In-Session Reflective Functioning in Psychotherapies for Borderline Personality Disorder: The Emotion Regulatory Role of Reflective Functioning

Objective: The capacity for understanding mental states (reflective functioning; RF) is considered essential for self-growth, social learning, and emotion regulation. Impaired RF is thought to play a central role in borderline personality disorder (BPD). We examined whether asking patients to consider mental states in-session has a down-regulatory effect on emotional arousal in treatments for BPD. Method: Early-, middle and late-phase videotaped sessions from a randomized-controlled trial of transference-focused psychotherapy (TFP; n = 30), dialectical behavior therapy (DBT; n = 29), and supportive psychodynamic therapy (SPT; n = 29) were segmented to therapist and patient talk-turns. Therapist talk-turns were rated as asking patients to consider mental state (bids for RF) or not. Patient talk-turns were rated for RF and acoustically encoded for arousal. Results: Bids were twice as common in TFP compared to DBT and SPT. Across treatments, therapist bids for RF predicted better RF, which, in turn, predicted lower emotional arousal. Conclusions: Asking patients to consider mental states has a down-regulatory effect on patients’ arousal in psychotherapies for BPD.