Psychiatry & Psychotherapy Podcast - Intergenerational Trauma Explained: The Role of Reflective Function and Mentalization in Healing Attachment

Episode Date: October 17, 2025

In this episode, we explore how intergenerational trauma shapes attachment patterns and how reflective function (RF) and mentalization can help break the cycle. Drawing on research from Fonagy, Slade, and Berthelot, we examine how trauma-specific reflective functioning influences disorganized attachment and how therapies such as Mentalization-Based Therapy (MBT), Transference-Focused Psychotherapy (TFP), and Minding the Baby (MTB) strengthen reflective capacity and promote secure attachment. Join Dr. David Puder and colleagues as they discuss the science of mentalization, attachment repair, and trauma healing, bringing together psychoanalytic, developmental, and biological perspectives to offer hope and clinical insight for patients, parents, and therapists alike. By listening to this episode, you can earn 1.25 Psychiatry CME Credits. Link to blog. Link to YouTube video

All right, welcome back to the podcast. I am joined today with three residents. We will be discussing an amazing paper called Intergenerational Transmission of Attachment and Abused and Neglected Mothers, the role of Trauma-specific Reflective Functioning. We have an R2, Khaled Itani. We have an R3, Sharia Cherlowe, and we have an R4, Fidel Schumann. Perfect pronunciation. Oh, three. They all three. Better than at graduation. So this is exciting.

We are doing this live. There's no video of this. We're doing it live in Winter Park, Florida. And I'm excited to go through this paper with y'all. Yeah, same. Thank you for having us. I was just telling Dr. Peter that, you know, when he first presented this article to me, it was kind of short in a way, but it's shock full of information, so much lore.

It's really, really dense with a lot of, you know, other stuff. studies that are interwoven in this. And I think this kind of ties it all together very nicely. Yeah, we've talked about reflective function on this podcast. I had Dr. Steele on, who was part of the manual. I had Phonigion who's part of the manual. Reflective function is essentially the measurement of the adult attachment interview in the adult attachment interview of the mentalization that's going on in the adult attachment interview. And then so this takes a step further and it looks at mothers. And I just want to give that brief introduction. But I think the why is really important, like why it's worth spending an hour, an hour and a half talking about

this article. Do you guys have a why? Do you imagine a why? Sharia? I definitely have a why. I think that it's really important to understand like intergenerational trauma and like how it can lead into a child's life and how they function afterwards. Yeah. Yeah. Yeah. For me, the takeaway the big why for me is like a lot of mothers or people in the community are afraid that the trauma will be passed on automatically, but a deeper understanding of, you know, this reflective function, higher reflective function. It doesn't have to be that way every single time. So it's worth exploring for sure.

Yeah. And I don't think it's a hopeless message. If we know, if we can clearly say this is the problem, here's the solution. And then as a culture, as a society, I'm hoping the more and more people understand this, the more and more we can create policies to actually reverse and help. Go ahead. Khaled. So for me, you know, the mentalization process is really a love letter to like our future generations. Because we're finding that, you know, we have like the therapeutic modes and we have some unresolved traumas.

And if we go out of our way to, you know, address those, resolve those, this will show in the future generation. And we're finding that in the infant, some of these attachment dysfunctions can develop very early on, sometimes as early as like four months. And so if more people were aware of this, they would pay more attention to how critical this early period is. Absolutely. Yeah. Yeah, I was reading this stuff when my kids were born. And I remember reading the Stillface Experiment. And I was reading Edtronic's book, which is like a thick research book while I'm bouncing her at night.

you know, like for hours because she had colic, I'm like trying to understand this stuff. And I think it made a huge difference. I think it made a huge difference. And it's not just mothers too. I think this study is specifically about mothers, but there are other studies about fathers. It's good to start with one study. I think this is a strong study. I think it was well done.

So we're going to start with this one. But the impact on fathers and on infants is actually very important as well. and we may have time to mention some of those things. Absolutely. So where do we want to begin? I think because it is a rather technical article, we can spend some time going into some of the very technical psychoanalytic terms

that I think are foundational to kind of pursuing this text further. I think we should give like an abstract before we get there. Like an abstract is in like this is why it's important. without any of the technical words, if possible. Yeah.

Okay? Yeah, yeah. Let's do that. So, and then let's get into the nitty gritty. Because I feel like we're going to lose people if we jump into the kind of the fun stuff right away. Which I actually had one listener reach out to me recently and they were like, actually when you say this is going to be really hard to understand, it actually inspires me to pay more attention and pull out a notebook. And so if this is hard for you all, get the article, listen to this, try your best understanding it, then get the article, read it, and then maybe re-listen to it.

And you'll get it. Okay. So what's the abstract? I can talk about it in, I guess, simpler terms. So basically the study is about how our patterns and trauma can reflect onto our children and how the ways in which you understand. interact with your children can affect their well-being in terms of, like, for example, how you react in a scenario, how you think of your thoughts versus a child's thoughts when something

goes wrong, for example. And something really important with this study is that it's never too late. Like, you can do this before you're pregnant, while you're pregnant, even after, and it still has lasting impact. Absolutely, yeah. And it's kind of the balance of as well, something that this article kind of ends with. It's almost like a point of optimism and a big takeaway that, you know, you have mothers who experience trauma. That experiencing of trauma is important, but their ability to mentalize that trauma, the ability to kind of process that trauma is really what can make the big difference in their relationship with the infant later on. So if anything, I found this article in a sense rather hopeful, and that it's kind of pointing to that very key fact.

Okay. Abstract. Yeah, I totally agree with those points, and it kind of mirrors, like, the attachment styles that were highlighted in the article, such as, like, you know, disorganized attachment styles and how that's built early on and how you can potentially avoid or negate some of those attachment styles from building as an infant and then later manifesting as an adult if you have that mentalization, I guess, skill or understanding of your trauma. Right. Okay. So here's my attempt. Okay. So if you have had abuse and your high reflective function in the trauma itself. So if you were to talk about the trauma, you're able to speak about it fluidly, detailedly, without dissociating, without disavowed emotion, if you're able to do that, you have a very high likelihood. that your child is going to have a secure attachment, an organized attachment, not a disorganized attachment style. And disorganized attachment style leads to future dissociation.

It's the simplest way. It's like a fear without solution. If, on the other hand, you have abuse and you have low reflective function when discussing the trauma, meaning low ability to mentalize what was going on, the emotions, maybe you dissociate during discussing it, that leads to a much

higher likelihood of having future disorganized attachment child. And so that's my abstract. Okay, now let's go into the details on each of the terms. So definitely to understand this article and kind of articles in a similar family, we need to know about mentalization as a term and reflective functioning. And the two terms work hand in hand because reflective functioning really is a measure of mentalization. So most texts, the way they tend to describe the mentalization, is like the capacity to think about oneself and others, in this case, the infant as a psychological being. In other words, more so reflective of how you interact, how you perceive the emotion, how you can kind of anticipate, how you can kind of relate, how you can respond.

And mentalization is correlated typically to better psychological outcomes because it's kind of related to, in a sense, how you process and how you kind of relay that back. Now, in the therapeutic practice from the literature that I was going through, there is a difference between mentalization and empathy. So mentalization can help with empathy, and some authors even argue you need to mentalize and able to empathize. I just thought that was a very interesting distinction that I came across. Yeah, well put.

So the ability to mentalize is to understand your own and the other person's desires, emotions, experiences, it's your ability to read a person accurately or accurately, but with a little bit of hesitancy that you're not able to really read them, right? So we know that like when people with borderline personality sort of, for example, lose their ability to mentalize that go into psychic equivalence mode,

which is a fancy way of saying that their experience of the other person is really, reality, even if that other person is saying, no, it's not reality. Okay. So to be able to mentalize the other is to be able to understand the other as a separate person. And so there's a humility there that needs to be there. And then reflective function is, do you want to talk about reflective function now?

I wanted to talk about like kind of the scale, like how it's determined what reflective function is in a way. So it's scored on a 11 point scale from negative one to nine. negative one is negative reflective functioning, which would mean totally barren or rejection of mentalization. For example, if someone asked you a serious question, like, what was your parenting style like when you were growing up? If someone just said, I didn't know, or they say, how would I know you're the psychologist? That would be a negative one. Right. It's the rejection of the question itself. So you have a why question. Reflective function is really looking at the why questions. And then

it's a rejection. I don't know. You tell me. You're the psychiatrist. You know, that kind of like grittiness or like, how dare you ask me? How dare you? That it's not just not reflecting. It's like the negation. So that's why they made it a negative one. Yeah. And then for me, I kind of like to bounce off that for a reflective function relating to like a mother and a baby. I kind of want to look at examples of it. And, you know, if a baby's crying in front of you or, like, crying in front of the mother, a good, like, person with a high reflective function could say, my baby's crying triggers my memories, but that's mine and not his. I can still comfort him. Someone with, like, a low reflective function could, like, see the crying and freeze and lash out and dissociate, like, you were

saying, but also, you know, in that relationship with the infant, inadvertently sometimes. Yeah, wow. Okay, I actually have an example of that it's kind of scary. Yeah. We had these people over to our house. I'm pretty sure they're not listening. If they are, we love you guys. Good people.

But this was a scary moment, okay? Yeah. So we're all around the jacuzzi, and their kid falls in the chakuzzi. And the mom is like one foot away. Sees the child fall in, freezes. Mm-hmm. Okay. My wife is like five feet away, sees this, goes over and grabs the child out of the pool from drowning.

you know and we we like we were like what the heck and I was like she dissociated yeah and it was that fast it was distressed dissociation so you know if you have a lot of unprocessed trauma and you dissociate very easily you know put a life fest on your child uh take take take take take the extra precaution but you know this is kind of like the extreme version of it right yeah um but it's that but think about like if they're talking about like if they're talking about their adult attachment interview and they're talking about the trauma in the adult attachment interview, then they may not, then they may dissociate during them talking about it. And so they're going to get a lower score there because they're not able to reflect on their

own experience and the other person's experience. They're out. They're out of it. Yeah. Okay. But keep going. I want you to go through the scores and what you learned. So then nine would be exceptional reflective functioning. So unusually complex and allowed. reasoning about mental states. So, for example, if someone had asked during the adult attachment interview, did you ever feel rejected as a child? How would you think that someone would respond with a nine? Or the question would be, why did, when you felt rejected as a child, usually it's like during a specific story, why did your parents reject you? Because that's, or I guess they could enter into a deep level of reflection without a demand question,

but the demand questions are really like the why questions. And so... So there are predictive questions, and then there's demand questions. So... The demand ones, or the demand ones demand the person to reflect. Okay? And so, so Abraham Lincoln. Deep dive here.

Here we go. Going back in time. I don't think I mentioned this on the podcast before, but I give lectures on reflective function to some like grand rounds or whatnot. And this is part of it. So he wrote a letter to John Stewart. This was after, I think,

Anne died, who was like his partner. And he said, 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 earth.

Whether I shall ever be better, I cannot 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. Okay. So I give that a five. Negative one to nine, okay? Now, I know a little bit about his life, and so now I'm going to make it into a nine, okay? Okay. This is my best thing, okay?

I mean, it's dark, but he seems like he understands... You can feel it. It's visceral, right? Maybe it's more visceral than mine. Very curious for the nine. Anne's death has overwhelmed me, bringing to consciousness old feelings that I now recognize as anger. Anger I dared to admit as a boy when my father punished my scholarly ambitions, instead turning the rage inward and reshaping it into persistent guilt and self-blame.

Likewise now, confronted with my helplessness to save Anne, the anger returns, but again finds no outlet, no target but myself, transforming once more into deep and paralyzing melancholy for which I see no escape. It's like textbook perfect. Do you think so? Because, I mean, even like the phrase like bringing into my consciousness really speaks to that, you know, reflective process that's occurring. So I think it's a higher score and I love, I love his own quote.

I mean, I think viscerally his own quote grabs me. Yeah. But specifically, I think this is high reflective function because he's connecting the past to the present. Abuse. The impact of his father and the powerlessness there with the powerless currently, so the connectedness of those,

the understanding of the internalization of anger into his depressive personality. He had a depressive personality style. So he kind of, like the understanding of his psychodynamics, right? And then the realization of why the anger is so hard to, because anger is usually you're moving towards a goal and there's an obstacle and then you get angry because you feel thwarted towards your goal and then the anger helps you

overcome the obstacle to move towards your goal. Okay. Tell me one example of anger that it's not that and I would be very surprised. It's always that, okay, in my mind. At this point, that could be a very low reflective function statement by the way, kind of an all or nothing, but in general, that's what I see. Should we score that at three? We could score that. If someone can prove me wrong, then it would score lower. But right now it's a nine. And then that egocentric scoring of myself as a nine also brings me down lower, though.

So that hurts it. So what a two right now? So I'm like digging myself a hole. No, you just went back up to a nine by calling it egocentric in a way. But I recognize I'm doing this to humor you guys. So that actually raises my score. There you go. Well, humor is like the highest cognitive faculty, right?

No, because I'm... Because I'm interpersonally aware of your responses and then tailoring my response to that, which also increases a reflective function. Okay, you can see how you can play this game. It's fun. So in the RF manual, there's, like, different sorts of types. Like, basically, this is an example of, like, how somebody would score.

So, like, for example, like, there's, like, self-serving RF, there's disavowal RF. Right. So that, exactly. Like, so if I say too many self-serving comments, You know, like, you know, people that always drop these like, I'm great, you know how great I am. That's actually a lower RF. So people with more narcissistic traits score in the threes more commonly.

Yeah. Okay. BPD 2.7, eating disorders, 2.7, inpatient around there. Prison across different prison studies, like one to low twos. So actually prison is lower, which kind of makes sense because. Because they're moving instead of in words, they're moving in actions, right? Yeah. Something was brought up in one of the articles we read that there was a lot of scores in the high-risk population from one to two.

And maybe there's need for a little bit more scoring within those categories because there's so many different types of high-risk population that you can't really score well. Yeah. So explain that? Basically there's an article saying that there's like high-risk populations. for example, like in the prison, that everyone would get a one or two, how do you differentiate it? So they needed to be a little bit more of like 1.5, 1.7, like they don't need to be more to that, to that scoring schedule that they needed to figure out. Yeah, maybe. I think if they're scoring in a one or two range, those are people that are pretty,

they're not really mentalizing. They're like, it's like pre-mentalizing. And these are people that have a hard time naming their own emotions or what other people, emotions are, right? These are people that like, like, you know, have a really hard time imagining another person's mind separate from their mind. Which if you're very, so we have to also realize not everyone will imagine your mind

in the same way that you imagine their mind when you're talking to them. What does a negative one look like? A negative one is just the disavowal. So it's like you, you have a disavowal. you ask any question, and then they get hostile towards you. So this is like the person withdrawing off of methamphetamines, who you're like, what brought you in here?

Get the, out of my room. How many times do I have to tell you? Get out, get out. And you're like, sir, I just need to know your medical history. I said, get out. And I would actually say, like, document that, okay? Get some notes from the nurses on what's going on. get some, you know, look at all the chart.

Collateral. Collateral. That's what you can do. That's what you can do. Don't spend an hour talking to that patient. It's probably going to get worse, right? So wait for the RF to increase a little bit. No, no, no, no. Let the meth get out of their system further.

Right. So, okay. Yeah, and then, so we talked about the scores a little bit. Okay, and I think that's important to understand. And so I teach these cohorts now, and we actually, like, once a week we'll go through RF questions, talk about they'll write something. And I'm not scoring them, like I'm not saying, that's a two, you know, that kind of thing. We're trying to create a space for everyone to kind of develop and grow and expand their RF.

So wherever their starting point is. All right. What's the next one? Are we talking about the other measures? Yeah. We can. But just before we wrap up on RF, there was just one tab I wanted to put in it. This article did something rather interesting.

It did make a distinguishing of RFT, so Reflective Function as it relates to trauma in specific. And this was a very intentional move, and they did comment on it. And the purpose for this is that deficiencies in reflective functioning as it relates to trauma does not necessarily indicate global deficits of other, you know, RF as it comes to other. things. So I thought that was something interesting to mention as well. Yeah, really cool. I think it was needed to separate those, and I think they found a really cool link between specifically RF in the trauma narrative, which is what I've found as well as I've started checking my patients, doing adult attachment stuff. They'll be low RF in one part of their story. Yeah. But higher RF, higher RF in other

parts. Yeah. And they'll have this one portion of their life or their childhood that where their state of trauma occurred. And there'll be a lot of disavowed emotion around that specific thing. And so it's like it gives me language to understand it. The other thing that was that's kind of linked in my mind, but a little bit different is in cognitive processing therapy or CPT, cognitive processing therapy. They will look for guilt in the trauma. And I think about how, like, if you are blaming yourself for something that you were the victim of, that's a lower RF sign. But in that type of therapy, that would actually be something that they would laser in on and try to decrease the guilt. If you can decrease the guilt, you can actually help them work through the trauma.

And so just having a score is like one thing, but then knowing how to do the work is, I think another thing. How do you reduce the shame and reduce the internal self-hatred and loathing of them in the midst of their trauma? I think that's where the magic of psychotherapy happens.

Yeah, I don't even want to know what my RF is. I don't know what that says about me, but... Well, that says that says that there's a healthy amount of concern. Yeah, we could probably score that. Yeah, we actually could help you with that. Unhealthy avoidance of the mentalization.

Well, because I haven't asked you a question yet on your, that would be like a demand question. I'm not going to score that one as a negative one. Okay. Thank you so much. Okay. No, I think there's a little bit of trepidation. Actually, I heard this from one of the, um... Well, if I'm comfortable with it, I can only imagine what patients feel, you know? So they were...

They even want to go there. You know, most of my patients that I've like... ask them to go through something like this, it's like they just want to get better. So if this is like something where you can pinpoint, like, hey, this is an area that we can get an idea of how you're doing in certain parts of your story, then we can try to deepen it, you know?

I think it's really good. Listeners embrace it. That's what I say. But, you know, so I've created, I haven't released it yet. Maybe like in a couple months I'll release it, but I'm creating like a reflective function. journal, which takes people through the process of how to increase their RF.

Okay. So this will be the first, like, this will be the first hint of that. But I'm excited to get that out there. Okay. Let's, so we talked about RF. We talked about that there was a separate RF trauma scale. So they gave these mothers the adult attachment interview. They scored their RF.

They scored their attachment style. They looked at passages where they spoke about trauma, near-death, experiences, lots of fear, right? And then they scored those separately and gave that a number as well. And what else do we want to cover in terms of like the particulars here? So we can kind of do a brief overview of what the disorganized attachment is then. In other words, like what we're looking for. I mean, we did speak about a little bit earlier. We do tend to correlate this disorganized attachment to dissociative states. And then we did also mention earlier as well that, you know, it kind of, it's almost like a third space at loss of better words

and the schema of how we kind of regard the attachment styles. So attachment styles, when they were first described, it was organized and then the disorganized ones. And even among the organized ones, you had like the secure and the non-secure. And then aside from that, we had the disorganized. So not all the organized ones are functional, a loss of better words. They're not all secure in that, you know, like for example, avoid an simplification, but tends to come from rejecting parenting, or anxious can come from inconsistent responses.

But then when we have secure, that's also following like a set predictable pattern, hence it's an organized response. But when we get to disorganized, it's almost as if, you know, you have two conflicting responses at play at the same time. And the way

you had described originally, it was like the fear without solution. And, you know, manifestation again being dissociative states, and above all a paradoxical pattern. And so there was some talk on what did that look like. And I think Dr. Peter maybe you can speak more to that on what that looks like in real practice. I mean, there's like a classic example they give in the text.

It's like the toddler that may walk towards their mom but with their head down or like turning away. They may briefly be very angry and then, you know, go back to normal. Sometimes this is a crowd does like a momentary response. Like they may start to move back towards mom but then dissociate and like freeze. like flop on the ground, and then go the other direction or go to mom, right? There's no organized way of reconnecting to mom. So in the attachment interview,

it's done about a year and a half of life. The mother leaves the room, comes back into the room, and then what does the child do when the mother leaves and the mother comes back in the room, right? And then they're scoring that. It's very consistent, statistically. And a lot of people don't even know that disorganized attachment style is a thing.

Like, have you guys ever heard of that before this? No. I have a psychology degree, so I do, I have heard of that before. You have heard of that in psychology group. Great. I mean, there's a lot of like, you know, when you're in a new parent, you read these, like, attachment parenting books. They won't mention that at all.

Like, it's like they don't really understand a lot of the research. And so it's disorganized attachment. I did two episodes on that. Me and Annabel Kuhn did a great. job digging into that. I want to do more on it in the future because it really helps explain a lot of things. So essentially, when the infant sees the mom, the mom comes back into the room, secure attachment, cries goes to mom, 30 seconds goes back in place. Okay, so like the bounce back to joy is pretty quick. And the, uh, the, uh, the, the thanks.

attachment may go back to mom and then they're distressed for like a lot longer they may be like hitting on mom a little bit they're like upset at mom and that it's like they're really upset and then the avoidant attachment which in the adult attachment interview becomes dismissing same thing dismissing is because they're dismissing of attachment words avoidant because the behavior is avoided so when the when the infant comes into the, the infant is in the room, mom comes back in the room, and the infant just continues to play.

But salivary cortisol, it's gonna be elevated, the child is stressed out. And so you see these kind of diets and adult relationships where you'll classically have, one of the partners who's more avoidant, or dismissing of like attachment stuff, you know, and they've been programmed from a very young age,

when they're distressed, to hide their distress, it's safest to hide the distress for whatever reason. And the more anxious, preoccupied partner will be more verbal, more angry, more trying to connect, more distressed, right? They're verbally worried more about their relationship. And they both can believe in their heart of hearts that, that the most important person in the world is their partner.

They both usually believe that. This is how EFT works magic, because I'm emotionally focused therapy, like helps them find that, you know, and find them, find the emotion, and express it in a way that's helpful, not unhelpful. Okay, so with, you have the anxious, you have the avoidant, And then on top of those things, you can be disorganized.

And so the disorganized, you can be secure and disorganized, or you can be insecure. Usually it's insecure. And it's kind of like this thing that they found where it's like they did these things that didn't make sense where it seemed as if the child didn't have an organized way of reconnecting with mom. So they start to move back towards mom and then they freeze.

Right? That's the classic one. So the main thing that the study found was that mothers with low reflective function in their trauma were 3.4 or 3 times more likely to have infants with attachment disorganization than were mothers with a history of trauma. But high reflective function trauma. So go ahead. I think it's like whenever you maybe you're talking about, talking with clients, they're wondering, like, why is this happening? For example, like, did I do something so, like, largely of a failure or did I really lack that much empathy with my child? Why are they reacting this way? But I think it's important to note, I think there was an article by Beebe in

2010 that said that it's not a, like, a global failure of empathy or engagement, but it's, like, specific failures when the infant is, like, manifesting a distress. So. Yeah, she had, like, this concept of like the momentary failure. Yeah. So Beatrice B.B. 2010. It's a 100 page paper, maybe more. I've tried to get Beatrice Bibi on my podcast multiple times. If you're hearing this, please come.

If you know her, please email me and help me get connected with her. Or anyone that worked on that paper. I would have anyone, actually. I should search them down. So it's a great paper. And basically, Beatrice Bibi videotaped. four-month-old infants and their mothers interacting.

And it was the diatic interaction and what was going on between them that predicted disorganized attachment later on. So if they were disconnected, like babies smiling, mama's got a grimace, babies trying to move away from mother, mother looms in.

So there's like, there's a, there's like, there's not a back and forth a two. a playfulness, right? Confusion. Some confusion, yeah. The source of my fear is also the source of my safety. So that's the confusion there on the infant's side.

Right. The source of my fear is also the source of my safety. It's very confusing. Yeah. And I will say as well, like even with kids with great childhoods, you'll get somewhat disorganized attachment style. And that's to be. because there's lots of things that are contributing.

And also attachment changes too. So it's not like fixed in stone. Like you're more likely to become the attachment of the people you spend like, the decade following the first two years' life, right? So you can change. It's not like once you're like this, always like this. Reflective function can grow too.

Okay. And so I think of it as like a lifelong journey more than like a six month project. But what I'm realizing though is like we have to create the pathway. The pathway needs to be like if you know where you're going, you're more likely to get there, right? So these are goals, right? Okay, we want to grow in these.

We want to grow in reflective function. We want to grow in our ability to hold. people's distress. Speaking about, I guess, meeting our heroes, while I was looking through these articles, I had run into Dr. Slade's work on programs for specifically her MTV program, which is like minding the baby programs. Okay. That were from, like they go from two months of age all the way to two years later,

and they kind of follow high-risk populations. And she actually emailed me back within 12 hours, which is wonderful. And she provided me with her latest article in her book, which she wrote in 2023, which kind of does a good summary of that timeline between the start to like all the way to two years out. Okay. And what did you learn from? Yeah, I can go into that for sure. This program provided intensive home visiting services for first-time mothers, babies and their families beginning in second trimester of pregnancy, and they're visited weekly.

through pregnancy, labor and delivery, the child's first year, and then biweekly until the child turns two. They were following the level of parental reflective functioning, the diatic communication, the quality of attachment, and then they looked into postpartum depression as well. They did screenings for those and post-traumatic stress disorder. They kind of found that in part there was an involvement of there being a social worker and a nurse along with this population that did help with, for example, increasing their rate of pediatric immunizations by one year, just by being involved with the social worker and having access to, for example, like necessities like diapers, and that also kept this relationship going until two years. They had two phases of the study, a phase one cohort and a phase two, and they found that the MTB group reported significantly fewer externalizing behavior problems than did the control mothers when children were between three and five. So it goes all the way out to those time periods. So less externalizing behaviors, so less aggression.

Right. So, yeah, and kids with more disorganized attachment actually have higher aggression in like the age six, five, six, like that age. Okay, go on. Yeah. And so the examination of the odds ratios with this study found that infants in the MTB intervention were 2.69 times more likely to be classified as organized than their control. group peers and 2.59 times more likely to be classified as secure than their controlled group peers. It's pretty significant. This is where we need to have intervention. This is the level that's going to make an impact, you know. And so great, put me in, send her my email. Definitely

will. Connect us over email. I'd love to have everyone. It's interesting too because, so Bibi has a YouTube channel. And on the YouTube channel, there's actually some videos, it's like an hour-long one, like a 30-minute one, that actually shows her sitting down with the mom and going through the interaction with the infant, picture by picture. And that process itself of just looking at the infant's reaction had some therapeutic benefit as well. And it forms some basis of the education. So yeah, we have like the more formalized model

that Steele and others are developing. But I think if it just comes the people's conscious, the interest will naturally spark itself. Is it Steele? It's Slade. Arieta Slade. Okay, I want to get that right. Yeah. I mentioned Steele earlier.

So, okay, that was actually helpful for me, too. When I was studying this was right before my kids were born. And so I was like really into Bibi. And I was like really studying this stuff. And it gave me an incredible meaning for what I was about to go through too. and I felt like any other training was very superficial. It seemed, it seemed, and I also have to thank Dr. Tar, because Dr. Tar was so into this stuff,

the attunement, the moment-to-moment connectedness. There's a video I have of my daughter, and I was singing to her, and she was singing back at me at seven weeks old. Wow. And I think it came from that, like, practice of attunement for that first seven weeks, you know, that I would, she would mimic me.

And so. It's a crucial period. You know, infants kind of, you know, earlier on, they mirror all of your behaviors. So if they see a stranger, right, earlier on they have stranger anxiety, they are going to look to your reaction first. And if you're smiling at the stranger, they're like, oh, okay, like this is fine. But if you have like some kind of weird interaction with them, they're going to adapt that too. So, you know, that's something to definitely keep an eye on as a parent.

Like those few weeks and months are just crucial, like what you're saying, the attumen and the mirroring. Yeah, absolutely. The mimicry, right? There's a lot of mimicry that goes on. And they need bidirectional mimicry towards them, too. Like, they get, like, when you see them doing something that they're excited, they need you to get excited with them.

or when they're venturing out and having a little adventure, it's like to kind of join them in that little adventure. And it's like, you know, probably the most, the biggest risk thing we have in our day and age is what? Devices. Devices. Yeah. Not being present.

Yeah. And I would say depending on like the severity of the household dynamic, right? But for most of the people who are probably listening, it's devices. and that's going to cause an interesting impact as well on people long term. Because kids are so smart because they know even though you're physically there, but if you're in your phone, they know emotionally you're not there, they can pick up on that, even from a very young age. Yeah.

Yeah. Something I notice that sometimes at bedside at Namor's Hospital is maybe one parent doesn't know how to interact with the child like when they're born. So I think this is all important to like communicate to parents that it matters, your interactions with your child, it matters, like, how your facial expressions go. Like, everything is being watched, even from birth. Yeah. Yeah, I think we need, I think we need to convince people who think, oh, communication doesn't

really start until they start saying words. It's like, no, no, no. Exactly. No, that's not, that's not how it works. Yeah. You know, part of it, too, at no point, like, does anyone ever get any formal instruction or really like an overview of what mirroring is. Like parents don't know that, okay,

it's not just some cute thing that you do and you just kind of pick up just by virtue of being human. But it's actually something that has actual tangible benefit from like day one. Yeah. And taking the way the device from the kid because you're like, they're getting addicted to it or something like that.

That's not going to solve the problem. You have to detox your own. No, you have to take it away from yourself. Exactly. They're not going to want to be on a device if you aren't also on a device. Yeah. That being said, I'm not perfect

By any means, like don't I'm terrible at this Nobody's perfect I'm not time though But you know With my kids We have quality time When we've chosen

To not have a TV in At my house actually No TVs in your whole house No TVs in the whole house Okay Yeah, we're serious We're serious But you know

If they really want to watch something They can watch it on the So fireplace is nice Probably Fireplace We do a lot of trampoline Walks? I'll play Minecraft for them.

We'll do Minecraft together. Chess, me and my son. He'll play chess a couple hours a day. Meaningful time. He's getting good. Neutral time together. Has he beaten you yet? Oh, he can beat me.

Fair and square. Wow. But not every time. That's an ego blow right there. No, not really. How old is he? Are you kidding? I'm excited for him.

I'm so proud of him. When he does it, I'm like, oh, man, he really got me. He's like, did you let me do that? He's nine. he's not okay so yeah he'll be

he'll be he'll be in a couple years that's what you want that's what you want you want him to be better better than you

yeah ultimately yeah I think it's pathological to actually have envy it's it's it's a little bit

pathological a lot it's a little bit pathological if you're envious of your child advancing

farther than you like that should be like the goal right so yeah Well, okay, let's go through and kind of make sure we cover all the things we wanted to cover. Yeah. What else haven't we covered that we want to talk about?

I guess we can get into the nitty-gritty of some of the findings of the actual paper. If you guys want to do that. Yeah. So, you know, through the findings, they found that in mothers with a history of abuse, with a high RF reflective function. The infants' organization was 63% organized and 37% disorganized. So they have this history of abuse,

but they have a high RF, and that's what the proportion was. Most of them, 63% were organized, the infants. So I just think two-thirds organized. Two-thirds organized. Two-thirds. If they had high-R-F, but these are very,

they picked an abused population. This is not a normal population of mothers, by the mind. It was like primarily Caucasian, and I think they were like mainly like middle class as well. There was some low. There was some low. There was some low. I don't think socioeconomic status actually made

that much of an impact. They did comment on that as well. It was a little surprising in the sense. I believe that they, I think it was anticipated that lower SES would contribute to like perhaps like more rates of like generating disorganized attachment. But again, like the big thing that they found that made all the difference was just that mentalizing process

itself, irrespective of demographic itself. sounds like. That's right. Yep. And then in the mothers that were abused with a low reflective function, two-thirds of the infants had a disorganized attachment style compared to a third of organized. So, you know, kind of like the exact opposite mirroring effect here. Yeah, and that's, that's a substantial shift. Like that's, that's not, I mean, you know, I'm so tired of studies that are like, the correlation was point two, you know, this is not a point two correlation. This is a, This is a big impact. This is a nice pie chart.

This is a nice pie chart. They did, you know, 3.4 fold difference, right? Which is substantial. The beta, do you want to talk about the beta on that? The risk of mothers being classified as unresolved, increased with a number of different types of maltreatment that a mother had been exposed to during childhood. The beta was 1.14. This is specifically talking about unresolved. as in like the adult attachment interview,

their attachment style was unresolved. And then it goes on, suggesting a dose response relationship between early adversity and unresolved attachment status. However, there was no association between dose of maltreatment the level of the mother's reflective function trauma score. So it's not like, if it's not like the, the women who was more severely abused, as scored by, by the way,

a very accurate dialogue between an interviewer and the interviewee. It wasn't that the severity decreased reflective function in the trauma. And then it goes on. And there was no association between the dose of maltreatment or infant attachment disorganization. That also was really fascinating. me. So worst possible abuse was possible at the time, but with a high RF, it was kind of protective

in that sense for infant organization. Yep. So it wasn't just the dose of the maltreatment that led to more disorganized kids. I think that's a very important thing. Okay, so it's hopeful because if the mother can do the work before, like if you're listening to this and you won't have children and you've never done therapy, this is a good reason to consider doing therapy on some of the traumas of your childhood. Okay. And I think this also points to like the resilience of people, you know, they can undergo these traumas and then, you know, if we put in the work we can have these positive outcomes. And it also reminded me a little bit of like the statistics that say that most people who experience trauma don't develop PTSD. And I thought that

was an interesting parallel? It depends on the severity of the trauma. It depends on the history of their own trauma. It depends on the personality type. It depends on they can develop manifestations, physical manifestations that aren't PTSD diagnosed in the DSM. So they can develop sequela, you know, like I've had a lot of patients of trauma

that develop all sorts of like very, you know, unique things that are not PTSD exactly, but they're still suffering. So they can still suffer in different ways. I think also it's different between childhood and adult, right? Childhood trauma, like in this study, they're mostly looking at childhood trauma in these women, like physical, sexual, emotional, neglect.

They're looking at the impact of those things. The percent of that was higher in mothers compared to fathers in the study. Which one are we looking at here? Is that the one where they had like singled out fathers from the father and the mother's impact on the child and they still saw that it was reflective of the mothers? I mean, there was a slight difference, but like it said among those who experienced neglect by primary caregivers, 89% identified their mother and 82% their father was neglectful.

among those who experienced parental antipathy, 79% reported antipathy from their mother and a slightly lower in their father. But it's almost the same percentage. Were you surprised by that? Is that what you're saying? So basically what this is reporting on is they were abused by either their mother or their father, right?

And most the neglect was from both mother and father, About the same? About the same, but like slightly higher in mothers. I wonder if there's anything there. No, I mean, these are small percentages. I mean, it's a small group and it's just, I think this is just more helpful in reporting the, like this is what they found in the, in this specific group of people. I think they found, to go back to Dr. Slade's article with MTV, they actually decided to organize it based on depression and PTSD as well. they didn't see any differences among having the diagnosis or not,

but it was mainly focused on if they had RF or not, like the level of RF. Okay. So I think that kind of provides evidence behind the idea that, like a diagnosis of PTSD, like someone who was diagnosed with PTSD but has a high RF, would be less likely to have a child with disorganized attachment than someone. Yeah, exactly.

Yeah. And I think that's what this is. study is showing, right? It's not if they're having a mental health crisis. It's like if they have a good RF, then they can get through it if it's not going to ripple into their kids as much. Now, that being said, if your parent is schizophrenic, bipolar, untreated, unmedicated, and currently psychotic, unable to take care of themselves, like, that's going to be a rough childhood for that kid. We, you know, So I think there's caveats to those, you know, like what is the severity of the depression? There's, if it's super severe postpartum repression, it's going to impact the kid.

Still face experiment, it's different for a depressed mother, first non-depressed mother, high rates of insecure attachment with post-farmine depression, stuff like that, which is why, you know, we should be passionate about helping people in that, in that group. Okay. I have some point kind of on caveats. Okay. I was looking a little bit into like epigenetic programming like from like in utero. So for example, like we have half of our genetic material formed five months in utero in your grandmother's womb in your mother's ovaries and does that have an effect.

There's some studies that kind of correlate maternal early life, sexual and physical abuse and both the maternal and infant. like cortisol levels. And they showed that children with the history of trauma and their mothers have significantly lower baseline cortisol's, but they tend to peak faster. So this is interesting to think about along with other studies, but it does, there are studies coming out. But here's the thing. I'm looking at this graph in the paper.

It's about the same, yeah. It's about the same. At the end. And this is where I think, like, I would be more interested in. in, now this cortisol response to a stressful situation or to what? It was a stressful situation, so they made like a loud noise and this is what it was in response to. But what I was getting to the point of is that there are articles coming out soon.

I think it's Corden who's coming out with them that is showing that these have lower important factors compared to like the reflective functioning. Right. I mean, I think if you're in a stressful, if you're talking about something stressful or going through something stressful, and you have an inability to reflect on it,

it's going to be registering more stressful in your body. You're going to have more stress hormones. That makes sense to me. But I think what with the mind is so complex, the biological stuff is just giving us a signal of something very complex. And so the question then is, how do you treat this very complex organ that we have, right? And is it just with biological means, or is it with human connection, exercise, diet, lifestyle?

You know, so, okay. Any other things from this? One concept, Dr. Peter, that I do want to hear kind of your insights about, and that they brought it up on the discussion, is a term that they themselves coined, and I suppose us being in October with the Halloween theme, this is appropriate. the concept of the alien self. So in their article, they brought up this term, and they described it as the formation of an unmentalized alien core in the infant as a result of a failure of the mother's mirroring

response. So it's also described, in other words, as internalization of maternal absence or like a formation of an incoherent sense of self due to an unmetabolized distress. the way I kind of rationalized it in my mind is almost a loss of better words. One becomes emotionally naked or emotionally vulnerable, and then they feel like they're just left out in the open. And then there's almost like a micro-shock or like a micro-embarrassment that occurs and causes someone to overcompensate and them being exclusively withdrawn and less trusting. I thought that was interesting that they kind of brought that up.

you know when you when you mention this and I think about this it's like I'm thinking about many patients you know and specifically some that I've walked with for years doing therapy and what their childhood was like was like a vacuum or like this kind of abyss you know and it's like when the emotion starts to come out it comes out so raw because it's been disavowed their whole life it's like they've been devouted their whole life it's like they've had no place for disgust, for anger, for any of these emotions, you know. And you can go through residency, and you can still have that be your reality. That's the crazy thing that I found. Like, you can function in life very high. You'd be a lawyer, you could be a physician, but you could

still have this, like, total, this total disavowal of a lot of your court, a lot of, a lot of experiences like anger, disgust, you know, all these things that, like, for whatever reason they were never attuned to, they were not allowed, they were not mirrored, right? Maybe there was so much going on in the family that there was no space for this.

And so when they come out, they come out very raw, they come out very big, right? Sometimes they're pointed at me. That's transference. And so actually transfers-focused therapy is probably the therapy type that has shown to increase reflective function the most. But they've also done the most studies on it.

DBT didn't do very much for it or transit focus therapy actually increased it from like in one study, it was like 2.7 to I think 4.3.3. 3.1. It was 2.75 to 3.31. That's one study. I mean, that's a big jump in a short amount of time. You have to think about this as like a journey.

So, yeah. I don't know if the alien self or like this kind of like this, there's a foreign part of myself. Yeah, for some people I think they can resonate with that. They also talked in here about sometimes because the infant has not had the ability to

get an experience represented from another. They will project it onto you, the therapist. and then you will identify with it. That's projective identification. And then you start reacting differently to them. And so this kind of like, this is where like therapy gets both complex, and I would say incredibly interesting

because these things, like enactments, when enactments, it's another way, it's like they're playing out the distress. Because a lot of these things happen in a pre-verbal way, right? and so it's like the human is trying to the human species we have a verbal ability but when the trauma is pre-verbal how do you play that out but by through kind of a more visceral means like so especially if a patient feels like the provider cannot understand them they will find a way for the provider to feel with them.

And so a lot of that feeling with them will be you starting to feel very distressed either towards them or with them or like it'll be very painful to share space, right? So it can come out in a number of ways and I've had people feel all sorts of things towards me that I don't think I fully... It's like no one really prepared me for that.

No one said, you are signing up for psychiatry, patients will feel everything towards you. But I think they do that in other specialties too. We just don't talk to them about it. It's like the patient's just enact it and you're like, oh, can't work with that person. Where it's like, we're like, no, we're like continuing

to work with each other. Yeah. So you say transfers, focus, psychotherapy is good and has, you know, scientific backing for improving relative functioning? Reflective functioning. Specifically. I would say anything where there's the interpersonal going on and there's a good frame,

you need some boundaries, right? Some boundaryed, empathic attunement with an understanding of the interpersonal, with mentalizing, I would say. So what does that look like? Like, is it more narrative-based? You're going to talk about what's going on between us, right? So both the positive and the negative, you know, so like, like what is the space between us like the interpersonal? Between sessions, did you have any thoughts that came to your mind about what are, what is going on between us?

So with one of the people that specifically had a very dissociated childhood, it's like, you know, she all. always was fearing that I was gonna be angry at her between sessions. During sessions, she could feel that I wasn't angry at her, but once I left, she would imagine me as being angry. And that was like distressing, right? So we check in on that, like as you're coming in today, like, what was this space like between us this last week?

And then there were periods of differing emotional states that were felt over the course treatment. And there was a long phase of complete dissociation from what she could feel between us. And that was very distressing to her. Interesting. So you kind of, it's a journey. I would say it's very different for different people. But the interesting thing on what leads to good outcomes in psychotherapy is having high reflective function yourself. Right. So in one study that was like 70. of what made the better therapist, better therapists. I mean, that's pretty incredible.

So that is like, okay, so how do we grow in that, right? And this is kind of the quest I'm on. It's like, how do we grow our reflective function? Like, it's not going to be rejecting everyone with a different viewpoint than your own. I'll tell you that for sure. Like one thing Nancy McWilliam talks about in her book, psychoanalytic psychotherapy

is the best preparation for a therapist is to read broadly of different cultures, of different societies, right? To read, you ought to be a great reader and become acquainted with literature of many countries and cultures. In the great literary figures,

you will find people who know at least as much about the human nature, as psychiatrist and psychologist tried to do. She's quoting someone here. Okay, this was Heinz Kohut, once encouraged a 14-year-old son of a colleague to write Anna Freud about his interest in becoming a psychoanalyst,

and this is what she responded to him. Okay, that's cool. It's beautiful. So, yeah, it's like a lifelong journey, right? And so think about how we can increase our reflective function conversations, in multiple domains of life. By the way, it's energy intensive

to increase this, right? It's kind of fun to root for only your team, okay? Look no further than politics. Look no further than sports teams, right? This is what the majority people enjoy yelling about.

Two fields with very high amounts of splitting. Idealization, devaluation, right? It's fun to have parts of our life where we're a little bit idealizing and devaluing, right? Mentally, it's less work, too, to be honest. It's much less work, yeah. Let's just do confirmation bias all day long, right? I'm right, you're wrong.

But if you tell someone that, then they'll be like, how dare you tell me that I have confirmation bias? What is that one? What's the score? How dare you? Negative one. Negative one, right? 100%.

Yeah. It's like no curiosity into my mind in how I got to that point of thinking in the complexity of that, right? An immediate rejection. Immediate rejection. No conversation, right? Labeling people something, right?

If your way of labeling past X's is just a diagnosis, that's actually a three in reflective function. So it's easier to just, you know, everyone I dated was a narcissist. maybe they were but when you say narcissist you also have to be high reflective function that you have to describe

what that means the why right so it's not enough to just put a label on someone but that's also thinking about how we talk about

our own patients as well right it could be a label can help us communicate quickly but also like how do we communicate in a way that's higher reflective function

because everyone's unique so yeah These are some things I think about. So what do you think is, I know there's like another type of therapy. I don't know if it's like part of this other therapy, the transference focus therapy. But mentalization based therapy, do you have experience like specifically? Yeah, we learned about that.

You know, when I went to the psychoanalytic institute, we had people coming in. We're experts to talk about this. And I've had Fonigie, who Bateman, who originated it. I've done an episode on mentalization based therapy for narcissism. I did episode on that as well. Some good books. I have about six books on my bookshelf. I mean, it's rich, right?

And I think it's a good approach. Absolutely. I have some of the key features of that approach, if you all want to hear, like a summary. So the therapist has asked exclusively to focus on patients' current mental state, their thoughts, feelings, wishes, and desire, with the aim of building up representations of internal states. They are asked to avoid situations where patient talks of mental states that they cannot link to subjectively felt reality.

Thus, there is deviation from traditional psychodynamic technique in that there is a de-emphasis of deep unconscious concerns in favor of conscious or near-conscious content, and less focus on past as it is represented in the present. The aim of therapy is not insight but the recovery of mentalization, achieving representational coherence and integration for intentional states. therapists avoid describing complex mental states such as conflict ambivalence unconscious and are asked to make small interpretations referring to ideation that is only slightly beyond the boundaries of the patient's conscious thinking. Right. So it's like instead of, we're not going to use complex words to describe things that are like archaic, right? Because I think that's, I mean, I've gone into a dermatology office and they are like are talking like,

I'm like, I have no clue what this person said. Even I'm an MD, I have no idea. It's like that probably level of interpretation is just not helpful for patients. Actually, it's low reflective function for patient to spout cliches or like words that they're disconnected from. Right. So it's like getting them into the visceral experience of what's going on in the here and now. Finding the emotions you can play with in a way, like finding that transitional area of relatedness. Yeah, and I would say it's, um,

it's a lot more complex, and I think that that's a good couple sentence introduction, but if you're interested in that, please go back and listen to Phonaget and Bateman. And by the way, their connectedness, me capturing that on YouTube,

is, it's priceless. Like, you can really feel the love between those two men. Like, they've worked together for years, you know, and they just have this like camaraderie,

right? Which is kind of what I would hope for, right? And people that, you know, You don't feel like a competitiveness at all between them. You would hope for that in someone with high mentalizing ability, spouting mentalization-based therapy. That's reassuring.

There's a genuine mentalization going on. Yeah. Because I think about like envy is also a breakdown of that ability to like a tune because you're like, oh, this person has this thing that I don't have so I can't be excited for them. Whereas like the revelry in each other's success and their ideas and stuff, it's just the banters. it's priceless in it of itself. So, just check that up. Great. Yeah, well, shall we put a cap in, cap in it for today, guys? And, like, this was a great, this is great. I really appreciate all three of you and your contributions and looking at this paper. And we left some of the paper, like, undigested for the

readers to go back and listen to themselves, or not listen, but, well, I guess you could put it in Speechify and listen to it. That's what I do, too. But yeah, guys, thank you so much. Appreciate you guys. And if you are listening to this in 2025 or later, or maybe years later after, all of this will be also on psychiatrypodcast.com. That's where we'll have links to the articles. We will have our own article kind of summarizing this.

And everything you might be curious to learn. Okay. Yeah. Thank you for having us. Thank you for coming. It was amazing. Thank you so much. Let's do it again. All right. We'll leave it there for today.