women (%) 68.8 68.8 68.8 ns
Pretreatment BDI–II mean (SD) 36.5 (9.5) 36.7 (9.6) 36.2 (9.6) .08 ns
Pretreatment MADRS mean (SD) 27.5 (6.5) 25.9 (6.2) 29.2 (6.5) 6.1 ⬍.05
Personality disorder (%) 49.5 44.7 54.3 .87 (1) ns
Antidepressant medication (%) 68 67 71 .44 (94) ns
On sick benefits at start (%) 37.1 42.0 35.0 .68 (92) ns
RF (SD) 2.62 (1.22) 2.58 (1.05) 2.64 (1.41) .21 ns
DSRF (SD) 2.37 (.98) 2.30 (.91) 2.45 (1.06) .66 ns
Note. CBT ⫽ cognitive– behavioral therapy; IPT ⫽ interpersonal psychotherapy; BDI–II ⫽ Beck Depression
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Inventory—II; MADRS ⫽ Montgomery Åsberg Depression Rating Scale; RF ⫽ reflective functioning; DSRF ⫽
This document is copyrighted by the American Psychological Association or one of its allied publishers.

depression-specific reflective functioning.

written on paper instead of spoken. The mean RF level in this r ⫽ .29, p ⫽ .01) but not to any of the other cognitive tests, and
group of 85 patients was 2.62 (SD ⫽ 1.23, range ⫽ 1– 6). The RF was unrelated to all cognitive tests (see Table 2). Overall, this
mean DSRF (N ⫽ 79) was slightly lower at 2.37 (SD ⫽ 0.98, suggests that RF and DSRF were not confounded with cognitive
range ⫽ 1–5). A paired-samples t test showed that the difference impairment or by depression severity.
in means between RF and DSRF was close to significant, F(79) ⫽ Both RF and DSRF variables were significantly skewed toward
1.77, p ⫽ .08. There was no difference in RF/DSRF prior to lower values. Log-transforming them reduced skewness to non-
treatment between patients assigned to IPT and an those to CBT: significance. However, in practice it turned out that model fit for
for RF, F(82) ⫽ 0.21, p ⫽ .83; for DSRF, F(79) ⫽ 0.66, p ⫽ .51. multilevel models was slightly better when nontransformed vari-
Women had significantly higher RF than did men (mean differ- ables were used, and because interpretation of parameter estimates
ence ⫽ 0.76, SE ⫽ 0.27, p ⫽ .006). are more intuitive when variables are untransformed, the raw— but
Table 2 shows intercorrelations between RF, DSRF, age, pre- centered—RF and DSRF values were used.
treatment depression severity, and cognitive processing speed
(Trail Making Test—A), executive functions (Trail Making Test—
B), and verbal fluency (FAS). RF and DSRF were significantly Patient Pretreatment Reflective Functioning Predicting
intercorrelated (r ⫽ .48, p ⬍ .001). RF was also significantly and Patient-Rated Working Alliance
positively related to patient-rated initial depression severity (pre- Initial tests showed that the intraclass correlation (ICC), show-
treatment BDI–II: r ⫽ .28, p ⫽ .01; Session 1 BDI–II: r ⫽ .27, p ⫽ ing the amount of nesting at different levels, was zero for the
.01) but not to observer-rated initial depression severity (r ⫽ .05, therapist level and .75 for the patient level, indicating that most of
ns). It is important to note that the direction of relationship be- the variance (75%) was at the patient level and the rest was at the
tween self-rated depression severity and RF was positive, meaning repeated-measures level. Observed WAI–SR scores were then
that higher RF was related to more-severe depressive symptoms. plotted over time, separately for each patient, as recommended by
DSRF was significantly related to executive functions (TMT–B: Singer and Willett (2003). Some of the trajectories appeared rel-
atively linear, whereas others seemed more quadratic, suggesting
that a random quadratic model might be a good approximation of
Table 2 the data. Starting with a linear random intercepts and slopes model,
Correlations Between RF, DSRF, Age, Depression Severity, we tested increasingly more-complex models using the likelihood
Cognitive Processing Speed, Executive Functions, and ratio test. A random cubic model with no constraints on the
Verbal Fluency covariances among random effects turned out to be the best fit to
Variable RF DSRF the data. Because initial BDI–II was significantly related to both
the level of WAI–SR and the level of RF, initial BDI–II was used
ⴱ
DSRF .48 as covariate.
Age .04 .01 In the initial model with all cross-level interactions included,
Pretreatment BDI–II .28ⴱ .21
Session 1 BDI–II .27ⴱ .11 there were no statistically significant interactions between RF and
Pretreatment MADRS .05 ⫺.04 the growth terms (ps ⫽ .18, .18, .26, for interactions with linear,
TMT–A ⫺.05 ⫺.01 quadratic, and cubic terms, respectively), showing that RF was
TMT–B .18 .29ⴱ unrelated to growth in patient-rated working alliance. In the final,
FAS .16 .22
trimmed model, the main effect of RF was not quite significant
Note. RF ⫽ reflective functioning; DSRF ⫽ depression-specific reflec- (coefficient ⫽ .15, SE ⫽ .09, p ⫽ .10), indicating that RF was
tive functioning; BDI–II ⫽ Beck Depression Inventory—II; MADRS ⫽ unrelated to initial patient-rated working alliance as well.
Montgomery Åsberg Depression Rating Scale; TMT–A ⫽ Trail Making
Test (cognitive processing speed); TMT–B ⫽ Trail Making Test (executive
The main effect of DSRF was statistically significant in the
functions); FAS ⫽ Verbal Fluency test. predicted direction (DSRF main effect ⫽ .33, SE ⫽ .11, p ⫽ .002)
ⴱ
p ⬍ .05. in the final, trimmed model (all the cross-level interactions with
 PATIENT REFLECTIVE FUNCTIONING AS PREDICTOR
growth terms in the initial model were nonsignificant; p ⬎ .05).
This indicates that higher DSRF was related to a higher patient-
rated alliance across treatment. Using the estimated standard de-
viation of the intercept of WAI–SR together with the observed
standard deviation of DSRF, we calculated a standardized regres-
sion coefficient to ␤ ⫽ .27. Adding treatment (IPT vs. CBT) as a
moderator did not improve model fit, likelihood ratio ␹2(2) ⫽ 1.23,
p ⫽ .54, indicating that the effect of DSRF on working alliance
level was constant across treatments. Figure 1 shows the effect of
DSRF on patient-rated working alliance.
Patients Pretreatment Reflective Functioning
Predicting Therapist-Rated Working Alliance
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The ICC for the WAI–S was .34 at the patient level and .36 at
the therapist level, showing that the largest source of variance for
therapist ratings was the therapists (i.e., 36% of variance compared
to 34% for the patient level and 30% for the repeated-measures
level). Thus, including a third level of random effect(s) seemed
critical. As with patient-rated scores, the WAI–S scores of thera-
pists were first plotted separately for each patient. The trajectories
for individual patients seemed more linear than for the patient data.
However, model testing showed that the WAI–S trends over time
was best approximated using a random quadratic model (a cubic
model was tested but did not converge) with only the intercept
varying among therapists. A model with covariances among
patient-level random effects estimated without constraints yielded
the best fit to data. The main effect of RF on therapist-rated
working alliance was not statistically significant (p ⫽ .48). How-
ever, the cross-level interactions between RF and linear and qua-
dratic time were both statistically significant (RF ⫻ Linear Coef-
ficient ⫽ .05, SE ⫽ .02, p ⫽ .002; RF ⫻ Quadratic
Coefficient ⫽ ⫺.003, SE ⫽ .001, p ⫽ .009). There was no
moderating effect of treatment, likelihood ratio ␹2(3) ⫽ 2.89, p ⫽
.41. To show the effect of RF on the course of therapist-rated
alliance, we plotted model-predicted fixed effects over sessions
Figure 1. Depression-specific reflective functioning (DSRF) predicting
higher level of patient-rated working alliance across sessions. The bottom line
(blue) indicates DSRF at 1.4, the middle line (red) DSRF at 2.3, and top line
(green) DSRF at 3.3. WAI–SR ⫽ Working Alliance Inventory—Short Form
Revised. See the online article for the color version of this figure.
73
(see Figure 2). As Figure 2 shows, for patients rated higher on the
RF scale, therapist-rated alliance increased faster until around
midtreatment, with this effect leveling off slightly toward the end
of treatment.
The same effect was shown using the DSRF (DSRF ⫻ Linear
Coefficient ⫽ .06, SE ⫽ .02, p ⫽ .004; RF ⫻ Quadratic Coeffi-
cient ⫽ ⫺.003, SE ⫽ .001, p ⫽ .003). As with RF, the main effect
of DSRF was nonsignificant (p ⫽ .92), and there was no effect of
treatment as moderator, likelihood ratio ␹2(3) ⫽ 4.04, p ⫽ .26. A
graph of the effect of DSRF on therapist-rated working alliance
was very similar to Figure 2, so no separate graph is provided.
Patients Pretreatment Reflective Functioning
Predicting Psychotherapy Outcome
As the main outcome analysis of this trial (Ekeblad, Falken-
ström, Andersson, Vestberg, & Holmqvist, 2015) showed, a qua-
dratic Level 1 model was the best representation of the change in
BDI–II over time. Because previous analyses showed a tendency
for superiority of IPT to CBT, treatment was entered as a covari-
ate. Also, RF was significantly related to pretreatment BDI–II
scores, so pretreatment BDI–II was used as a covariate in all
analyses.2 The interpretation of the main effect of RF then is the
effect on change in BDI–II from pre- to posttreatment, rather than
just the effect on final session BDI–II score. In the initial, full
model, the quadratic change rate was not statistically significant
(RF ⫻ Quadratic Change Rate ⫽ ⫺.00, SE ⫽ .02, p ⫽ .85), so this
term was constrained to zero. However, in the trimmed model the
cross-level interaction with the linear term was statistically signif-
icant. Results showed that in the final, trimmed model, RF signif-
icantly predicted change in depression severity from pre- to post-
treatment (RF main effect ⫽ ⫺3.19, SE ⫽ 1.16, p ⫽ .006) as well
as linear change rate (RF ⫻ Linear Change Rate ⫽ ⫺.30, SE ⫽
.10, p ⫽ .002). The interpretation of this model is that improve-
ment in BDI–II scores from Session 1 to 14 is 3.2 points more for
each higher RF score. Using the estimated standard deviation for
BDI–II at termination (SD ⫽ 11.09) and the observed standard
deviation for RF (SD ⫽ 1.22), the effect of RF on change in
BDI–II amounts to a standardized regression coefficient of .35,
that is, a medium-sized effect of RF on outcome. A moderator
model, in which the main effect of RF and the effect of RF on
linear change rate in BDI–II over sessions were moderated by
treatment, was tested but found not to improve model fit, likeli-
hood ratio ␹2(2) ⫽ 2.45, p ⫽ .29.
The same models were tested using DSRF as predictor. As with
RF, the cross-level interaction with the quadratic term was non-
significant in the full factorial model (DSRF ⫻ Quadratic Change
Rate ⫽ ⫺.01, SE ⫽ .02, p ⫽ .68), so this effect was constrained
to zero. The main effect of DSRF in the trimmed model was
statistically significant (DSRF main effect ⫽ 4.49, SE ⫽ 1.38, p ⫽
.001), as was the cross-level interaction with the linear term
(DSRF ⫻ Linear Change Rate ⫽ ⫺.34, SE ⫽ .12, p ⫽ .005). The
main effect of DSRF is interpreted as each higher DSRF score
being associated with the treatment effect being 4.5 BDI–II scores
larger. This relationship corresponded to a standardized regression
2
We chose not to use the Session 1 BDI-II score as covariate, out of a
concern that this would amount to using the same information twice (i.e.,
Session 1 BDI-II used as both a predictor and an outcome).
 74 EKEBLAD, FALKENSTRÖM, AND HOLMQVIST
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Figure 2. Reflective functioning (RF) predicting change in therapist-
rated working alliance across sessions. The bottom line (blue) indicates RF
at 1.4, the middle line (red) RF at 2.6, and top line (green) RF at 3.8.
WAI–S ⫽ Working Alliance Inventory—Short Form. See the online article
for the color version of this figure.
coefficient of ␤ ⫽ .41. The moderator model for treatment on the
effect of DSRF on outcome was tested but found not to improve
model fit, likelihood ratio ␹2(2) ⫽ 2.35, p ⫽ .31. The results for
RF and DSRF as predictors of outcome are illustrated in Figure 3,
which shows outcome at the mean and at plus/minus one standard
deviation of RF (left panel) and DSRF (right panel).
Finally, because RF and DSRF were significantly intercorre-
lated, it was deemed of interest to test whether they predicted
outcome independently or whether it was the common variance
between the two that was most important. RF and DSRF were thus
entered together as predictors. Results showed that DSRF still
significantly predicted BDI–II at termination (DSRF main ef-
fect ⫽ ⫺3.11, SE ⫽ 1.55, p ⫽ .04) but not change over time
(DSRF ⫻ Linear Change Rate ⫽ ⫺.18, SE ⫽ 0.13, p ⫽ .16). RF
was close to significance for BDI–II at termination (RF main
effect ⫽ ⫺2.12, SE ⫽ 1.25, p ⫽ .09) and significant for linear
change rate (RF ⫻ Linear Change Rate ⫽ ⫺.25, SE ⫽ .11, p ⫽
.02). Because these results are a bit confusing, they were plotted to
explore the partly conflicting results (i.e., why last session was
significant but not change rate for DSRF, and vice versa for RF).
Plots showed that although the model was controlled for the
pretreatment BDI–II measure, there was still a correlation between
RF and Session 1 BDI–II. A post hoc test was performed in which
estimated Session 14 BDI–II minus estimated Session 1 BDI–II
was compared between patients one standard deviation above and
below the mean for RF. This test showed a statistically significant
difference of 7.70 BDI–II points (SE ⫽ 3.35, p ⫽ .02) between the
groups. However, for DSRF this test showed a nonsignificant
difference of 4.71 BDI–II points (SE ⫽ 3.39, p ⫽ .16). Thus, it
seems that RF contained some unique variance that still predicted
outcome after controlling for DSRF, whereas the opposite seemed
not to be true.3
Discussion
The aim of this study was to analyze mentalization measured as
RF and DSRF as predictor of alliance and outcome in the treatment
of MDD using IPT and CBT. The main finding was that patients
with higher initial RF and DSRF attained more symptom reduc-
tion, and there were indications that the working alliance was
worse for patients with lower RF.
Our results replicated results from previous studies (Fischer-
Kern et al., 2013; Fischer-Kern et al., 2008; Taubner et al., 2011)
that have found depressed patients to have a reduced capacity for
reflecting on mental states in the context of attachment. There
seems to be an important distinction between patients with depres-
sive disorders and patients with anxiety disorders with regard to
the general level of RF. In their study of psychotherapy for panic
disorder, Rudden et al. (2006) found that panic disorder patients on
average had normal general RF, and Kullgard et al. (2013) found
almost normal general RF scores in patients with obsessive com-
pulsive disorder (OCD). Although it is possible that this difference
would be due to the generally lowered cognitive functioning often
seen in depression but usually not in anxiety disorders, we found
little evidence for a relationship between cognitive impairment and
RF in our study.
The average RF score for the depressed patients in this study
was on about the same level as what other studies have shown for
borderline personality disorder (BPD) patients (Fonagy et al.,
1996; Levy et al., 2006) and considerably lower than what has
been shown for nonclinical samples (around RF ⫽ 5; e.g., Falk-
enström et al., 2014; Fonagy et al., 1998). It should be noted that
there was considerable Axis II comorbidity in the present sample,
which to some extent may explain the low RF. There may also be
different causal explanations for low RF in Axis II disorders such
as BPD and Axis I conditions such as MDD. Because MDD is a
less-chronic condition than are personality disorders, it is conceiv-
able that low RF is a result of MDD rather than the cause. If this
is the case, then RF should return to normal levels when patients
recover from depression. If not, it is likely that RF is more of a
personality factor making patients vulnerable to depression. Such
a vulnerability theory would be strengthened if patients who, in
addition to recovering from depression, also increase their RF
during treatment were less likely to relapse during follow-up.
RF and DSRF were not associated with observer-rated depression
severity. The significant relationship between RF and pretreatment
patient-rated BDI–II was in the opposite direction from what was
expected; higher RF was related to higher initial depression severity
(see Table 2). If this is not a spurious correlation, it may suggest that
patients with greater reflective capacity may be more aware of and
attentive to depressive symptoms. The finding also indicates that it is
highly unlikely that low RF was a simple side effect of higher
depression severity. Observer-rated depression was not associated
with RF level. A possible explanation for the discrepancy between
self- and observer-rated depression could be that low-RF patients are
less aware of their depression than are high-RF patients but that the
depression of low-RF patients is nevertheless communicated—per-
haps nonverbally through posture, tone of voice, and so forth—so that
trained clinicians pick it up. Upon further speculation, it may be that
depression in low-RF patients is perceived not as a mental state but as
3
This can also be seen in the left-hand panel of Figure 3, where higher
RF is associated with slightly higher estimates of Session 1 BDI–II scores,
meaning that the effect of RF on change during treatment was slightly
underestimated using this mode.
 PATIENT REFLECTIVE FUNCTIONING AS PREDICTOR 75
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Figure 3. Reflective functioning (RF; left panel) and depression-specific reflective functioning (DSRF; right
panel) predicting change in depression severity from pre- to posttreatment. Left panel: The mainly bottom line
(green) indicates RF at 1.4, the middle line (red) RF at 2.6, and top line (blue) RF at 3.8. Right panel: The bottom
line (green) indicates DSRF at 1.4, the middle line (red) DSRF at 2.3, and top line (blue) RF at 3.3. BDI–II ⫽
Beck Depression Inventory—II. See the online article for the color version of this figure.

objective reality, or what is called psychic equivalence in the men-
talization literature (to some extent clinical depression may always be
experienced in psychic equivalence mode, but perhaps more strongly
so for some patients). If true, this might indicate an alternative
interpretation of the finding that low-RF patients have worse outcome
than do high-RF patients, namely that change in depression in low-RF
patients does not show on self-report measures, due to their incapacity
to accurately perceive their own mental states. Although this might
undermine our findings in the sense that it could mean that low-RF
patients do not have worse outcome than do high-RF patients after all,
it is still reasonable to think that incapacity to self-rate depression
would be an obstacle to treatment success. It is even conceivable that
this would be especially so in brief symptom-focused treatments such
as CBT and IPT, because these treatments start focusing on depressive
symptoms from the first session with the assumption that patients
know that they are depressed.
The associations between RF and DSRF ratings on the one hand
and alliance on the other were complex. Patient-rated alliance in-
creased substantially during treatment irrespective of pretreatment
DSRF or RF ratings. But the level of patient-rated alliance throughout
treatment depended on the level of pretreatment DSRF, with higher
DSRF scores being related to higher alliance. No significant relation
was found between RF ratings and the level of patient-rated alliance.
One interpretation of this may be that patients with less capacity to
mentalize about their depressive symptoms may feel frustrated about
perceived demands from the therapist to understand the psychological
causes for their depression. This lower alliance would be specifically
related to symptom-specific mentalization and not depend on the
general reflective capacity.
Therapist-rated alliance was predicted by pretreatment RF and
DSRF in the sense that in therapies with higher RF and DSRF ratings
the therapist-rated alliance increased faster until around midtreatment.
No associations with alliance levels at the beginning of therapy were
found for either RF or DSRF ratings. Thus, it seems as if therapists
who meet patients with higher mentalization capacity gradually, over
time, feel stimulated and engaged and perceive the therapeutic col-
laboration as better than when meeting patients with lower capacity
for mentalization. This is a response both to the general mentalization
ability and to reflections about symptoms.
Both RF and DSRF ratings predicted symptom reduction sig-
nificantly. Higher pretreatment RF was associated with faster
symptom reduction. No difference was found between the therapy
methods in this respect. It is apparently important to assess the
patients’ ability to reflect about their experiences in attachment
relationships and about their symptoms in order to be able to
predict their response to these two therapy forms.
Previous findings have shown RF to be relatively independent
of other measures of similar constructs such as mindfulness and
affect consciousness (Falkenström et al., 2014) and personality
(Fonagy et al., 1998). Because of this relative independence of RF
compared to other variables, it is the more striking that the ratings
so strongly predicted outcome across the two most empirically
supported treatments of depression. Our findings indicate that
these treatments work better with patients who have a better
 76 EKEBLAD, FALKENSTRÖM, AND HOLMQVIST
capacity for mentalization. Bateman and Fonagy (2004) have long
argued that patients with borderline personality disorder need a
treatment focused specifically on restoring the patients’ capacity
for mentalization. It may be that depressed patients with a reduced
capacity for mentalization also need some form of mentalization-
based treatment to recover. Another possibility is that patients with
the most reduced RF/DSRF are better helped by longer term
treatment, or by other forms of treatment/combined treatments, as
pharmacologic treatment and supportive care.
It could be argued that because DSRF is a much shorter inter-
view and is much easier to rate than is RF on AAI, it could replace
the AAI interview for RF scoring. However, because there were
some differences in their ability to predict outcome, it might be
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wise to do both interviews until research can firmly establish
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whether they measure the same or different constructs.
Assets and Limitations
Strengths of this study are the use of structured interviews to assess
patient diagnosis, repeated measures to assess change in depressive
symptoms and alliance, randomization to assign patients to treatment,
and the use of manualized treatments with integrity checks. In addi-
tion, an important asset is the relatively large number of patients who
were assessed for RF on the AAI and DSRF. This data set made it
possible to analyze the impact of pretreatment mentalization capacity
on symptom development and alliance with a repeated-measures
design, which allows for analyses of the successive development of
symptoms and alliance. The possibility to check relationships between
RF and several possible confounders, including tests of cognitive
performance, is another strength.
Limitations include the slightly heterogeneous CBT intervention.
We do not know whether the current results would hold for more
“pure” forms of cognitive therapy or behavioral activation, or whether
it holds for only the combination of CBT techniques used in this
study. On the other hand, this combined treatment is most likely more
representative of how CBT is done in clinical practice than the pure
versions tested in most trials, so in this respect it increases general-
izability and external validity. In addition, the DSRF measure has not
been thoroughly validated previously, and the use of a slightly short-
ened AAI should also be seen as a limitation. In particular, the
shortened AAI did not include questions about losses, which may be
particularly relevant in a depressed sample (Taubner et al., 2011).
Finally, it would be important in future research to test whether RF
predicts change in observer-rated depression.
Conclusions
Results indicate a poor average capacity for mentalizing in
patients diagnosed with MDD. The patients with lower mentaliz-
ing capacity had significantly less-successful outcome than did
those with better mentalizing capacity. The finding may indicate a
possibility to differentiate between patients who are more or less
apt for these psychotherapies, or who may need longer treatments.
It should however be noted that patients with low RF also im-
proved to some extent. Future research should focus on under-
standing in more detail why these patients are not improving as
well as those with better mentalizing capacity, and how these
patients can be helped better.
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Appendix
Depression-Specific Reflective Functioning Interview
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Adapted from Rudden, Milrod, Target, Ackerman, and Graf If yes: What may this be?
This document is copyrighted by the American Psychological Association or one of its allied publishers.

(2006). If yes: Do you have any ideas about how these things might
connect to your depression?
1. Why do you think you are depressed?

2. Have your ideas about why you are depressed changed

over time?
Received February 2, 2015
3. Do you ever notice that you get more depressed by Revision received August 18, 2015
certain events, thoughts, or feelings? Accepted August 21, 2015 䡲