Episode 249: Intergenerational Trauma Explained:The Role of Reflective Function and Mentalization in Healing Attachment
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Article Authors: Khaled Itani, MD, Sreeya Cherlo, MD, Faddel Chouman, MD, Anjali Kapadia, BA, Allison Riege, PsyD, LPC, Liam Browning, MD, & David Puder, MD
Understanding Intergenerational Trauma: Key Concepts in Reflective Function, Mentalization, and Attachment
This audio dialogue and corresponding article explores the mechanisms by which reflective function (RF) and mentalization mediate the relationship between intergenerational transmission of trauma and disorganized attachment. Integrating psychoanalytic, developmental, and biological perspectives, it examines how disruptions in mentalization, particularly trauma-specific reflective functioning, contribute to attachment insecurity. First, we aim to define and elaborate key terms discussed in the audio dialogue, followed by a deeper discussion of the longitudinal study that followed a sample of mothers with childhood abuse and neglect histories and their infants over 20 months. Subsequently, we discussed theoretical foundations, empirical studies, and therapeutic modalities that demonstrate the potential to restore reflective capacity and promote secure attachment across generations.
Reflective functioning and mentalization
Mentalization is generally understood as the capacity to think of oneself and others as psychological beings, and the ability to interpret one’s own and others’ behavior in terms of underlying thoughts, feelings, intentions, desires, and beliefs (Choi-Kain & Gunderson, 2008). The modern psychological usage of the term is credited to Peter Fonagy, a Hungarian psychoanalyst who expanded the concept through his research on borderline personality disorder in the 1990s (Fonagy & Target, 1997). In Episode 206 of the Psychiatry & Psychotherapy Podcast, Fonagy discussed the development and clinical applications of mentalization with Dr. David Puder, highlighting its central role in understanding attachment and affect regulation. The concept of mentalization has been applied to numerous therapeutic approaches that include attachment dysfunction, trauma, eating disorders, and school violence, to name a few (Choi-Kain & Gunderson, 2008). Of note, the process of mentalization is distinct but related to the process of empathy: “in psychotherapeutic competence, mentalization helps in understanding the patient or client, while empathy allows the therapist to establish an authentic, congruent, and deep emotional connection” (Arabadzhiev & Paunova, 2024, p. 4). One can argue that the ability to mentalize is integral to emotional attunement and empathy. A core feature of mentalization is the fundamental sense of others as separate beings who have a unique psychological experience different from one’s own, and that their experience and behaviors are informed by myriad underlying biological and environmental influences.
Reflective functioning (RF) is a term used to gauge and discuss a person’s level of engagement in, and capacities for mentalization. RF was operationalized for research purposes and measured on a scale from –1 to 9 with lower scores (–1 to 2) indicating prementalizing processes, or the inability to consider one’s own or another’s thoughts and feelings. Higher scores reflect increasing abilities to understand the nature of mental states and the relationship between internal experience and behavior. Generally, the more detailed and nuanced a narrative reflection, the higher the score, indicating an integration of the complexity of human behavior (Slade et al., 2005a). A more comprehensive explanation of the operationalization and scoring protocol of RF can be referenced in the RF manual developed by Fonagy et al., (1998). For comparison purposes, the following quotes highlight meaningful components of RF that indicate an improvement in mentalization (see also episodes 205, 206, 213, 234, 239, 244, and 247).
Here is a quote from Abraham Lincoln, which would be scored a 5:
“For not giving you a general summary of news, you must pardon me; it is not in my power to do so. I am now the most miserable man living. If what I feel were equally distributed to the whole human family, there would not be one cheerful face on the earth. Whether I shall ever be better I can not tell; I awfully forebode I shall not. To remain as I am is impossible; I must die or be better, it appears to me. The matter you speak of on my account, you may attend to as you say, unless you shall hear of my condition forbidding it. I say this, because I fear I shall be unable.”
—Lincoln, in a letter to John Stuart, 1835
Here is a made up quote from Dr. Puder on increasing the score to a 6-9:
“Ann's death has overwhelmed me, bringing to consciousness old feelings that I now recognize as anger—anger I dared not admit as a boy when my father punished my scholarly ambitions, instead turning that rage inward and reshaping it into persistent guilt and self-blame. Likewise now, confronted by my helplessness to save Ann, the anger returns—but again finds no outlet, no target but myself, transforming once more into a deep and paralyzing melancholy from which I see no escape.”
In the second quote, Lincoln would evidence linking his past experiences in childhood to the emotional overwhelm he feels at present. Beyond that, he is becoming aware of a disavowed emotion - in this case anger - that deeply influenced his persistent depression and feelings of guilt. In doing so, Lincoln is able to better understand his own emotional processes and vulnerabilities that contribute to his articulated sense of misery, passivity, and hopelessness.
Of particular relevance to the present discussion, limitations in mentalization related to trauma do not necessarily reflect a global failure in mentalization (Berthelot et al., 2015). An individual may generally demonstrate strong reflective function yet become disorganized or regressed when confronted with unintegrated or unprocessed traumatic experiences. For this reason, the authors distinguish between general reflective function (RF) and trauma-specific reflective function (RF-T). To examine the intergenerational implications of RF-T, their study explored reflective function within the context of trauma as assessed through the Adult Attachment Interview.
Disorganized Attachment
Attachment patterns can broadly be grouped into organized attachment and disorganized attachment. Organized attachment represents coherent working models that allow infants to select consistent, adaptive strategies based on the nature of their relationship with their caregiver. Organized attachment is categorized into three subtypes: Secure attachment from responsive parenting, avoidant attachment from rejecting parenting, and anxious attachment (also referred to as ambivalent or resistant) stemming from inconsistent responses in parenting (Paetzold et al., 2015). Disorganized attachment was added at a later time in effort to describe a distinct style characterized by a breakdown in attachment behaviors evidenced by inconsistent and often opposing methods for coping with distress and in seeking out/responding to an attachment figure. The disorganized attachment label gets added onto the secure, avoidant or anxious subtypes. A disorganized attachment response has been described as the simultaneous activation of two competing responses to an attachment figure; a paradoxical pattern of infants approaching the source of their fear in effort to alleviate their fear, while freezing and/or rejecting the caregiver at the same time. There also appears to be an association of disorganized attachment with dissociative symptoms (Main & Solomon, 1990; Paetzold et al., 2015). Of note, avoidant attachment traits are not necessarily mutually exclusive of other attachment styles, they can overlap (Sekowski & Gambin, 2025). Additionally, Beebe et al. (2010) found that 4‑month mother–infant interaction patterns predicted later disorganized attachment. A comprehensive discussion of disorganized attachment is beyond the scope of this article (see also episode 87 and 88); however, Lyons-Ruth and Spielman (2004) noted that “disorganized attachment strategies in infancy consistently have been shown to be risk factors for later psychopathology in preschool, in middle childhood, and in adolescence”.
Understanding Disorganized Attachment and Intergenerational Trauma
Attachment theory posits that early relational experiences shape internal working models of self and other. Organized attachment strategies (secure, avoidant, or ambivalent) reflect adaptive responses to caregiver behavior, whereas disorganized attachment arises from fear without solution. Infants simultaneously approach and avoid caregivers who are both sources of comfort and fear (see also episodes 69, 192, 194, and 222).
In her formative works on attachment, clinical psychologist Beatrice Beebe has applied the concept of mirroring in the dyad, defined as the bidirectional and dynamic relationship between caretaker and infant (Beebe et al., 1992). Mirroring refers to the action of the caregiver reflecting the infant’s emotional needs, usually by means of facial expression, vocalization, and body movements, ideally to soothe and engage the infant. Failures in affective mirroring are believed to contribute to a disruption in cohesive identity development, healthy object relations, and emotion regulation (Slade, 2005).
Fraiberg (1975) conceptualized this phenomenon through the metaphor of “ghosts in the nursery,” ghosts representing unresolved trauma or loss that can repeatedly disrupt, or “haunt,” caregiver-infant relationships across generations via unconscious, unresolved impairment in attachment patterns. Berthelot et al. (2015) expanded upon earlier work with the concept of the “alien self,” describing the formation of an “unmentalized” alien core in the infant that results from a failure of the mother’s mirroring response. The alien self can also be understood as an internalization of maternal absence, or the formation of an incoherent sense of self due to unmetabolized distress, a process that has been connected to later experiences of derealization and dissociation.
Together, these perspectives illustrate how disruptions in early mirroring and unresolved caregiver trauma can fracture the child’s developing sense of self, setting the stage for disorganized attachment. Understanding these dynamics provides the groundwork for exploring how reflective function and mentalization may serve as mechanisms for repair across generations (for more resources about mentalization, see also episodes 29, 206, 227, and 244).
Analysis of Intergenerational Transmission of Attachment in Abused and Neglected Mothers: The Role of Trauma-Specific Reflective Functioning (Berthelot et al., 2015)
This study investigates how attachment patterns and reflective functioning, specifically related to trauma, contribute to the transmission of attachment styles from mothers who experienced childhood abuse and neglect to their infants.
Study Methods and Sample:
Study Type: longitudinal study followed a sample of mothers with childhood abuse and neglect histories and their infants over 20 months.
Measures:
Adult Attachment Interview (AAI): During pregnancy, maternal attachment states and reflective functioning were assessed using the Adult Attachment Interview with scoring regarding reflective function separated for abuse related questions and non-abuse related questions.
Strange Situation Procedure (SSP): This is a 30-min laboratory separation procedure aimed at assessing the quality of the child’s attachment to his caregiver. The procedure yields one of primary attachment classifications: secure (B), avoidant (A), resistant (C), and additionally considers disorganized (D) (which can be given to secure, avoidant or resistant types (Ainsworth et al., 1979)).
Study Demographics: Pregnant mothers who screened positive for child abuse & neglect were assessed with the Adult Attachment Interview, and then subsequently the infants were assessed at 17 months with the Strange Situation Procedure. 57 dyads finished. 78% Caucasian. 52% were below the low income cut off; of note the mothers prior rate of abuse were:
58% physical abuse
39% sexual abuse
79% neglect
86% antipathy
73% had marked maltreatment of at least one type
Central findings of Berthelot et al. (2015):
In this study 83% of infants of abused or neglected mothers were insecurely attached.
In this study 44% of these infants exhibited disorganized attachment.
Prior studies have found around 15% in low risk populations and 40% in high risk populations
The magnitude of maltreatment the mothers endured increased the risk of having an unresolved attachment status but did not predict neither their trauma specific reflective function nor infant attachment disorganization.
“Mothers with low RF-T [less than a score of 3] were 3.43 times more likely to have infants with attachment disorganization than were mothers with histories of trauma, but high RF-T.”
Two thirds of mothers with low RF (less than a score of 3) on the trauma narratives had children with disorganized attachment
Trauma-specific RF predicted attachment disorganization.
Trauma specific RF accounted for twice the variance (41%) in infants with attachment disorganization in contrast to unresolved trauma (which accounted for 22% of the variance in infant attachment disorganization).
Note. Reprinted from “Intergenerational transmission of attachment in abused and neglected mothers: The role of trauma-specific reflective functioning”, by Berthelot et al., 2015, Infant Mental Health Journal, 36(2), 200–212.
Per conversation with the author, Nicolas Berthelot, the cut off for high vs. low RF as represented in figure one was 3.
The study emphasizes the importance of a mother's capacity to mentalize about her traumatic experiences to support healthier attachment in her child.
Implications:
When a mother has difficulty speaking with intact mentalizing capacity specifically regarding childhood traumas, this places infants at higher risk for disorganized attachment, which has been linked to later emotional and behavioral difficulties including dissociation. Psychotherapeutic approaches that strengthen RF could buffer against disorganization in children of trauma-exposed mothers.
Limitations of the study:
Lack of a Control Group: While the study provides valuable insight into attachment patterns in mothers with maltreatment histories, the absence of a control group limits the ability to draw direct comparisons or establish the distinct impact of trauma on reflective functioning and attachment outcomes.
Cross-sectional or Longitudinal Limitations: While longitudinal, the study assesses infant attachment at 20 months only, leaving attachment outcomes at later developmental stages unexplored
Confounding Variables: Other psychosocial factors influencing attachment (e.g., ongoing maternal mental health, social support, partner relationships) may not be fully controlled, potentially confounding results.
Self-report and Interview Data Bias: Self-report data and interview-based assessments can be affected by social desirability bias or recall bias, especially concerning trauma.
Treatment Models and Future Directions
Therapeutic Approaches: Reflective Function in Practice
Transference-Focused Psychotherapy (TFP)
Transference-Focused Psychotherapy is a manualized psychodynamic treatment developed for patients with borderline personality disorder based on the theoretical framework of Kernberg. It focuses on integrating fragmented internalized representations of early attachment relationships that underlie affective instability and identity disturbance. The therapeutic process uses the transference relationship to help patients recognize and integrate split perceptions of self and others within a consistent, emotionally engaged framework (Doering et al., 2010) (see also episodes 41, 77, 170, 231, 234, 239).
In a randomized controlled trial, Levy et al. (2006) investigated whether Transference-Focused Psychotherapy (TFP), Dialectical Behavior Therapy (DBT), or supportive psychotherapy could enhance reflective functioning among 90 adults with borderline personality disorder. After a year, only the participants in the TFP treatment group had a significant increase in their mean Reflective Function scores from 2.86 to 4.11 (p < 0.05). These findings suggested that TFP compared to other standard treatments for BPD could be particularly effective in increasing reflective functioning and shifts to greater attachment security.
Later, in another randomized controlled trial, Doering and colleagues (2010) assigned women aged 18 to 45 with borderline personality disorder to either TFP or treatment by experienced community psychotherapists. Significant changes in personality organization analyzed by Structured Interview for Personality Organization (STIPO) were associated with a large effect size in the TFP group (d = 1.2) compared to a small-to-moderate effect in the control group (d = 0.4).
Fischer-Kern et al. (2015) later analyzed data from this randomized control trial to examine changes in mentalization using Reflective Function scores from Adult Attachment Interviews (AAI) conducted at baseline and after one year of treatment. The TFP group resulted in an increase of Reflective Function Scale scores from a baseline of 2.75 to 3.31 and paired t-tests revealed no significant changes in the experienced community psychotherapy group. Both groups had a mean baseline of 2.7 and the between-group effect size ranged from d = 0.34 to d = 0.45. This improvement reflects a transition from limited or naïve understanding of mental states to a more coherent and integrated awareness of internal experiences. Additionally a significant negative correlation was noted between reflective functioning scores and personality organization impairments (r= -0.31) indicating that as patients' capacity for mentalization improved, their level of personality disorganization decreased.
Mentalization-Based Therapy (MBT)
Mentalization-Based Therapy is designed to enhance an individual’s capacity to reflect on both their own and others’ mental states in the context of attachment relationships. Fonagy and Bateman (2006) described MBT as a structured psychodynamic treatment that supports patients in maintaining curiosity about thoughts, emotions, and motivations when attachment distress is activated. A key feature of the therapeutic stance is collaborative exploration, where the clinician facilitates reflective thinking during emotionally charged interactions rather than providing interpretation or insight.
Early studies identified mentalization failure as a defensive adaptation to trauma. Patients with histories of physical or sexual abuse may exhibit a functional decoupling between cognitive and affective processing, reducing their ability to link feelings with thoughts (Fonagy & Bateman, 2006). MBT aims to restore this integration by focusing attention on the immediate, observable state of mind. The therapist avoids abstract theorizing and limits interpretations to experiences just beyond the patient’s conscious awareness.
The principal features of MBT can be summarized as follows:
Focus on current mental state. Sessions emphasize the patient’s present thoughts, feelings, wishes, and desires to build coherent internal representations.
Anchoring in subjective experience. The therapist redirects discussion when mental states are not connected to felt reality.
Small-step interpretation. Rather than exploring the deep unconscious, the therapist offers modest clarifications that slightly extend the patient’s reflective range.
Collaborative play space. Treatment fosters a safe relational field where emotions and thoughts can be considered, tested, and revised.
Enactment awareness. When relational missteps occur, they are examined in real time, emphasizing the emotional sequence leading to the rupture.
In a randomized controlled trial by Bateman and Fonagy (2009) empirical evidence supports the effectiveness of MBT as it showed reductions in self-harm frequency and psychiatric hospitalization compared with treatment-as-usual groups (p < .05). This trial did not report on measures of mentalization or reflective function. A service evaluation by McGowan et al. in 2021 conducted a short term (11 weeks) MBT intervention, pre and post self-reported Mentalization Questionnaires were collected and revealed capacity to mentalize was higher (mean difference score 5.1, p<0.001). The mentalization questionnaire is a 15 item test with a maximum score of 60 rated from 0 to 4 with higher scores indicating higher mentalizing capacity, however it would be wonderful to have the full AAI with RF tested in the future.
Minding the Baby (MTB)
Minding the Baby is an interdisciplinary, attachment-based home-visiting program that translates Mentalization-Based Therapy (MBT) principles into preventive work with new mothers (Slade et al., 2018). The program targets first-time mothers aged fourteen to twenty-five at social or medical risk. Beginning in the second trimester of pregnancy, families receive weekly home visits by a nurse and a social worker through the child’s first year, followed by bi-weekly visits until age two. The intervention evaluates
(a) parental reflective functioning,
(b) dyadic affective communication,
(c) infant attachment quality, and
(d) maternal depression and post-traumatic stress.
Reflective functioning in the phase 2 MTB program was assessed using the Parent Development Interview revised (PDI-R) rather than the Adult Attachment Interview (AAI). The revised PDI is a 45 minute, 20 question qualitative interview that aims to assess the parent’s capacity to reflect upon childhood experience, self-development, and parental representations of the child. It was developed by adopting questions from the Adult Attachment Interview and the Working Model of the Child Interview that enhance assessment of reflective functioning (Slade et al., 2016). The Parent Development Interview (PDI) transcripts were coded using the Reflective Functioning Scale (RF) scoring from -1 to 9 and categorized into groups (PDI/RF); prementalizing (1-2.5), low RF (3-3.5), moderate RF (4-4.5), and high RF (5+). At 24 months, there was a significant difference (p </= .04) between mothers in the intervention and the control group raised to a higher category of PDI/RF scores (odds ratio/OR: 2.15). However, exact pre- and post-intervention RF scores were not reported in the publication (Slade et al., 2018). To determine child attachment, at 12-14 months the Strange Situation Experiment was conducted and categorized into secure, insecure (avoidant/resistant), and disorganized. Children in the intervention group (p<.01) had higher odds of being classified as organized (secure or insecure-organized versus disorganized) (OR=2.69) and secure (OR= 2.59) compared to the control group.
Notably, Phase 1 of the MBT study revealed positive outcomes even when mothers began the program with low prenatal reflective functioning with mean scores increasing from 2.0 in pregnancy to 3.6 at 24 months and no significant change in control group scores. RF mean scores isolated in mothers with less than 12th grade education resulted in significant increase from 3.0 in pregnancy to 3.8 at 24 months in the intervention group and no improvement in mean score of 2.9 in the control group. Secure attachment and maternal RF gains became most evident after sustained participation, suggesting that consistent relational engagement across infancy and toddlerhood is critical for enduring change. (Sadler et al. 2013).
A prospective longitudinal follow-up study examining the intermediate effects of Phase 1 MTB found that one to three years post-intervention, mothers in the intervention group also reported significantly fewer externalizing behavior problems in their children, with a large effect size (F = 9.14, p = .004, η² = 0.166). RF mean scores increased from 3.31 to 3.63 in the intervention group and the control group decreased from 3.95 to 3.79, though were not found to have significant changes over time (Ordway et al. 2014).
Sleed et al. (2013) extended principles from this program to an eight-week program coined New Beginnings for incarcerated mothers and infants. Using the Reflective Functioning Scale derived from the Parent Development Interview, the intervention group showed a statistically significant gain in mean RF scores from 3.18 to 3.54 (t = –2.43, p = .02), while the control group showed a significant decline from 3.59 to 3.15 (t = 2.52, p = .02). There was no significant change in depressive symptoms over time across both the intervention and control group as measured by the Center for Epidemiologic Studies Depression Scale (F = 0.089, ns) demonstrating specificity of this model for mentalization rather than mood.
Closing Reflections
Based on recent and emerging studies, the assessment of RF, specifically RF in the context of trauma, appears vital to ascertaining the degree to which mothers/caregivers are at risk of perpetuating intergenerational trauma though impaired attachment patterns. While formal guidelines for increasing reflective functioning are still emerging, early research indicates that psychotherapeutic interventions that focus on the processing and integrating of trauma can have the potential to improve mothers' attunement and responsiveness with their children, increasing the likelihood of organized attachment patterns. In prior episodes we have highlighted how high RF therapists have faster rates of improvement in their clients, and we imagine it will be the case that high RF therapists lead to higher RF clients (episode 213). Increased awareness of the impact of trauma on RF, and the relationship between RF, parent-child interactions, and the development of attachment styles, should encourage special attention to the importance of early, targeted intervention for mothers/caregivers with a history of trauma. Broadly, the article conveys significant hope, as research suggests that it is the processing of maternal trauma that is predictive of childhood attachment, rather than the presence of trauma itself. Thus, a history of trauma does not necessarily result in a deterministic cycle of abuse or negative outcomes in early childhood attachment. With proper support and intervention, maternal trauma responses can and should be viewed as treatable. For clinical purposes, exploring levels of RF in a mother or expectant mother with a trauma history would be a worthwhile treatment focus in the effort to develop interventions aimed to improve infant-parent relationship patterns and prevent early attachment injuries.
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