Episode 268: Trauma-Specific Reflective Functioning (T-RF): 5 Trauma Mentalization Profiles & Impact on Parenting

Episode editing and preparation help: Anjali Kapadia

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Introduction (00:00:00)

Puder: 

Welcome back. I am joined today by Nicolas Berthelot and Julia Garron- Bissonnette, and we are going to be talking about some of their research. If you remember my prior episode where I discussed reflective function (RF) in mothers, and how they followed the mothers and looked at the children, the study showed that mothers with low reflective function and, specifically, their trauma narratives, had much higher rates of disorganized attachment—almost twice [as much] [see episodes 213, 249 and 260]. This is going to be a longer form discussion with the researchers who published that article and we're going to be going through trauma-based reflective function and some of the different narratives that come up, how they score it, and we're going to be talking about some of their other research, as well. So welcome to the podcast.

Garon-Bissonnette:

Thank you.

Berthelot:

Thank you, David.

Discovering and Defining Trauma-Specific Reflective Functioning (01:12)

Puder:

Let's start with talking to me a little bit about the early research in this, and then take me through the history of how you guys got into this and how it started.

Berthelot:

All right. I think you already introduced it quite well since the study you've been talking about, where we document that trauma-specific reflective functioning (T-RF) was important for the mother-child attachment, was the very first study on that concept of trauma-specific mentalizing. So that's a work I've been doing at Université Laval in Quebec, Canada with professor Karin Ensink, during the course of my PhD dissertation where we were working with quite a large sample of pregnant women who have experienced childhood maltreatment, so childhood abuse or neglect. And we were looking at their adaptation to motherhood and how the relationship with their infant eventually unfolds. And we had access, in the course of that research, to narratives about their experiences with their attachment figures.

Berthelot:

And we were coding attachment and reflective functioning. And one thing that we did notice when doing that work is that, surprisingly, several mothers were reflecting quite well, better than we thought at first, regarding their past experience of attachment relationships. But we did notice that when they were coming to discussing childhood abuse and neglect during that interview, their mentalizing skills kind of fell apart. It was much more difficult for them to organize their thoughts or to reflect on the impact of these experiences on their current functioning. So we kind of observed and decided that we should give separate scoring to these specific parts of the interview on abuse and neglect than the scores we were giving for the other parts of the interview. And that's when we start developing that idea that mentalizing trauma is not the same as mentalizing in general attachment relationships.

Puder:

So you're scoring them and you're recognizing that in some parts of their narrative they were scoring high and in other parts, they were scoring lower. This is something that I recognized as well, as I'm investigating this in my patients and in myself. Actually, I had my own AAI [Adult Attachment Interview] done. And not all passages of your AAI are the same. Right? And so some people, specifically with trauma, score lower. Julia, how did you get involved and tell me more about this study.

Garon-Bissonnette:

I started working with Nicolas in 2017 as an undergrad and then we continued together through my PhD. And now we still collaborate as I moved away from the lab. But still, I'm not really far. I had a lot of interest in childhood maltreatment and in parenting, and specifically, the parent-child relationship, and really trying to understand the processes that are happening when people parent and the predictors of attachment security, for example. And I got really fascinated when I started working with Nicolas about reflective functioning in general. My own dissertation focused on attachment-based reflective functioning in the Adult Attachment Interview. But I really started working on this trauma-specific reflective functioning as well, and just thinking about the ways that we measure reflective functioning in general. And so I think the manual, even Fonagy’s manual, really accounts for the fact that there might be drops in some areas (Fonagy et al., 1998). And so the overall score is not immune, for example, to scores in different questions. Right? So we have to think about the whole, the overall functioning and flavor. But I think what we're trying to do is really to better understand the low end of the scale. And especially in people who've experienced child maltreatment.

Puder:

Yes, I think part of our time today is that we're going to be talking about what these actual narratives look like, because I think that as clinicians, I'm mostly speaking to clinicians, we can start to notice in someone's narrative when they have lower RF in portions of the narrative. And it's something that I have found very helpful and kind of helps me zero into someone's story in a different way. So I'm applying this primary literature that you guys are working on to clinicians, and I'm hoping that the clinicians who listen to this can kind of grow in this ability. You have this 2025 article called “Characterizing the Heterogeneity of Disruptions in the Resolution of Trauma among Women Exposed to Childhood Maltreatment” (Berthelot & Garon-Bissonnette, 2025a). Do you want to describe this study, maybe in general, and then we can get into the specifics on the different types of profiles that came through in the trauma narratives?

Characterizing the Heterogeneity of Trauma Resolution in Women After Childhood Maltreatment (06:55) 

Berthelot:

Yes, absolutely. If you introduce the ideas behind that study, it is built based on very general observation. The first one is that we know trauma is quite frequent in the general population. And in our patients, it represents at least one-third to one-half of our patients who have experienced severe abuse or neglect during their childhood. And we know it's a very powerful determinant of mental health. And the second thing we know, as we already discussed, is that not only trauma impacts mental health, but it also has an intergenerational transmission. And knowing that it's a powerful determinant of mental health, another idea, which is very important and led us to that study is the idea of heterogeneity. This idea being that even though childhood trauma is one of the most powerful risk indicators for later mental health problems, about half of people who have experienced severe abuse or attack during childhood are showing striking resilience and are doing quite well.

Berthelot:

So, something is happening during the developmental trajectory arranging the risk trajectory toward resilience or towards depression, or personality disorder, or psychosis, or something else. And we know very little about the developmental determinants that arrange the risk trajectory toward one path or another. And the hypothesis we made is that how people have psychologically processed or resolved their traumatic experiences during development is a core determinant of later functioning. And that's why we tried to observe in a large sample of 800 pregnant women we were working with, all of whom had experienced some type of abuse or neglect during their childhood, whether we could have observed different profiles in the way they were thinking about their traumatic experiences and thinking about the impact of these traumatic experiences. So, to do so, we used a questionnaire we developed, since, as you already said, I think the very best way to capture trauma mentalizing as a therapist or as a researcher is only to pay attention to what people are saying about their experiences, to be curious about that, and to listen carefully.

Five Trauma Profiles Identified Through the Failure to Mentalize Trauma Questionnaire (09:34)

Berthelot:

And generally, we get a good idea whether they are reflective or not. But in research, it's not always possible to do so, at least with a very large sample such as ours. So we developed a self-report measure to kind of capture different types of impairments in reflective functioning. So, that instrument is called the Failure to Mentalize Trauma Questionnaire (Berthelot et al., 2022). It's readily available in English and multiple languages and when we administer that questionnaire, we're able to identify five different profiles, five different ways people were reflecting or not reflecting about their experience of childhood trauma. You want to add something, Julia?

Garon-Bissonnette:

No, I think that's a good introduction. 

Puder:

And you guys, also in this article, have some narratives that you pull out. And so how many people did you do more of a narrative? You know, a qualitative portion of the interview? 

Garon-Bissonnette:

Well, I don't know. I couldn't tell you the exact number in this specific sample that the paper we're talking about includes. But we have about, I would say, probably 250 across different studies and they're called Trauma Meaning-Making Interviews (TMMI) (Berthelot et al., 2025b; Simon et al., 2008), which we typically will use to code trauma-specific reflective functioning. And we pulled from those from participants in the paper who had completed interviews to really try to illustrate what that might look like in a conversation or in an interview.

Profile One: Identified With the Perpetrator (11:18)

Puder:

Okay. I see. So some of the profiles are like, “Profile One: Identified with the perpetrator.” Describe this one for me.

Berthelot:

Yes. This group of people that we identified were expressing two specific types of disruption in mentalizing trauma, one being justification of trauma. They were explaining that trauma was kind of a good way to behave. The abuse was deserved, for instance. And they identified with the perpetrator as well. In meaning, it seems like they emerge from a maltreating relationship by defensively identifying with hostile attachment figures, probably in an attempt to cope with the fear evoked by trauma. So, the kind of people who now are probably harsh in their relationship with others and may try to be in control in their relationship with others, and, by doing so, they are less afraid of being abused or neglected again, being the one in control. So that's one group we did observe, one type of profile we did observe in that study.

Puder:

Okay. Yes. So this is either they're justifying the trauma, they're identifying with the perpetrator, and then you have some great example comments like, and I think this is kind of helpful to talk through. This is the kind of thing that we would hear actually in therapy sessions too, right? So like, one of the questions, “Does that experience affect you now that you are older?”, so that maybe you're asking the person this, “Does this experience, the trauma, affect you when you're older?” “No, no, no. But if I see him in the street, I won't hesitate to spit on him. When I was younger, I used to hide from him. Now I'm old enough. If I see him on the street, I'll spit on him or run him over with my car.” So talk to me, why is that identifying with the perpetrator?

Berthelot:

Probably all people hearing us already have ideas about that since I think it's quite clear in that example that there's a lot of anger, anger toward the perpetrator, which is something we can absolutely understand. I mean, people who have been experiencing quite severe abuse or neglect may still have conflicting thoughts, ideas, and negative emotions regarding people who commit these experiences. The first thing that makes it clear that it's not reflective functioning is that when we ask that person if she thinks that the experience affects her now that she's older, she says no. If she had said, “Yes, I think it makes me feel very angry about these experiences,” we would've seen it completely differently. But she says, “No, it doesn't affect me at all, but if I see him, I will run over him with my car.” So we see two different parts here that cannot relate with one another, are very conflicting, and that make it clear that it's not reflective functioning. And the type of disruption we observe here is totally in the form of undergoing anger toward that person and feeling justified to revenge.

Puder:

Yes, it's kind of like, I've thought about this in terms of like the stages of grief. Right? Where if they're caught in a state of anger, still wanting to spit on the person, run them over the car, it's like they're moving from putting to words how it impacted them to action. Right? So it's like, it's a denial that it impacts them, but they would still act upon the emotion that's underneath that isn't completely processed.

Berthelot:

Yes. Yes, absolutely. And what is concerning when we observe that type of situation, if we let it go, and do nothing about that, is that we know that this specific profile, people having such responses highly correlates with the specific types of symptoms and difficulties in their own life, including here, externalized behaviors including intimate partner violence perpetration. So it's not only about the narrative when they think about trauma, it's something that unfolds in their own life and their current relationship as well.

Puder:

So that, because the reflective function is low, they're moving to action, they're moved into violence when they're having emotions. Right? Okay. Let me read a couple more of these narratives here, “I tell my kids, ‘Mommy is going to get mad, and she can give big slaps, big slaps on the butt,’ but if it's on the butt or the fingers, it doesn't hurt. It's not that strong. So, you know, she cries, but she cries just because she feels something else, not because, you know, she really is not used to it.” Maybe that one, I don't know. Does that make sense? Did I read that okay?

Berthelot:

Yes. Yes, absolutely.

Puder:

It's confusing to me. I mean, there's something about the confusing nature, so tell me what this means or what the context is. Maybe how this makes sense to you, Julia.

Garon-Bissonnette:

Well, I think the context is about how it might influence how the participant then parents her kids. So I think that context might be helpful here in understanding this specific citation. Right? And so thinking, talking about repetition of child maltreatment behaviors. So it's her kids now. And so a different way of seeing perhaps this identification with being a perpetrator or really this active cycle, even if in this case here, which is why I think we had used it as an example of this of this profile as well, not fully organized, which I think we see a lot in lower reflective functioning narratives as well. Which is why maybe it leaves you, David, with a bit of a confusion there. 

Puder:

Yes, it is like, am I reading this correctly? Yes, but there's a little bit of that confusion there. Right? Yes. I'll read another one. “I gave my father a punch. I gave him a black eye. That was one hell of a show.” It's kind of like this rejoicing in violence.

Garon-Bissonnette:

Yes. It's excitement flavor. Right? 

Berthelot:

Yes. So that's another good example. So, that identification with the perpetrator may take different forms, different colors. And the previous example we just saw was a clear repetition of the abuse. The mother was saying, “I hate my daughter,” but she's crying, not because of her—she's crying because she's not used to it. So that's what we see as unconscious repetition. But in that current example, there is clearly excitement when talking about difficult life experiences. So the person is laughing saying, “Well, that was one hell of a show,” discussing an argument with her father where she hit him. So again, the idea, the problematic aspect here is not that she has experienced that type of situation or that she's angry at her father, it's that she's talking about that in a way which makes it a funny experience. And she's excited to tell us about that and wants to tell us more. So that's the main point there.

Puder:

Interesting. Okay. I'll read another, “I pity the next guy who tells me, ‘My lunch is not ready.’ Sit down, I will give you your lunch. I'll fill his lunchbox directly in his mouth, you know, [and then there's laughter.] I am not your slave. No, it doesn't work that way. I like talking about that. I find it fun. It lets off the steam.” Describe what's going on in this story here.

Berthelot:

It's probably a situation that she was explaining an argument she had with her partner. And probably her partner said that his lunch was not ready and she gets very mad and she expresses it that way, that the next time she will fill his lunchbox directly in his mouth. And she's laughing and she tells us, “I like talking about that.” So that's another good example. I think that most people will discuss that type of situation, that type of argument with ambivalent feelings. They would not be excited talking about that and they would be shy about these experiences. They certainly wouldn't be comfortable, but she's in the totally opposite direction. She's particularly comfortable talking about such experiences being violent or expressing violent fantasy regarding her partner which is the thing that makes it possibly concerning here.

Puder:

Okay. Yes, there's a little bit of almost sadism in the enjoyment of the hurting of the others in this type of persona. Also, I'm thinking this sounds like some, the defenses seem a little bit more grandiose or, you know, a little bit narcissistic flavor a little, you know, psychopathic, like the power, wanting power, wanting control, that kind of identifying with the perpetrator, ending up with those kind of spectrum of thought process.

Berthelot:

Yes, totally. And I want to underline here that, these narratives, these examples we’re talking about, that these are real examples that came from participants we met in our studies, who were not people recruited because they had severe mental health problems. These were people that were recruited only because they were expecting a child. So these are women from the community. But we see from these examples that when we ask about their childhood trauma, when we ask about these experiences, we have access to something particular. And in clinical practice, it tells us that it'll be very important at one point in the process to pay attention to these experiences, pay attention to how the people talk, mentalize, reflect, feel. When she's talking about difficult life experiences, we may observe distinct processes that we do not observe when she's talking, or he's talking, about other types of experiences.

Profile Two: Functionally Grandiose (22:52)

Puder:

Okay. Let's go on to Profile Two: Functionally Grandiose. So there's some grandiosity they develop, maybe this kind of representation of themself that is invulnerable to the effects of the trauma or having the strength to move on. There's an avoidance of discussing painful emotions. Tell me about this type.

Berthelot:

Yes. There are many people who say, “Trauma doesn't impact me at all. It has no effect. I was strong enough to suffer that without any impact.” It may be true in some instances. But they are characterized by that representation that it had no effect, no impacts over time and because they were strong enough to undergo it without any types of difficulty. And that profile is especially intriguing. Intriguing since they are distancing definitely from trauma, from their emotions. And it reflects when we look at their mental health or their symptoms through the absence of symptoms as well. So they seem like being in fact resilient, as they do not express any post-traumatic stress disorder nor depression anxiety with, which fits with the fact that they are emotionally distant as well from their experiences.

Berthelot:

So we still have to understand more about that part of our subgroup, follow them over time, and to see what happens when the child is there, for instance, since they are all parents who will be particularly interested in looking at their parent-child relationship. So, because they will be with a child, which of course will express vulnerability, and they are definitely a group of people who are not comfortable with vulnerability, so it will be interesting to see what happens when they are confronted with the child who's crying, who’s expressing distress, that type of thing.

Puder:

Let me go through some of the narratives here, to kind of make this a little bit more real. So this person said, “I remember talking about it with my sister. I used to tell her, ‘I know that if it were you, you would have never been able to make it through. Me. I'm capable of confronting every situation, even the most painful ones, and in a positive way, not a negative way.’” So it's kind of like there was some abuse, and then this person is talking to their sister and they're saying, “If it was you, you would've crumbled. Me? I can confront anything. I can move through it. I can push. I could bear this.” Julia, what do you think when you hear this?

Garon-Bissonnette:

Well, I think I was thinking about what Nicolas said a bit earlier about how it might be that they are doing well and that they, you know, are on a resilient trajectory. But I think with examples like these, we really see that this is not really a reflective process, right? That the participant is showing us they're not really walking us through perhaps how they developed that resilience and how they were able to face those experiences. And so I think that's what's lacking here when we're looking at something like reflective functioning. Right? And I think the vignettes are really helpful for illustrating that piece.

Puder:

Yes, it's like there's that jump to resilience without the ability to mentalize the process. Right? Because it's very different if someone was like, “When it happened I was at first very numb and disconnected from it, didn't think about it. And then I went through a phase where I was angry, and then, I was really sad that it happened, and it felt, you know, like I had to really rectify my understanding of my father and why he would do that. And then subsequently, I've been able to kind of move past it where it doesn't bother me as much. I don't think about it as much. I have compassion for myself as a child having gone through this.” So they're showing the mentalizing journey.

Garon-Bissonnette:

Exactly, yes. And you understand how this adaptation came about, so it doesn't have that grandiosity aspect to it. 

Berthelot:

Absolutely. And I think your example is quite great, David. And there are some people who are not able to express that in such nice words, but at least will say, “I'm surprised that I made it through and that I'm doing well today.” And so, they will express some kind of curiosity about that process, and they will understand that developing well in the context of childhood is kind of surprising. There's something that happened that helped them make it through. But as you said, I think it was the right words, there's a jump from the total treatment to the resilient without an understanding  of the process.

Puder:

And I think as therapists, what I would say is that it may be that if someone is a little bit more grandiose  in the jump, we may think to ourselves like, “Oh, we don't really need to talk to them about this. Or this trauma's resolved in their brain,” but it might not be resolved. I have this one set of brothers that I know really well, one could tell you about the trauma, could tell you how it impacted them, and the other one doesn't even remember. They're like, “I don't remember that happening. And, that's in the past. You don't need to even think about the past. The past isn't even important to think about,” but they both went through the trauma. Right? They both went through the same thing. Let me read the second one here. “I put a cross on that. There are other things in my life that I think you have to go on, not live in the past. When you go through such experiences, you have to be able to say, ‘Okay, that's enough.’ And put the cross on that.”

Puder:

Julia, what do you hear when you hear this?

Garon-Bissonnette:

I think this is kind of an act of rejection. Right? In thinking about those experiences. And so a little bit of a different illustration than the one we just looked at for this specific profile. But I still think this idea of not really going into the vulnerability or going into affects or thoughts or feelings that might arise when they think about experiences.

Berthelot:

Yes, absolutely. That's a good example of an over investment in cognitive reasoning and it's not a good understanding of the human mind. The day you decide that it's enough, it's enough; and you won't think about that anymore. It won't affect you anymore. It doesn't work that way. And she kind of expresses that people have to have that ability, and she implies that she has that strong ability to just decide to let things go. And from that moment, that doesn't impact her anymore.

Puder:

In my mind, it's like a superficial spirituality too. Right? There's a difference between someone who's really done the work. There's maybe some spiritual aspects that have helped them through the work. This is more of like a hypomanic defense of sorts, that's combined with spirituality, where it's like you just put a cross on it. That's good. That's all you need to do. You know? No need to feel anything. You can move on from it. Yes. Okay. So that's number two, functionally grandiose. Number three is absorbed in trauma. So tell me about this one.

Profile Three: Absorbed in Trauma (31:26)

Berthelot:

Yes, that particular subgroup presents several of the impairments in mentalizing trauma we assess through the questionnaires—one being identification with the victim, the other one being disorganization of thought, the other one being absorption in trauma and avoidance. So it's a subgroup of people who have a tendency to take responsibility for the trauma or to consider the abusive behaviors to have been deserved. When they think about these experiences, they have very important problems in reasoning that take the form of depersonalization or even destructive behaviors when they are connected with trauma-related emotions. So their discord, the narrative becomes very confused, very disorganized. There's a clear interference of memories of trauma with the monitoring of thought and behaviors. So they may become highly dysregulated. They may have the urge to, for instance, cut themselves when they think about trauma, and they have very negative thoughts and emotions when they are discussing these experiences. So the types of difficulties we see here highly fit with the diagnostic criteria for post-traumatic stress disorder (PTSD). So it really relates to people when they think about trauma, they get absorbed in these experiences.

Puder:

Julie, anything you would add to it before we read some of these comments?

Garon-Bissonnette:

Really, I think this is a good description. I think it's a little bit, if we think about the scales of the questionnaire…so the questionnaire includes seven scales, and so this profile shows a little more impairments across different scales than the two we just looked at, which were a little bit more specific in terms of one or two types of impairments. So this one might be a little bit more global. We have one that's even more global. The last profile, I'm sure we'll get to it, but this one includes a little bit more of these disruptions.

Puder:

When I heard the first one, I was thinking there's a little bit of that, almost like sadism with the second one. I'm thinking more of narcissism or narcissistic defenses you know, narcissistic personality style. With this third one, I'm thinking of a more depressive personality style, dependent personality style. When, you know, they blame themselves for the trauma when they have a dissociative personality style. And so maybe I'll read one of these. “You know, when he took his belt and then there's like a ten second pause and folded it in two and made noise with another six second pause, scared another four second pause. It scared us, but he never hit us with it. It was scary as hell. And then you want a reason to cry, and he takes his belts and he comes to me and, oh, we cried even more. It was, it scared us. He was really strict.” So yeah. When you hear this, I'm hearing the pauses. Is there a dissociation in that? Almost like the telling of it, it's so distressing. There's a little bit of that dissociation. Sometimes I'll hear pauses in people's stories when they're going through something like that. There's a lot of fear. Maybe. What are your thoughts on this one?

Berthelot:

Yes. Yes, I think your comments were right on it. These are probably good examples of illustrations of dissociative processes. So probably just thinking about trauma was highly painful and dissociative processes interfere with the way she talked about these experiences. So, as you said, she has difficulty organizing her thoughts. She's still quite afraid, and we can see it when hearing or reading through the narrative. There's a long pause. She's switching from past to present. At one point, she's talking in the father's words when she was experiencing the trauma. So that's a good example of that probably still highly vivid traumatic representation that comes with dissociative defenses. 

Puder:

I don't see this person blaming themself for the trauma or for what happened there. 

Berthelot:

No, no. This profile is practically vulnerable to blaming themselves for right. Our experiences. But you're right. We do not see it in that narrative.

Puder:

Not in this narrative. Yes. And then the other thing I would say is, when I hear a narrative like this, I often think to myself, “Well, there's more there that's not being said yet.” You know, sometimes there's more of a surfacing narrative of, there's no actual hitting in this narrative, for example. But there's dissociation, there's the fear as if there was going to be hitting. So that's one of them. Here's the other one: talking about a verbally abusive stepfather. Okay. So that's the context. “I started my period when I was like 10, and I had quite important mood swings. I was like, around fourth grade. And then he really didn't know how to deal with me. He really did his best, but I was so difficult.”

Berthelot:

So probably then you see the tendency to feel that they are to blame for the trauma that we were not seeing in the previous example, but it's more clear here.

Puder:

Right. So there's a little bit of the blaming. Yes. “He was doing his best.” There's a little bit of that idealization of him. Devaluation of herself. “I was the one with mood swings. I was difficult to deal with. I was so difficult.” This is around, this is in the context of maybe before this passage, there was some discussion of his verbally abusive words or something.

Berthelot:

Okay. Yes. And it's being disconnected from the developmental experience of what it is to be a young, 10-year-old girl having her period. I mean, it's a complex experience. And when the response you have is verbal abuse, at least we would've expected her not to say that she was the one being difficult and that she deserved that her father or stepfather treating her this way and being more grounded in the complex experiences that she had at the time, and how she would've expected that the caring parent would've responded.

Puder:

Yes. It's like sometimes I'll hear someone tell something traumatic that happened to them and then subsequently they're trying to make less of the badness of the person that caused the trauma to them. Right? And it's really hard as a kid having a parent that you don't idealize. Right? That you don't look up to. So maybe it was psychologically easier or maybe psychologically more beneficial in the relationship to take the blame, even if the other parent was to blame. Right? Let's say the stepfather was to blame. He was a jerk. He was an asshole. But if she had that narrative of him, life would be so much worse. And so this person figures out ways psychologically to make herself bad and make him good continually, because that makes less trauma coming towards her. But it's not a high reflective function position because she hasn't been able to, as an adult, now see how that was adaptive for her growing up to idealize him and how it was adaptive for her to go bad on herself. Now it's not adaptive, it's maladaptive, but it was historically adaptive.

Berthelot:

Yes, you're totally right. And I think that what you raise here is important, that we would probably have different expectations if we were to assess for a specific reflective functioning with children or adolescents that are still living with their parents, than when we're evaluating reflective functioning with adults who aren't dependent anymore on their parents for survival. So of course, I totally agree with you that when you're a child in that particular situation, shutting down, mentalizing, or putting responsibility on yourself is important for survival. You don't want to have a representation of your parents as being dangerous. Otherwise, you'll feel constantly on the trip. But once you emerge out of that relationship, you're an adult and it's your turn to become a parent. If you are still kept in that representation of yourself as being the one to blame, and as your parents as having done the best they can in that situation, that may be problematic. And that's when we see the intergenerational cycles of trauma, that if she still had that representation, she will probably repeat the same way.

Puder:

And I think that what's interesting is that you guys found that it's specifically with trauma reflective function. Right? I think also when it's these heightened moments that lead to the mis-mentalization, a lot of times parents can be completely normal, you wouldn't be able to see the dysfunction, but then when a big stressor happens, it's like they may regress into earlier reflective function gaps. Right?

Berthelot:

Yes, absolutely. If I can open the parenthesis here. And we did document that through our research, that when we evaluate different types of reflective functioning—attachment-based reflective functioning, parental reflective functioning, and trauma-specific reflective functioning, we see that these different types of RF are correlated, but not that much. They are not assessing the same construct exactly. They are, at some point, independent from one another. Our data are especially surprising since they suggest that it's trauma-specific reflective functioning that most strongly predicts parenting and the parent-child relationship even more so than parental reflective functioning and the attachment-based reflective functioning. So it seems that how people mentalize these emotionally hot moments when they are  where past trauma comes to mind, seems that it's especially predictive of how they will behave as parents in emotionally hot moments as well.

Profile Five: Global Failures in Mentalization (43:23)

Puder:

Okay. So that's the third profile. Let's jump to the fifth one and then we'll go back to the fourth one. So this is global failures in mentalization of trauma. And so you're seeing a lot of the different things all at once. Is that correct? You're seeing identification with the victim, identification with the perpetrator,  disorganization of thoughts, grandiosity, avoidance, absorption in the trauma, justification of trauma. Tell me about this one. Julia, do you want to try?

Garon-Bissonnette:

I can. And so a questionnaire has, just for context, seven scales. And we see all seven scales here in this profile. So all seven disruptions that can be assessed using our questionnaires are being represented in this profile. And this profile can include a mix of all the things that we've just looked at, basically. And so maybe some grandiosity, maybe some lapses in some absorption. Maybe some disorganized narratives too. So lacking coherence and not really walking us through thoughts and feelings and emotions. Contradictions. We can see contradictions as well in either one specific answer or throughout the interview. Right. Things that don't really add up. 

Puder:

Talk about the contradiction. Because I think that's a very important thing for us clinicians.

Garon-Bissonnette:

Yes, I don’t think we have mentioned it yet. Yes. I don't think we have an example about that, but we do see those. And even in adult attachment interviews, we can see those as well. Where people, for example, will at some point kind of deny implications of trauma. Right? Say that it doesn't impact them at all. But there might be lapses here and there where oh, but maybe it does in the end. And so I think that's where interviews are really helpful too, to catch those brief moments that might not even be fully conscious. Yes, I don't know. Nicolas, if you want to add something to that?

Berthelot:

I totally agree. I think that that group is different from the other since we see much more severe mentalization and mentalizing impairments, and most of the time it shows a true narrative that we cannot make sense of. So it's almost a psychotic way of thinking about trauma, and there are elements that do not fit together. So, contrary to the other subgroups we've been discussing, it seems like these participants don't have a consistent and current strategy to deal with past trauma. And it shows true, very disorganized narratives most of the time.

Puder:

Yes. So let me read one of these to bring it to life: “So he did not, he did not hit. It never went physical.” Okay? So that's the first statement. And then, so there's a pause, there's five minutes of interviewing going on, and then the person says, “It happened once that he hit me. It was with a belt, and it was quite bad. I had to go to the doctor.” And then later in the interview, the person once again says, “Other moments were when he came home drunk. Really, my dad was not a violent person.” And so you could see some inconsistencies in that narrative. Part of me wonders…sometimes what I'll see is when the person is new to me, their shame might be so high, or they might be dissociated away from memories, and then as the connection increases, as the shame decreases, they might have a better ability to remember things. But I think that what you're seeing in this narrative is that there's an inconsistency, like, “Oh, it happened once that he hit me.” But then even later in the interview, “There were other moments when he came home drunk.” You know? So there's more there. And there's this kind of lack of memory, lack of consistency in the narrative.

Berthelot:

Yes. I understand what you said, David. I think the example you've been giving, that when we see someone for the first time and there's not that alliance, so far that person doesn't feel secure enough. There was a person maybe reserved or not fully expressing difficult life experiences. And I think these are good instances of higher order defense mechanisms like repression, that kind of thing. But with these narratives, with what we see with people who have global failures in mentalizing trauma, in that after one hour, you shake your head and just say, “What the hell? What happened with that person?” You cannot understand what she's been saying. She's been saying one thing and definitely the opposite. Like here we see in a few words that she said, “My dad never went physical,” but a few minutes after she described an instance when she was hit so bad with a belt that she had to go to the doctor, and, later she starts discussing a situation when the father came home drunk, and something happened, but she doesn't go into that direction, and she ends up saying, “Really, my dad was not a violent person.”

Berthelot:

So it definitely does not make any sense. It goes in all directions. And most of the time you end up having the feeling that you don't know that person. You have no clue about her or what really happened. It was highly confusing. And that's the type of situation, since you've been discussing that as a profile, as being probably reflective of people with depressive personality or avoidant personality and the other profiles with the sadism or narcissistic personality here. That's the type of discourse we see with some people with severe borderline personality disorder or complex trauma, that kind of fragmented discourse about their life history. That's highly difficult to make sense, and that we have to pause and reflect on these experiences. 

Puder:

Yes. It's a borderline level of functioning and the psychodynamic theory of where you can idealize one moment and then devalue the next [see episode 29 and 231], or it's almost like that in idealizing of the father that they can have moments of one in the same interview, that they have moments where they can disclose stuff. So that's one thing I'm thinking about. The other thing I'm thinking about is with the dissociation, right? If the person you're interviewing is highly dissociative and your countertransference is confusing because you're feeling some of that dissociation as well. So when I'm working with clients like this, I will sometimes feel confused and I'll have to ground myself because the confusion I'm feeling is actually the dissociation. The dissociation, it kind of puts a haze in the room. It puts a haze in the conversation. And this is a very unprocessed trauma when someone is dissociating like that. So as we go back to it again and again, I don't feel that same dissociativeness, that narrative coherence is there. Their narrative coherence, one thing leads to another, leads to another, leads to another. There isn't this incongruence. 

Berthelot:

Yes, yes. Totally. So the dissociation is there. I think what adds with that particular profile is that it's not only dissociation. There's that, but there's definitely something at the level of self and other representation. So these are a subgroup, and it's a minority of people. I don't remember the percentage. I will look at it, but I think it's something like 6%, or something like that. So a minority of people who have experienced trauma, that seems like the trauma has been embedded within self and other representations and in a very consistent fashion. So it interferes generally, broadly with the way they think about themselves and others. Whereas people who only dissociate even though that's quite painful, it doesn't come to confusion all the time to all the narrative.

Puder:

Right. Okay. So maybe I would say what you're describing sounds like identity diffusion. You know, this is kind of like what Kernberg talks about with the borderline level of functioning and you have the idealization, the devaluation, the projective identification, the identity diffusion [see episodes 239 and 247]. This kind of big, overlapping thing. You could have different personality styles. You could have a dependent person, you could have a depressive masochistic. You could have various different types of styles of personalities is the way that I understand it, but then it's like you have this fracturing of the self. Right? This is really, really, really difficult. It takes a lot longer to do the therapy.

Berthelot:

Yes, absolutely. And just a confirmation of that, in that particular study we administered an instrument, which is the Self and Interpersonal Functioning Scale (SIFS; Gamache & Savard, 2017), which is based on criterion A of the alternative model for personality disorder of the DSM-5 [Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR)]. And we evaluate self and interpersonal functioning, and we did observe severe impairments on both domains in people from that profile to the point that more than half of people in that profile definitely respond to the criteria for personality disorder. So yes, I totally agree with that and that's one element that we did assess with that instrument, the definition of identity diffusion of Kernberg. And, totally, this was strongly present in people of that profile, which was not the case for people in the previous profile we were talking about that were absorbing trauma and didn't have the same level of identity diffusion. It was more the level of interpersonal problem that would present in the previous profile.

Puder:

Okay. So you also said here, the participants express unintegrated bizarre or inappropriate representation of self and others and a clear misunderstanding of psychological functioning. And I'll read an example: “Maybe if she would have loved me, I wouldn't have been good to my children.” So it's like a statement that doesn't quite make sense. Right.

Berthelot:

Absolutely.

Puder:

Or another one. This was talking about sexual abuse during childhood. This person said “He was a man who really, really loved women. So whenever he was in my company,” well, so it's okay, I could see it's a bizarre representation that this person loved women and then sexually assaulted her because of that love. Right? 

Berthelot:

Yes, that's what you're saying. Absolutely. And if she has that representation that the man who loves women is normal, that he's interested in children, as well, I don't know what will happen in her current relationship with her partner, but it's a highly risky situation. And we might expect, what we often see is a repetition of sexual abuse over her generation, and we can understand why when we see that kind of representation about others here.

Profile Four: No Major Failures in Mentalizing Trauma (55:32)

Puder:

Okay. So that's profile five. Let's go to profile four, which is no failure in mentalizing trauma. You want to talk about this one?

Berthelot:

Go ahead, Julia.

Garon-Bissonnette:

I can start. These people were low across the board on all the failures of mentalizing trauma that we experience that we measured and also experienced fewer symptoms and personality dysfunctions. And so we could think of them as potentially, at least by these correlations, that we see as resilient women. And so they are. We don't know that from the questionnaire, but with the illustration, we can see that they perhaps have processed the experience of trauma. They're able to understand mental states in that context and to make sense and to tie those, the behaviors, and to really understand developmental features and the nature of mental states. And so people who are showing a reflective process like we would expect to see for higher scores.

Puder:

Okay. So these people were not having identification with the victim, identification with the perpetrator. They were not having disorganized organization of thoughts. They were not having grandiosity where they were not being avoidant of their emotional world. They were not having absorption in the trauma or justification of the trauma.

Garon-Bissonnette:

They might. Just a note, these are not dichotomous variables, they're continuous, but they presented the lowest levels of all of these. It doesn't mean that their functioning or their reflective functioning was perfect or, if we think about a -1 to 9 scale, was a 9 all the time. That wouldn't be the case. But their levels of those elements were the lowest.

Berthelot:

Yes. And most of the time when they present that type of disruption, they are able to note that and comment on that. So there may be instances where they get quite absorbed in trauma, but they will say in the course of the interview, “I can see that I'm still much more affected by these experiences than I thought I was. Just talking about that makes me very emotional.” So they are able to comment on these processes, on these defenses we've been talking about during the last hour. They see that happening. They're conscious about that. They are trying to act upon that and we think it is very, very interesting. And what I find amazing is that the majority of people are quite surprising and for me, I'm glad to see that when a majority of people talk about very severe experiences they had during their childhood, they are quite reflective.

Berthelot:

And they are saying very interesting things. And it is very optimistic too for us to see that. And we may expect that they'll be quite good parents, even though they have experienced quite severe experiences. What we note, however, is that it's not because you're reflective on your past trauma that it always protects you from suffering at some point. You may be quite reflective, see the impact it has on yourself, being able to reflect on that but still experience pain, experience grief and feel depressed or anxious. 

Puder:

Yes. Let me read one of these and we'll talk about it. “Well, I thought it was just by seeing how I react to these memories. I thought I had forgotten about it. Not forgotten, because some things leave a mark forever, but I don't define my life by that experience, you know, I always try to do better. I know I had a troubled childhood. I don't want to replicate it over again, nor with my children, nor with my husband. But still, when I talk about it, I can see I am still sensitive about it. Like it's still there, you know, because I never really had the chance to sit down and talk about it with someone.” 

Berthelot:

That's a good example of what we've been saying. There's still an issue there. She has the instinct to be like the people who are functionally grandiose to say, “It's in the past. It doesn't affect me anymore,” but she's not doing the same. She's able to see that unfolding and to reflect on that.

Berthelot:

So, as Julia said, being reflective doesn't mean being free of any types of defense and free of any types of suffering, but it's being able to connect with that, reflect on that, and be curious.

Puder:

Yes. What would you score this? What would this little passage be scored, do you think?

Berthelot:

It's not an impressive passage. She's just identifying mental states in the course of the interview. There are some elements that are quite rational here. Probably we will be at the lowest side of the good mentalization scoring. So, I don't know, somewhere between 5 and 6. What do you think, Julia?

Garon-Bissonnette:

Yes, I was thinking around a 5, too. I think we're meeting the threshold of reflective functioning, but we're not seeing a lot of sophisticated, developmental stance or freshness elements.

Puder:

Yes. Yes. I was thinking 5. 

Garon-Bissonnette:

Yay. We all agree.

Puder:

We're in agreement here. -1 to 9, which Miriam [Steele] said she's almost never given a 9 [see episode 260]. She's usually “5 plus.” It's like, there's some passages that are 5 and some that are more than 5. 

Berthelot:

Okay. Yes. And I will comment on that if you permit me, David. That's an issue we have sometimes with the RF scale since it's, as you said, this is a scale ranging between -1 and 9. So a 10 point scale. And in many studies, what we see is that our scores are between 3 and 6 or 3 and 7. There is not a lot of variability. But what is very interesting when we look at trauma-specific reflective functioning, using an interview such as one (we use Trauma Meaning-Making Interview) is that we do see a lot of variability, and we generally use most of the scale from -1 to 8. You're right, I think we never code 9. It's something that most people rarely do. But it's a scale that permits us to capture the variability and mentalizing process. That's very interesting.

Puder:

That's good. Of course, when you do my score, it'll come back at a 9.

Berthelot:

Of course. Of course.

Puder:

So of course, that's grandiosity. So that'll bring me down a little bit right there. But that interpersonal knowledge might increase me a little bit. 

Puder:

But then knowing that I'm doing this to make you laugh, maybe that increases me as well. Right? Good. Okay. So being playful with it there. Okay. So here we go. So here's another passage: “I worry too much about what people, particularly my parents, think, and I think it's related to the abuse. I just, I'm not as free as I would like to be. I mean, I'm going to be 39 next week, and I sort of like, in the back of my mind, I'm still thinking, ‘Oh, would Dad be okay with this?’” Okay. You could see in this passage it's different when the person is just unaware of their idealization of their father, maybe, when they don't have the insight. Right? There's a little bit of insight here into how the early childhood abuse may play out in the present.

Puder:

Is that what you're thinking?

Berthelot:

Yes. Absolutely. I see three elements in that very short passage that I find very interesting. The first one, when called reflective functioning, you know, we have to get a sense that the person is aware of the nature of mental states. And here we do see that she's recognizing the persistence of certain trauma related mental states, despite the willingness to change. She would like to feel different, but that's the way she feels. And even though she works on it, she sees she still has that emotion, that underlying feeling that is there. And that's, I think that's a good understanding of the world of mental states, that we may change, but it's difficult. And some things are lasting over time. The other thing I think is freshness. She's describing things as they are happening in the moment. I'm not sure if she's saying things that reflect a lot prior to the interview, something unfolding here. And the last one is what we often see when we evaluate reflective functioning, the explicit effort to tease out mental states underlying behaviors. Here she's describing the impact of trauma on herself, on her mental states, on her thought processes. So that's very interesting. Again, that's not something at the high end of the scale. It's probably around a 6. But I think it's totally interesting. 

Puder:

Yes. That's good. Okay. Let me read another one of these. So you said there are little instances of denial, minimization, or self blame. When this happens, these speakers are able to identify that it represents an attempt to keep a distance to difficult emotions. Okay. So one of them is, “I laugh, but it's not funny.” So it's like they laugh. They recognize that it's not funny. It's like they're recognizing the defense of laughter. Laughter, humor is a higher order defense. Another one says, “I said at the beginning that my dad was not violent, but I realize that he was, in fact, quite violent. I think it's difficult for me to acknowledge that. No one likes to say or admit that one of your parents is violent, you know. My father was really violent verbally.”

Berthelot:

Yes. I think we tried to give an example that reflects more subtle indicators of reflective functioning. Since people on the high end of the scale, people who are highly reflective, it's quite easy to observe most of the time. We are like, “Wow, that's amazing what she said. I don't think I could have said that myself.” Probably you could, David, since you're 9 on the scale, but being a 5 or 6, I'm impressed.

Puder:

I'm not 9.

Berthelot:

Just kidding. But yes. So, these are examples that are more subtle. We see people still undergo some suffering about trauma. They are still dealing with it, but they can see themselves going. They can look at themselves from the outside, see these processes. And I think that's what will eventually protect them from repeating these experiences within the relationship with their child, even though trauma is not totally resolved.

Puder:

Yeah. I could see here. So it starts out, “I said at the beginning that my dad was not violent, but I realize he was, in fact, quite violent.” So it shows a progression even in the midst of talking about something. They're aware that they are changing their sort of wordage. 

Garon-Bissonnette:

I think it's a good alternative to the one we looked at for the prior profile where there was a lot of contradiction. Right? About hitting and ending with, “Really, my dad was not violent.” And here we see a reflective process that shows that we're reaching a novel interpretation during the process of the interview or realizing the implication of abuse on her functioning. And I think it's a nice alternative to something that can be quite similar.

Puder:

Or even when this person says, “I think that it's difficult for me to acknowledge,” that there's an awareness of the difficulty to say that her dad is violent. So it's like there's maybe a propensity to want to imagine her father not as violent. There's an awareness of the difficulty of that. Right? And then she says, “No one likes to say or admit that your parent is violent.” So there's this kind of knowledge of the idealization of not wanting to sugarcoat the abuse, to want to not see the abuse. And then there's this acknowledgement, “My father was really violent verbally.” So yeah, you could kind of see this person working through and mentalizing in real time, or changing, or kind of adjusting. Right?

Berthelot:

Yes.

Puder:

Yes. So what would you score this one? Five? 

Berthelot:

Yes, it is difficult since when we score, we have access to the whole response, a big portion.

Puder:

This is just a small portion. 

Berthelot:

Yes. Probably that person, from what we see here, is around 6 or more, since she's quite reflective. And if we had access to the whole narrative, probably we would see more complexity to that.

Puder:

Okay. And then this last one, “Oh, sometimes I would just be studying and she would have a tantrum for no reason. But now I can understand. She was in a frustrating situation with her husband because he was never there. He wasn't taking care of his children. So I was the one who paid the price for it. That's how I see it today. It's like she took her frustration out on me.” So it's kind of like there's an acknowledgement of the mother's displacement, of the mother's anger from the husband onto her. It seems a little bit overly justifying the mother's bad behavior. So I could see why this is a more subtle example. Right? Tell me about this one.

Berthelot:

Yes. I think she's doing, what's the most difficult to do when you're mentalizing trauma is to try to tease out the perpetrator's mental state. So it's much easier to reflect on your own mental states than reflect on the perpetrator's mental states. Here we took that example again to make the difference between when you're justifying past abuse saying it was deserved, a good way to react. Here, she doesn't take the blame for the abuse. She says she had knowledge that this was inappropriate, but she can see that the mother was undergoing a conflictual situation. It was not easy for her in that, as you said, there was a lot of displacement of the mother on her. She acknowledged that developmental perspective. She can say, “That's how I see it today,” implying that when she was younger, she didn't see it this way. So there's something interesting again here. Having only that passage, it will probably be around a 5. It's not, there's something missing. But that's some interesting. Yes. Interesting response.

Puder:

Very good. So tell me, maybe, I think we're probably going to have to do a follow up, getting more into the details of things like the different scorings and stuff as you get further along. I know you guys are developing a manual for that, specifically for trauma. I think that you've shared an early version of this, and I know you're working on finalizing it, which I'm excited for you guys to get that out there and start doing trainings and such. And more people hopefully will do research. I have people email me quite often and they're like, “You know, I'm an undergrad. I want to do a PhD in this. What do you recommend?” And I've started to point them towards labs that are doing this kind of work, because I think it's so important. It's really good. And we need a lot of youthful energy to do these, because it's very time intensive. Right? To do the scoring. 

Garon-Bissonnette:

Yes. Yes. I had a lot of youthful energy. A little bit less now, but….

Puder:

Oh, yeah.

Future Directions in Trauma and Attachment Research (01:12:54)

Puder:

Oh, it's like there's a reason why there's only so many score studies on reflective function. Yes. And it's because it's very time intensive to do an adult attachment interview and then to score it for reflective function. Right? Yes. It's costly. So hopefully, at some point, I can do some fundraising for this type of research. So we'll have to hope that I can raise some money for further studies like this. Where do you think that…when you think about where the studies are today, what would you like to see in the future? What are you hoping for, Julia? You're young, you're in your postdoc at Vanderbilt. What are you hoping someday to have as part of your lab and to see accomplished?

Garon-Bissonnette:

Yes, that's a good question. I think what both of us are hoping to move forward to is really complimentary. And, for me, I think I really am trying to better understand what's happening in those moments of either lapses or good reflective functioning. So we have a study right now in Quebec that Nicolas is leading that he can talk about more about, really processing and using multimodal information to really better understand reflective processes. And for me, I'm really interested in how that relates to functioning for individual-level mental health, for example, but also how that relates to the parent-child relationship, and really, in those moments. And so trying to really have more of a microscopic view of those processes. I think a lot of the theory around mentalizing is that it is somewhat a co-regulatory process when you're in a relationship with others, especially with kids, who are highly dependent on their parents. And so trying to better understand how that co-regulatory power of reflective functioning occurs in these moments.

Measuring Parent–Child Co-Regulation in Ecologically Valid Contexts (01:14:56)

Puder:

Interesting. Yes. I'm thinking there was this moment where I took my daughter to this really hard basketball practice. She was young. She was probably in fourth grade. Yes, fourth grade. End of fourth grade. And it was so hard. There were a couple balls that hit her in the head, passed too quickly, you know, there were older girls, she's crying. It was like she got in the car and she's like, “I never want to do this again.” And it was really hard to watch the practice. It was painful. I was suffering watching the practice. You know? And this is probably the way that I remember talking about it was, “Yeah, it makes sense. It's really hard. It was a really hard practice. That was the hardest practice you've ever been through, but I'm so impressed that you got through the whole practice, despite it being as hard as it was.”

Puder:

And then we did like some meaning-making about how doing hard things is good because it's how we grow and I said, “Look, if you want to continue to do this, it's up to you. I think it's going to help you be a better basketball player eventually. It's going to take a lot of work. It's going to take a lot of these things.” It could have been almost a traumatic experience, but I think that the post discussion, and she was completely regulated afterwards. We had ice cream, and then we went home. She was in a great mood. What do you think about that in terms of an example of putting words to? Is that kind of what you were talking about? How we put words to things? How we connect with someone in the midst of distress?

Garon-Bissonnette:

Definitely. And I think that's a great example of doing it. I think, unfortunately, in labs and in research, we tend to sometimes miss those moments. So I think it's about finding ways to measure moments that might be ecologically valid for families or that might, in the lab, kind of lead to negative affect or frustration in kids and how we can then look at how parents adjust. So I think those moments are harder to see in the laboratory. And so that's kind of where I want to see them in the lab. Yes. But that's kind of where I see a lot of work being needed and especially, if we think about it. I tend to study younger kiddos for whom the language of meaning-making, like the direct path of how the process that you're illustrating with this experience with your daughter, might be less direct. Right? If we're thinking about doing this with an eight-month-old kid, then what is it that makes it make sense? I think we still have a lot of work to do there. And I'm sure it is important. But I think we still have a lot of ways that we could better understand the active ingredients of this.

Puder:

Yes. I think about, in the psychoanalytic tradition, you'll often do these home observations. So they find these families that are okay with you just basically standing in the home observing mother-infant interactions. You're not talking. You're just observing and you're actually just like a fly on the wall. Right? And you might be there for 10 hours, just kind of  watching a day of this person's life. Yes. And then I'm thinking about the patients that I have that have had issues with bonding and have kids, and it's not every day that they're going to have issues. Right? Maybe they're extra sleep deprived. Maybe they're having an argument with their spouse and they're more dysregulated. And it's in those moments that they're not feeling as connected or they're having these very, very strong intense emotions. How do you start to capture that in a lab if you're not in that sort of situation where you would get that evocative day? 

Garon-Bissonnette:

Well, I don't want to get us too far from the topic of the podcast, but I think now, with technology advancements too, we have a lot more ways to have cameras that are a lot less invasive. I know of people who use the baby monitors that people put on top of cribs, and then they can have access to the recordings at pretty much any time that someone's in the baby's room. And so I think we can try to use these technologies in research as well. So maybe it's not happening in the lab, it's happening in the home. But I think we can have better ways of capturing it now.

Puder:

Love that. Yes. That's good.

Berthelot:

That's exciting.

Puder:

Yes.

Berthelot:

And, I think the example you gave with your daughter is really evocative of the things we're trained to capture. And we think that trauma RF is a good proxy of how parents will respond in such a situation. Because I think your example is highly evocative of how complex it is to be a parent and how complex it is, especially in an emotionally odd situation. And it's so difficult because, as you said, when you see your child in pain, you feel the pain as well. So, you have to accept experiencing that, validate that emotion, contain that, reflect on that, and then intervene with your child. And that's why we think trauma RF is so important because people who have experienced trauma have intense stress during their life.

Early Findings and Clinical Promise of the STEP Program (01:21:00)

Berthelot:

So when they see their child in pain, it may be much more difficult than other parents. And even in other parents who did not experience trauma, that's a very difficult situation to manage. And I think trauma RF helps us to understand that some parents will have a very inappropriate reaction under these circumstances, will laugh at the pain of their child, or will jump on the field and yell at the coach. But we can understand that  from what they went through. And to respond to your initial question, what we want to do next with the future. I think that knowing that, what we can try to do, is try to prepare parents as much as we can. And the way we do it, Julia and I, and our team, is to intervene from pregnancy based on these principles of trauma-specific reflective functioning and mentalizing. So we did develop an intervention, which is called the STEP program, supporting the transition to an engagement and parenthood program, which is one of the very first interventions especially designed for survivors of trauma, where we have nine sessions trying to mentalize about different elements, but especially about themselves as people, as parents, and their experience of trauma for them to be more comfortable when situations, as the one you described, will eventually arise and the child will be there.

Puder:

Do you have a result of this yet? How has the STEP program been?

Berthelot: 

Yes, we have several results. First, we took the time to develop that program since it's kind of tricky discussing trauma during pregnancy, which is a very sensitive life period. So we have good data supporting the acceptability of the program, both from the point of view of experts and from the point of view of parents. And then we evaluate the program with, I think we reached about 80 participants so far. Parents, women who have experienced trauma, who participate in the program. And when we look at how they evolved during the program, when contrasting with people who had undergone trauma but did not receive the program, we see a decrease in depression, a decrease in anxiety, an increase in emotional regulation and a decrease in unresolved trauma as well. So it seems like it's highly beneficial. And now, we're following these families over time and trying to see how the relationship with their child unfolds. And that's where Julia's expertise will be quite important for the future to look at the parent-child relationship.

Puder:

How much did the RF scores change pre and post?

Garon-Bissonnette:

We don't know that yet. We're coding right now. So hopefully they did change. We think it's at least a mechanism of change, but it'd be fantastic to see it as an outcome too. 

Puder:

I know the changes, it takes time. Right? So nine sessions would be surprising to me at this point. But I would be happy to see that. And transference-focused therapy (TFP), we know that twice-a-week therapy over the course of a year can improve a change in reflective function. So we do know that there are studies that show there can be an increase [see episodes 140, 170, and 231]. 

Puder:

So I run cohortsand we're potentially going to be doing some research to see if eventually we'll be maybe looking at pre and post reflective function, as well. And I would like to see if a provider’s reflective function can increase a little bit over the course of a year. I think they do, from what I read of their responses to questions. We have weekly reflective questions, but this is great. This was a great conversation. I'm excited to connect with you guys. I'm looking forward to maybe having some further episodes down the line as new papers get published, as you get further along in your journey. And if you're incredibly wealthy, and you're listening to this, I'm sure they could use some funding, so you could find them and provide them for their research teams. 

Puder:

Alright. Yes. Any other final thoughts or any other final things going through your mind? I'll have links to your articles on my website. People can find your links to your bios, and it was wonderful having some primary research on here and getting into the details. So thank you.

Berthelot:

Thank you very much, David, for the invitation. It was a very nice discussion. It was a pleasure.

Garon-Bissonnette:

Yes. Thanks so much for having us. It was great. 

Additional Reading

Anis, L., Perez, G., Benzies, K. M., Ewashen, C., Hart, M., & Letourneau, N. (2020). Convergent validity of three measures of reflective function: Parent Development Interview, Parental Reflective Function Questionnaire, and Reflective Function Questionnaire. Frontiers in Psychology, 11, 574719.https://doi.org/10.3389/fpsyg.2020.574719

Berthelot, N., Ensink, K., Bernazzani, O., Normandin, L., Luyten, P., & Fonagy, P. (2015). Intergenerational transmission of attachment in abused and neglected mothers: The role of trauma-specific reflective functioning. Infant Mental Health Journal, 36(2), 200–212. https://doi.org/10.1002/imhj.21499

Brugnera, A., Zarbo, C., Scalabrini, A., Compare, A., Mucci, C., Carrara, S., Tasca, G. A., Hewitt, P., Greco, A., Poletti, B., Esposito, R., Cattafi, F., Zullo, C., & Lo Coco, G. (2018). Attachment anxiety, reflective functioning and well-being as predictors of burn-out and psychological distress among psychotherapists: A longitudinal study. Clinical Psychology & Psychotherapy. https://doi.org/10.1002/cpp.2823

Clarkin, J. F., Levy, K. N., Lenzenweger, M. F., & Kernberg, O. F. (2007). Evaluating three treatments for borderline personality disorder: A multiwave study. American Journal of Psychiatry, 164(6), 922–928.https://doi.org/10.1176/ajp.2007.164.6.922

Cologon, J., Schweitzer, R. D., King, R., & Nolte, T. (2017). Therapist reflective functioning, therapist attachment style and therapist effectiveness. Administration and Policy in Mental Health and Mental Health Services Research, 44(5), 614–625.https://doi.org/10.1007/s10488-017-0790-5

Doering, S., Hörz, S., Rentrop, M., Fischer-Kern, M., Schuster, P., Benecke, C., Buchheim, A., Martius, P., & Buchheim, P. (2010). Transference-focused psychotherapy v. treatment by community psychotherapists for borderline personality disorder: Randomised controlled trial. The British Journal of Psychiatry, 196(5), 389–395.https://doi.org/10.1192/bjp.bp.109.070177

Fischer-Kern, M., Doering, S., Taubner, S., Hörz, S., Zimmermann, J., Rentrop, M., Schuster, P., Buchheim, P., & Buchheim, A. (2015). Transference-focused psychotherapy for borderline personality disorder: Change in reflective function. The British Journal of Psychiatry, 207(2), 173–174.https://doi.org/10.1192/bjp.bp.113.143842

Fonagy, P., Steele, M., Steele, H., Moran, G. S., & Higgitt, A. C. (1991). The capacity for understanding mental states: The reflective self in parent and child and its significance for security of attachment. Infant Mental Health Journal, 12(3), 201–218. https://doi.org/10.1002/1097-0355(199123)12:3

Fonagy, P., Steele, M., Steele, H., Leigh, T., Kennedy, R., Mattoon, G., Target, M., & Gerber, A. (1996). The relation of attachment status, psychiatric classification, and response to psychotherapy. Journal of Consulting and Clinical Psychology, 64(1), 22–31. https://doi.org/10.1037/0022-006X.64.1.22

Fonagy, P., & Target, M. (1997). Attachment and reflective function: Their role in self-organization. Development and Psychopathology, 9(4), 679–700. https://doi.org/10.1017/S0954579497001399

Fonagy, P., & Bateman, A. W. (2006). Mechanisms of change in mentalization-based treatment of BPD. Journal of Clinical Psychology, 62(4), 411–430.https://doi.org/10.1002/jclp.20241

Hörz-Sagstetter, S., Mertens, W., Isphording, S., Buchheim, A., & Taubner, S. (2015). Changes in reflective functioning during psychoanalytic psychotherapies. Journal of the American Psychoanalytic Association, 63(3), 481–509. https://doi.org/10.1177/0003065115591977

Josephs, L., Anderson, E., Bernard, A., Fatzer, K., & Streich, J. (2004). Assessing progress in analysis interminable. Journal of the American Psychoanalytic Association, 52(4), 1185–1214. https://doi.org/10.1177/00030651040520041301

Katznelson, H. (2014). Reflective functioning: A review. Clinical Psychology Review, 34(2), 107–117. https://doi.org/10.1016/j.cpr.2013.12.003

Keefe, J. R., Levy, K. N., Sowislo, J. F., Diamond, D., Doering, S., Hörz-Sagstetter, S., Buchheim, A., Fischer-Kern, M., & Clarkin, J. F. (2023). Reflective functioning and its potential to moderate the efficacy of manualized psychodynamic therapies versus other treatments for borderline personality disorder. Journal of Consulting and Clinical Psychology, 91(1), 50–56.https://doi.org/10.1037/ccp0000760

Kivity, Y., Levy, K. N., Kelly, K. M., & Clarkin, J. F. (2021). In-session reflective functioning in psychotherapies for borderline personality disorder: The emotion regulatory role of reflective functioning. Journal of Consulting and Clinical Psychology, 89(9), 751–761. https://doi.org/10.1037/ccp0000674

Levy, K. N., Meehan, K. B., Kelly, K. M., Reynoso, J. S., Weber, M., Clarkin, J. F., & Kernberg, O. F. (2006). Change in attachment patterns and reflective function in a randomized control trial of transference-focused psychotherapy for borderline personality disorder. Journal of Consulting and Clinical Psychology, 74(6), 1027–1040. https://doi.org/10.1037/0022-006X.74.6.1027

Sadler, L. S., Slade, A., Close, N., Webb, D. L., Simpson, T., Fennie, K., & Mayes, L. C. (2013). Minding the Baby: Enhancing reflectiveness to improve early health and relationship outcomes in an interdisciplinary home visiting program. Infant Mental Health Journal, 34(5), 391–405. https://doi.org/10.1002/imhj.21406

Slade, A., Holland, M. L., Ordway, M. R., Carlson, E. A., Jeon, S., Close, N., Mayes, L. C., & Sadler, L. S. (2020). Minding the Baby®: Enhancing parental reflective functioning and infant attachment in an attachment-based, interdisciplinary home visiting program. Development and Psychopathology, 32(1), 123–137.https://doi.org/10.1017/S0954579418001463

Steele, H., Perez, A., Segal, F., & Steele, M. (2016). Maternal Adult Attachment Interview (AAI) collected during pregnancy predicts reflective functioning in AAIs from their first-born children 17 years later. International Journal of Developmental Science, 10(3–4), 117–124. https://doi.org/10.3233/DEV-16201

References

Berthelot, N., Savard, C., Lemieux, R., Garon-Bissonnette, J., Ensink, K., & Godbout, N. (2022). Development and validation of a self-report measure assessing failures in the mentalization of trauma and adverse relationships. Child Abuse & Neglect, 128, 105017.https://doi.org/10.1016/j.chiabu.2021.105017

Berthelot, N., & Garon-Bissonnette, J. (2025a). Characterizing the heterogeneity of disruptions in the resolution of trauma among women exposed to childhood maltreatment. Development and psychopathology, 37(3), 1176–1189. https://doi.org/10.1017/S0954579424001019

Berthelot, N., Garon-Bissonnette, J., Muzik, M., Simon, V., Menke, R., Stacks, A. M., & Rosenblum, K. L. (2025b). Resolving trauma: The unique contribution of trauma-specific mentalization to maternal insightfulness. Development and Psychopathology, 37(3), 1280–1293. doi:10.1017/S095457942400110X

Fonagy, P., Target, M., Steele, H., & Steele, M. (1998). Reflective-functioning manual: Version 5 for application to adult attachment interviews. University College London. https://discovery.ucl.ac.uk/id/eprint/1461016/

Gamache, D., & Savard, C. (2017). Self and Interpersonal Functioning Scale (SIFS) [Database record]. APA PsycTests. https://doi.org/10.1037/t72315-000 

Simon, V., Kobielski, S., & Feiring, C. (2008). Trauma Meaning-Making Interview [Unpublished protocol]. Wayne State University.