Psychiatry & Psychotherapy Podcast - Reflective Functioning: The Key to Attachment with Dr. Howard Steele

Episode Date: May 17, 2024

In this episode, we discuss "reflective function," which is a precursor to the concept of mentalization. Reflective function is best understood not as synonymous with mentalization, but as a scale from -1 to 9, based off certain adult attachment interview questions that measure the person's ability to describe their own and others' internal states, motivations, and articulate a nuanced and unique understanding of life from 0 to 12 years old. This scale was developed by attachment researchers at the University of London, including Dr. Howard Steele and Dr. Peter Fonagy. By listening to this episode, you can earn 1.5 Psychiatry CME Credits. Link to blog. Link to YouTube video.

Welcome back to the podcast. I am joined today with Dr. Howard Steele. He is a full professor in psychology at the department in the new school for social research in New York City. He has written multiple books on attachment. He is the chief editor of a journal article called Attachment and Human Development. He was co-author in the initial reflective function manual. with Fonigy, and he is, I would say, he's the top voice on reflective function. He teaches it every year. He teaches a course on reflective function. And if you've been listening to this podcast for a while, you know that I have been interested in mentalization-based therapy, which Fonigy and Bateman created. Interestingly, I found out recently that Fonigy and Dr. Steele co-authored the reflective function

manual. This manual is something I became very interested in because there was an article that I got exposed to, I found, which was really looking at like what separates the best therapists versus average therapists. And so in this article, they split therapists into three groups. They looked at their outcomes with their patients through the OQ45 point, which is one of the best ways of tracking session to session change in someone. And so they were following a bunch of therapists' patients, and they split them into three groups, and they found that the therapists

with the highest reflective function had the best outcomes. And it was 70.5% of what made the best therapist, the best therapist. So this was kind of like, for me, usually in research when we look at common factors, we see correlations of 0.3, this is huge.

This was a huge sort of like, oh, wow, I got to look at this. manual, and Steele was one of the authors of the manual, and so we've been in conversation about reflective function, and I thought, why not bring in the expert himself, who has written books on this, who does courses on reflective function. So Dr. Steele, welcome to the podcast. Thank you so much for it to be here, David. So maybe just to kind of like talk a little bit about what reflective function is and how you got into studying this. sure i'd be happy to it takes me back to the early days of my phd studies which i undertook in london

england that's where i met peter faunegie and many other people we were using something called the adult attachment interview which had just come on stream as it were something that was introduced in a 1985 publication and um dating my but I began my PhD studies in 1986. The publication introducing the Adults Attachment interview was a publication by Mary Maine, Nancy Kaplan, and Jude Cassidy. And that was a watershed moment in developmental and clinical psychology. It introduced an interview that asks people to talk about their childhood experiences

with mother, with father, as far as they can remember. And then to evaluate those experiences via questions like, why do you think your parents behaved as they did during your childhood? Now, some people when they're asked, why do you think your parents behave the way they do as your childhood, might say, my parents, why they behaved the way they did? How should I know? You've got to ask them.

Or my parents behaved the way they did because they loved us. Don't all parents love their children? yet other people respond to that question, why did my parents behave the way they do? Hmm. I have to think about my grandparents and the lessons that my parents learned from their parents, which they may have been guided by in how they behave toward me as a child. When we saw those kinds of responses to that question in the Adult Detachment interview, we thought, this is fascinating.

Some people, when they're asked to talk about other people in close relationships, they make an informed guess as to what the motives were that guided the behavior of the others. Now, in the initial scoring system that is valid and still use, and I teach it in two-week Adult Attachment Interview Institutes, there is a notion of metacognitive monitoring. That is speech is a behavior. And when we monitor our own speech, we have the capacity to stop and correct ourselves.

And we do it all the time. When we say, oh, I didn't quite mean that. Let me put it differently. That's a virtue, if we can do that. But we looked at that idea, and we said monitoring your own speech behavior and thoughts, What about monitoring other people's speech, behavior, and thoughts? Like some people do when they're asked,

why do you think your parents behave the way they did during your childhood? And so we expanded that notion of metacognition and eventually came to call it reflective functioning. And Bateman and Fonagy, rightly, as you pointed out, took the reflective functioning idea and turned it into mentalization-based treatments, which are everywhere for every kind of problem that people might be having. So there's something very powerful in the idea of reflective functioning, and I'll say two or three other things

about it. It's not a new idea. People, since they've been studying psychotherapy, have known that psychological mindedness is a good thing. That goes back many decades, psychological mindedness. it's a nice idea it speaks to the possibility that some people might have an informed idea about how the mind works but there was no way of measuring it operationalizing it similarly there was an idea of the self-observing capacity of the ego when ego was very popular in the 1950s 60s and 70s there wasn't a great way of measuring that with reflective functioning

we have taken those ideas and come up with an 11-point scale from very low reflective functioning, even hostility toward the idea, to people who embrace, play with, explore the idea of guessing what's in the minds of other people, and what are the motivations that other people have for the behavior that they show. Yeah. And I'll just jump in here. So negative one is the lowest score and nine is the highest score. So a negative one would be, and we all have heard this in clinical practice, it's like, oh, what was that like for you as a kid?

Like, I don't know, you tell me, you're the psychiatrist. Exactly. So it's like a denial of. But it's more than a denial. It's a harsh rejection of reflective functioning. It's sort of like, how the hell should I know the answer to that question? and as if you're repelling the possibility of thinking about the motives guiding other people, that's minus one.

And we saw that. We had to create that minus one point when we looked at interviews from people incarcerated for violent crimes and people who were incarcerated for repeat drunk driving offenses. So those are people who have not been well-legged. who have not been given the experience of interacting joyfully with another human being. And so they've probably had a lot of harsh, very abusive experiences, and they are abusive in return. Not everybody, but we know about resilience and reflective functioning is the way out of harsh

experiences. But those people who commit violence toward other people, it makes sense. that they wouldn't have an appreciation for the humanity of the other. And if you don't have that appreciation, then you can, of course, behave quite dismissively and violently. Yeah, we're talking, are you talking about the Cassell Hospital study? Is that the one? Yes, that's right. And am I, is it correct that you were the one actually doing the adult attachment interviews or grading the adult attachment interviews on that study? Or was, I was reading and reading the attachment interviews on that study. There was a research assistant collecting them.

She got into a little bit of trouble with the therapist on the hospital ward because she was showing a lot of interest in questions in the attachment interview. And she frequently asked, you know, do you think that had an influence on the kind of person you are today in adulthood? And do you think that had an influence? And what about your mother? And what about your father? And then those patients went to their therapist. And they said, why aren't you so nice and inquisitive as the researcher who asked those people? Wow.

That was one of the studies. It was actually, it wasn't so much the Castle Hospital study, but a study, as I say, because those were in-patients on a psychotherapy ward. No, it was studies done in prisons with incarcerated individuals that I could share the references with you. But anyways, the prison health center study, right. And, oh, you know what was interesting when I saw the mean reflective funer. score in that. It was 2.5, right? So this is 22 prisoners, 11 of them with BPD, and compared to that to normal controls of 5.8. So remember, 11 point scale, I'm going to be talking numbers. We're going to learn it. So negative 1 is the lowest, 9 is the highest. So the prisoners had on average a 2.5.

Let's not confuse prisoners with that castle study. They were not prisoners. Those were psychotherapy patients. Yes, yes. 2.5 average was the average of people. living with long-term mental health troubles. To 2.5, okay, thank you. Yeah, and in terms of the scoring, we think of anyone with a score of three or lower as having low reflective functioning, that is people who have difficulty in an organized way,

guessing what's in the mind of the other. Okay, so the case, thank you for that clarification. The Cassell Hospital study, this was inpatient psychiatry. But what I found interesting about this, was that the average for people with borderline personality disorder was 2.7, standard deviation of 1.6, whereas depression was 3.8, so it's still pretty low. So I'm looking at these numbers. I'm trying to kind of, I don't know, compare them. Well, I know that table you're looking at in the clinical sample studied in that paper, the lowest levels of reflective functioning were

shown by the people whose primary diagnosis was borderline personality disorder or individuals living with an eating disorder. And then depression was a little bit higher. And the average for the community controls was about five. So we think of five as the kind of on the nine, on the 11 point scale, that's a good enough score, somebody who shows moderate levels of reflective functioning. Yeah. Okay. So one of the reasons, why I think this is so powerful is because there's this study on transference focus therapy. And with the transference focus therapy,

they're meeting twice a week with the therapist. They're talking a lot about what's going on between them and the therapist. And in this study, there was an increase in reflective function from the beginning to the end of the study. Whereas with like something, I think one of the control arms was dialectical behavioral therapy,

which I imagine if you're a dialectical behavioral therapy fan, you probably will look at this study and find some problem with how they did dialectical behavioral therapy in this study. But nevertheless, transfers focus therapy had an increase in reflective function. I'm trying to pull up those actual numbers. Yeah, that's a study by Ken Levy and colleagues, and that was helpful in validating the concept of reflective functioning

and showing that through therapy, even with people living with the troubles that borderline personality disorder suggests, there are treatment modalities that can move people to a higher level of reflective functioning. And in brief, we can call that a move toward a greater appreciation of the humanity of other people and one's own humanity with all the complexity that that includes. Okay, here's the actual numbers. So the mean start of reflective function in that study was 2.86, and it increased to 4.11, whereas the DBT group showed no improvement, and the supportive psychotherapy treatment showed no improvement. And so Bateman and Fonagy say that their mentalization-based treatment is very similar to transference-focused psychotherapy.

and there's a lot to be said for dialectical behavior therapy. And I think you're right to say that someone who practices DBT might want to study that paper and ask who is delivering the DBT, because I do think that DBT is not so different from MBT either. In mentalization-based treatment, you monitor the patient's thoughts and feelings. In DBT, you closely monitor the patient's behavior. Right. I think, okay, so I want to kind of get a little bit more help in wrapping our heads around what we're actually looking at. And I think one thing that I found really helpful when I was trying to understand this was when you're looking at the adult attachment interview, you're really focused on a couple key questions in the adult attachment interview and scoring the reflective function.

Like, why did your parents behave as they did during your childhood? Do you think your childhood experiences have an influence on who you are today? Did you ever feel rejected as a child? What is it about these certain types of questions that were, why is it helpful to look at those questions when gauging reflective function? Thanks, David. Those questions include the word why or how. So they are questions that demand evaluation or demand reflection.

If I ask you describe the childhood experiences you can remember from the family into which you were born, there's no requirement to be intensely reflective. You can simply say, I grew up in this place, my father and mother were involved in this work outside the home, I had two or three siblings or no siblings, there was a dog, there were grandparents. So it's a question asking people to describe circumstances. And in describing circumstances, it's quite important, but it's not reflective functioning. Reflective functioning is the task of thinking about why people in our lives behave the way they do, what motivates them, what motivates us, and how can I think about ways of connecting

with other people and showing some understanding and the empathy toward them. Okay, so if the person responds to why did your parents behave as they did during your childhood, and you said, well, my mom was a narcissist, and that's why she behaved that way, is that low reflective function or high reflective function? And why? Yeah. When people use clinical terms like that, my mother was a narcissist, my father was a chronic depressive. We do not consider it reflective functioning. We consider it a bit of a cop-out,

drawing on some label that's widely used in the psychiatric or clinical, psychological, and social work literature, but it's not emotive, it's not personal. So we say to ourselves about those use of those words, You can't score the passage above a three. You have to decide how low you go, but three is miscellaneous low RF, simple RF, or a hyperactive RF,

as if someone's spinning their wheels in the sand and not going far. So that would get a score of three or lower and would never be scored above a three for that reason, that it's a bit of a cop-out, It's leaning on some well-known label that applies to many people. And with reflective functioning, we want people to talk in a way that speaks about events and circumstances deeply personal to them with details about parents' life, mother's life, father's life, other people. And to lean on labels is a, as I say, a bit of a cop-out. but it's understandable because there's some safety in doing that.

So I think that was like a very helpful point for me to come across. So remember back, like I found out about reflective function through reading this score that talked about like what are the best therapists. So you have to imagine the best therapists, the high reflective function group, this was seven or higher. And I was thinking to myself like, okay, what is it that as someone who's seven or higher that's doing? Like what would it be like to sit in the presence of someone who's seven or higher? And this is seven or higher about their own attachments, right?

This isn't about like, because I think some people are very skillful at empathizing with people they're disconnected from. This is like looking deep, this is someone who's looked deeply at their own childhood, right? That's right. I mean, the other thing is, I'll answer your question, but reflective function can also be observed in literature. We see high levels of reflective functioning at the level of of seven in some of the most classic, important, enduring pieces of writing. Not pulp fiction

or romantic novels so much. Those are great examples of description of passionate states of mind, but the complexity of mind and the capacity to hold multiple distinct truths that on the one hand seem contradictory, but the person with level of seven can hold them together in a way that shows a valuing of relationships or a valuing of attachment. The other thing to note is that in the Reflective Functioning Manual, we have discrete dictionary-like definitions of moderate to high reflective functioning that goes into a score of seven, and there are 23 discrete indicators of moderate to high reflective functioning. there are only six or seven indicators of low reflective functioning.

So low reflective functioning indicates a narrowing of the mind. High reflective functioning represents an opening of the mind to a range of possible considerations from a point of humility. Because one of the central characteristics of high reflective functioning is that the speaker shows an awareness of the limited, on understanding. Possibility of knowing exactly what's in the mind of others. You don't get a high score for saying, oh, why did my parents behave the way they did? I know exactly why they behaved the way they did. That's not possible. It's not possible for us to have a transparent,

clear understanding of our own minds. The issue at heart is whether we give up on that account and say, well, that's impossible. I can't understand who I am or other people. Fuck it. I'm not going to engage with you about this topic. But the interesting thing is that the person with a score of seven says, it's worth it. I'm going to take a chance at guessing what are the motives of other people that I care about? How did they come to be the people they are?

And how did I come to be the people, the person that I am? So I'm referring here to the recognition that there are limitations on insight, a kind of psychodynamic idea, can't understand everything. Freud had the notion of overdetermination that anything we care about is determined by multiple causes that we won't ever be able to fully capture. But it doesn't mean we shouldn't try. Yeah, okay. So in the Reflective Function Manual, 4.1.1, the opaqueness,

of mental states. This is the idea that the person who's receiving this adult attachment interview is tentative about their hypothesis on other people's feelings or thoughts. Are they acknowledging the complexity of it? So it's like it's not completely clear, right? The glass is not completely clear. It's a little bit opaque. Is that kind of a good way of understanding this? So- Absolutely. People know those shower doors that are opaque. You take a shower, you don't want someone to look into the shower necessarily. We choose to create windows and blasts like that.

The notion is that when we look into the mind of the other, as I look at you, David, and with your earphones on and I try and guess what's in your mind, I can be tolerably accurate, I hope, but I can't know for sure. So there's an opaqueness around mental states. And related to that as well is the notion that mental states are amenable to disguise. That's 4.12. Yes, good, good. And what I'm referring to here is the fact that a three-year-old who gets a gift from their grandmother,

that they hate, the grandmother's going to know it. The child might give a sad, sad face, look to the parent, throw the gift down. The grandmother will know because a three-year-old is more transparent in their feelings than that same child will be at age seven. At age seven, a child who gets a gift from grandmother that they don't like, grandmother is going to hear a nice thank you. they won't know that the child hates the gift the child will know that you have to sometimes show on your face one emotion

while you feel inwardly another and knowing that that mental states are amenable to disguise is a good thing okay so so with that I was curious so one of the examples of a four so four was

I am so angry at her but I would never show her that to, I would never show that to her. So why was that only a four and how would it become more than a four? Sure. Well, it's only a four because it suggests that the speaker understands that mental states are amenable to disguise, but the example is not detailed enough to merit a score of five. So we give a score between three and five, that is a four. Now, it would be a four if the person said, I was so angry at her, but, you know, I tried not to show it. She was my mother. I depended on her. And I didn't want to inflame her anger even more. And so I protected myself by not showing my anger. You know, something a little more detailed and personal is required. to give a higher score of five.

And so we often settle on those interval points between the odd numbers. And a four is not a bad thing. You saw in the study of people with borderline personality disorder, that was the outcome from therapy. So a four. And the other thing to say is we score when we look at a transcript, and it's possible to score reflective functioning in psychotherapy transcripts, not only in attachment interviews, in any spontaneous speech sample.

And what we do is we circle every mental state word. Every time somebody says, I think, I feel, I considered, I realized, I thought. And the word, no, K-N-O-W is interesting, because sometimes people say, how should I know? We circle a no. And we ask, is this being used in a way that advances an understanding of self, other, and relationships? or is it being used defensively? With I don't know or how should I know, that's rather defensive,

shutting down conversation rather than opening it up. I think it might be interesting to go back to this idea of literature. I know I'm jumping around, but I'm kind of curious, do you have any passages that you can quickly pull up or pull up in a minute or two and read to us and kind of explain why it's a high reflective function passage? Well, this dawned on me when I went to a conference a few years ago, David, discussing reflective functioning and literature.

And there's a Vietnam memoir with the title, The Things They Carried. The author just now escapes my memory. But that's a very powerful memoir of the thoughts and feelings, an American – military person had with respect to their memories of their experience in Vietnam. And they talk in a very compelling way about what motivated them to accept the draft and go away. The close relationships among comrades and the fears, the dreams, the hopes that that person had. And then on return, the thoughts and feelings that the author has, had about family life, the impingements or difficulties they had. So there's one point where

the author of this book, The Things We Carried, remarks on his daughter asking him, did you kill anybody when you were in Vietnam? And he gives a very thoughtful reply that there are sometimes circumstances where you have to protect yourself and engage in behavior that you regret, but all the same, it's required, and it's all very complex. And then, as I cited these remarks about the book, somebody approached me afterwards and said, I heard, I want to say Tim O'Brien, but anyways, the author had spoken on a previous occasion. Somebody told me they heard that author speak, and that they put into the book a lot of fictional stuff, and that they're not a parent. There is no daughter.

Oh. But in imagination, it made a very compelling story. Huh. So I want to make that point that we see high levels of reflective functioning in

literature. Yeah. It doesn't necessarily mean that it's a reflection of the imagination of the writer. Absolutely. And I think all good literature probably has higher reflective function. And there's a lawyer, a future lawyer that's working for me on some projects. I've been having him read through

this as he prepares his personal statement, and we're trying to increase the reflectiveness in his personal statement, because I think that something intuitively that we know when we see it, it's like it's beautiful, like Shakespeare, Shakespeare and Dostoevsky, they can describe in a couple lines what it might make, what it might take me to pages, you know? It's just so densely packed with like such beautiful ways of describing things so concisely. Maybe it would be helpful if I tell you just the broad outlines, because we've talked about two of the 23 indicators of moderate to high reflective functioning, the opakness of mental states, mental states is amenable to disguise. But the 23 indicators break out into four domains. First of all,

what we've talked about, opaqueness of mental states, mental states amenable to disguise, those are part of five examples or indicators of how people show an awareness of the nature of mental states. Okay. There are seven indicators to do with links between mental states and behavior. There are further seven indicators to do with developmental aspects of mental state. So mental, let's go back, mental states with behavior. So did they tie a specific, how would you describe that? Talk more about that. example of that is when people make what seem like accurate attributions of mental states to others. Yes, yes. So when a person gives a specific common sense account of a behavior in terms of the thoughts

or the emotions that underline the behavior, is that? Well, we can say, for example, you have listeners who will be watching this video. We can guess that many of the listeners will be very curious. Many of the listeners will be perhaps a little bit frustrated if we're not making clear what reflective functioning is. And those are hopefully, I think, accurate attributions to your listeners. That would be an example of that. And then the other thing is speculating on mental states underlying behavior. So you're asking the interesting questions about reflective functioning because you're motivated to come up with a compelling podcast, a compelling conversation. and you want reflective functioning defined.

So that might be an example of mental states tied to behavior. And there are many different elements to this. But it's talking about the here and now and how mental states influence behavior and how behavior leads to mental states. The development piece is the there and then, back then, in the past. the power of my thoughts and feelings changed about the past. And let me deepen my sort of reflectiveness on the audience at this point, okay? So the audience at this point, well, first of all, you have to know, most of these people who listen are mental health professionals or they aspire to be mental health professionals.

Or the serious, curious, you know, the person who is really wanting to take their own mental health journey to the next level. And pretty much every person that has reached out to me to console on a case or see me to do some work, I've run the big five on them. And they all have one thing in common. So the big five is like, you know, the most studied personality inventory. They're all high openness, like two standard deviations above the mean. Wow. Which I wonder if there's something about the way that I ask questions. or the topics that I cover,

how I cover the topics, that it just drives anyone who's not high openness, absolutely crazy. Because I'm not just telling people the answer often. I'm trying to like, this is what we know, and then you kind of have to form your own conclusions. You have to dig deeper. You have to be curious.

And I'm kind of on a journey with them. So this, you know, like I'm on a journey of like, when I reached out to you this week, I was like, okay, I'm ready to do this episode. out of all the episodes I want to do, it's this. I want to learn more about this. And I know I can struggle through the manual. The manual is dense.

It's hard to read. So my hope is that if someone's listening to this, they'll be curious enough to read the manual, maybe read some of your research that you've done, actually look at the hardcore papers because I think there's a lot of meat there to understand human nature, to understand what we do as mental health professionals.

And so I'm imagining someone listening to this and hoping that it gives them a little bit of a head start when they start to crack open those studies in the manual, you know, to kind of like, okay, I kind of have a framework, I have this general idea of what we're talking about here, you know, because it is hard to understand, but people want something deeper than just the superficial attachment research, right?

And I think it's hard to know how to get into it. You know, it's hard to know how to jump into it. So I hope that this kind of elevates them. Maybe this is a good point for me to say that I once or twice a year, I offer these three half-day seminars on reflective functioning. And what we do is we get right into reading interviews and what it means to circle mental state words and think about how that mental state word is being used. Is it being used, as I said earlier, to advance an understanding of self-other and relationships? or is it being used to kind of shut down thinking to close off the conversation? And I'm gratified by what you say about the high levels of openness among your listeners,

because I think that is actually an important part of reflective functioning, the capacity to be patient, to be reticent, if you like, to wait and see and listen and ask questions and form of, a judgment that you have high confidence in, but not absolute confidence in. Yeah. You know, high openness, people, they're usually more creative. I find that if you're very, very high openness, like two, three standard evisions above the mean, you usually do some sort of art, whether it's writing, actual, like, drawing,

artwork, music, and often the people who, I think they make good therapists because I think when they approach someone, there's a natural curiosity and openness to discover something new that they didn't know before. Sure. I mean, another thing that's relevant here, and many of your listeners will know about the value of metaphors. And there are therapists who work from a point of view. They want to encourage their clients or patients to.

use metaphorical language. And there is an overlap between metaphorical language and reflective functioning. I had a PhD student, Lauren Dent, some years ago, show that empirically. But it was reflective functioning that predicted child outcomes better than metaphor use. So it is the case that reflective functioning overlaps with so many of the things that psychiatrists, psychotherapist, counselors, social workers aim to teach the people that they're trying to help. And I think the piece of it that I think is so central and vital is the developmental piece. And we see that very clearly in response to the question that you raised, I raised, why do you think your parents behave the way they did during your childhood? And when someone talks about their grandparents in response to that

question, they're taking an intergenerational perspective. We all have a history. We're very curious about ancestry. There's Louis Gates on PBS, helping famous people explore their ancestry. We know that we have a history, but some of us are more interested in than others. And to be interested in your history, your own personal history, the history of your parents, history of your that's a good thing and it might well dovetail with taking an intergenerational perspective taking a developmental perspective revising thoughts and feelings about childhood in light of understanding gained since i'm sure you and many of your listeners will be able to think about aspects of their childhood experience that they have changed their thoughts about

there's one of the most powerful examples of reflective functioning that persuaded us that this really matters was a pregnant woman expecting her first child and she used the word fear to describe her relationship with her mother during childhood and she was asked to elaborate on it and she said well it this is one thing one thing that i recall about my childhood as if to say there's other things i recall there's other things I don't recall, but this is one thing I can recall, that my mother's way of keeping control was to frighten us because she was physically unwell, frequently physically unwell and in a lot of pain, and it suited her to keep us at a certain distance and frighten us. Now, as a child, I felt very frightened. You learn to cope with that as you get older, but as a child, I remember feeling very

threatened. The interesting thing there is, it's a coherent speaker who gave more detail than I conveyed, who could talk about an experience in childhood when fearful emotion was felt, but as an adult recalling it, they don't feel afraid. They feel organized. They feel feeling. They feel They can describe childhood, their thoughts and feelings as a child, and indicate that, well, as I said, you learn to cope with that as you get older. She had a quite positive relationship with her spouse, and she was able to talk about positive experiences in therapy that no doubt helped. So the central piece here is that we gain reflective functioning through conversations with other people. Yeah, yeah. And I would say in my own therapy journey, it's like, which is ongoing. It's not complete. Will it ever be complete? I don't know. You know, like, it's like every now and then I realize something else in the pieces of things, you know. And that helps me understand something that was going on. I'm curious.

in your own journey of, you know, doing your own work, psychotherapy, has learning about reflective function been helpful for you? Or how have the two sort of intermixed? Yeah, no, I agree. In my own journey's reflective functioning has been enormously helpful. I've actually, early in my career, I was patient in quite a classical psychoanalyst, experience. where I was lying on the couch five days a week for about 15 months until I said, this isn't for me. But I did, in the process, come to some understandings of my childhood that I didn't have before. So as a young man, for various reasons, I was very angry with my father.

And it was, it was troubling. But I learned in that not-so-satisfying psychoanolite experience that he was doing the best he could. that I didn't any longer feel a need to be angry with him. So that is one typical experience that people arrive at new understandings of their parents' behavior that prior to that understanding they were troubled by, preoccupied with. So that's one thing I can share. and can ask a follow-up on that. Do you feel the, I don't know,

it sometimes happens with transference that you feel some of that anger towards the therapist that you may have felt towards your father. Was that part of the journey that was helpful, maybe at the time or later on? That was part of the journey. And of course now people work with interpersonal, particularly in the contemporary world in New York City,

there's many different interpersonal styles of therapy that do indeed pay attention to transference, counter-transference, but they do so from a relational perspective where the experience of transference is also acknowledged as a kind of enactment that each partner to the interaction are participating in. where the patient prescribes, if you like, a role to the therapist and elicits from the therapist behaviors that remind the patient of typical interactions from their childhood or adolescence or paths. And knowing that, one can look at it and talk about those enactments and what was it that I was communicating that might have elicited that behavior. or why was the therapist willing to engage in that role that was assigned to them?

It's all very much in the domain of reflective functioning. Do you feel like that style, which I tend to lean more there compared to the classical, you know, analytic perspective that it's 100% the patient, right? So in this sort of new genre of attachment work, and probably stemming from attachment theory comes this idea of enactment where you kind of enter into a role that might actually be a different role than you're not usually in with a particular patient, right? So maybe in your early analyst work, somehow, the analyst got drawn into the role more of your father, right, and kind of embodied some of those characteristics in some way. I don't know. Is that what you're saying? No, that's fine. And I think you put it, you put it quite well, Ned Ackman. I mean, my teacher of that stuff was someone called Joseph Sandler,

who said that we have scripts in our minds that bring us a sense of comfort and safety, because they're very familiar. Scripts for how other people are likely to be. people in power, how they're likely to behave, how I should behave in response. And what we do with transference is we bring those scripts into view. And we, I mean, I'll give you a definition of transference. It's the thing we do to make the strain seem familiar. I try to elicit behavior from you that reminds me of people that I'm very familiar with. And if I can do that, I'm going to feel safer.

but I should, if I'm doing that, it would be helpful if I know that I'm doing that and with you to analyze why I'm doing that and consider ways of interacting with more freedom in the present that acknowledges you're a person in your own right and I shouldn't try and impose a role on you. I should listen to you and see what it is you can teach me, what it is we can achieve together. So I would put it that way. And you're quite right that attachment is hugely popular. And I think it's so popular because attachment research has validated an important assumption of Freud. And that was the assumption that what happens in childhood matters and has an influence on later development. And we have some 50, 60 years of research showing that that is just the case that childhood experiences with attachment figures, mother, father, and parent substitutes influence how we relate to other people across the lifespan. There is pretty robust research along those lines. And reflective functioning is one of the mechanisms that allows people to overcome

adverse experiences and arrive at an understanding of them that frees the individual to be more secure and promote security in others. I want to jump to this one study by Peter Fonaguy at all 1996 of 82 non-psychotic impatience. And in this study, he looked at the interaction between abuse reflective function and borderline personality disorder. And he concludes that the likelihood of reported abuse being associated with BPD was greater in the group of patients with low reflective function than those with high reflective function. Thus, and then this is kind of dot to dot, thus reflective function in itself does not appear to be an independent risk factor for BPD, but is highly predictive of BPD in the presence of abuse.

Has that research been found to be true as studies have been repeated? Have there been studies that have countered that kind of idea? But the idea that I'm hearing here is that you have some child with lower reflective function who undergoes abuse, and that kind of seems to be highly linked with BPD. later developing. Yes. Peter Fonigy talks about this is the paradox of reflective functioning, that when we need it most, it's unavailable. So for the child who's suffering from neglect and likely abuse, it would be good if they had a sibling or an alternate parent who could

help them understand what's going on, but often that's not the case. So in the moment when we need it most were activated, amygdala activation, and we are fearful. And in a fearful state, we can't engage in making sense of our experience. And that is the kind of experience that may lead, not in all circumstances, but may lead to borderline symptoms and eventually borderline pathology. But you have the Ken Levy study and work of Fonigan Bateman to show that mentalization-based treatment, calmly attending to the mental states of patients, validating their thoughts, inviting them to consider other people in the group, all of that facilitates reflective functioning and helps people with borderline personality disorder move out of that diagnostic category and achieve success at work,

and success in relationships. So the study that you cite from 1996, yes, I just suggested that there are different pathways to borderline pathology. Some of them include explicit examples of abuse. Some of them, that's less clear. And I think that's validated in other reports. I think going back to this initial study that excited me about reflective function. Let me just pull up this image so you can see how pronounce this is. And if you're on YouTube, you can kind of see what we're looking at here. So this is the OQ45 and the different patients changing over time comparing the different high reflective function, medium reflective function, low reflective function. And so you can see the OQ45 in that low reflective function group does not change. In the medium, it decreases, but

but the slope is not as large as the high reflective function group. And so more than just mentalization-based therapy or trans-focus therapy, I think what we're seeing across modalities is that a high-reflective function therapist is going to give the best results. And so therefore, it's like my listeners are going to be curious, like, okay, how do we increase our reflective function?

What do you think? Well, I think I'm being familiar with the concept and how to measure it is one way of increasing one's reflective functioning. Also, as we highlighted earlier, reading literature, reading poetry, being appreciative of the diverse ways that people make sense of experience is all very helpful. There is a fourth element of reflective functioning that we haven't talked about very much, which is mental states in relationship to the interviewer. And I think the point there, we've sort of demonstrated a little bit as each of us tries to imagine what are the aims, goals, purposes of the other in this conversation.

And I think that simply engaging in curiosity, organized curiosity about the motives that underlie behavior and the mental states that are the consequences of behavior is going to be very helpful. And of course we know in many forms of therapy, tracking feelings is central. So often as psychotherapists, we inquire about the feelings of the other or the thoughts. But there is a keen interest to track the emotions underlying the speech and underlying the behavior of the other. So much so that we have a very successful mode of therapy known as emotion-focused psychosovoysmobile. therapy. Which, I don't know if you heard, but Sue Johnson passed away yesterday or the day the day before yesterday. That was on my mind and led me to remark on that. Of course, that was Les Greenberg and Jeremy Saffron's creation many years ago. And then Sue Johnson trained with them

and made an enormous contribution in the couple therapy work. She didn't call it reflect functioning necessarily, but she did call it emotion focused. And the goal of the therapy was to get people to talk about their feelings. Yeah. I, um, yeah, so a couple things. One is, uh, she was on the podcast, so I got to meet her and interact with her, which I never felt like, I, which was a huge blessing. Like I never imagined myself when I was going through training a decade and a half ago being able to interact with her. And so she's a wonderful person, just absolutely wonderful. And her writings, her approach is phenomenal.

And so, yeah, I was sad. And I guess she had a three-year fight against cancer, which is publicly known. That's right. And I gather she was 76 when she passed away a couple of days ago. She spoke at a conference. I had the pleasure of meeting her and hearing her speak at an international attachment conference that took place in Vancouver, Canada in July 2019, and I knew her before that. So it's interesting.

And of course, it's experiences of loss and trauma that destabilize us. Obie said that they, if it's a loved one who's suddenly lost, we feel disoriented and disorganized, which is the antithesis of reflective functioning, disorganized, not being quite sure where you are, disoriented, not sure what time it is. And reflective functioning is all about mapping our circumstances, thinking about time, thinking about what precedes what, what follows from what. And so reflective functioning is a path out of loss, out of Trump, is a powerful proxy for what we called resilience. Yeah, I'm thinking about Sue Johnson.

I've had some EFT therapy that I've experienced myself. And I think one of the most helpful aspects of it is, like, let's say you're angry, and that's kind of what's on the surface. And I think what EFT does well is it helps you find other emotions, like fear and maybe sadness that are underneath the anger. For example, I had a patient just the other day who said, like, you know, I don't feel respected. I feel angry because I don't feel respected by my wife.

And then kind of like pulling out and helping him reflect deeper on, you know, what are the things that are underneath that is a fear of not being appreciated for all the hard work he does. his attachment with his parents where his dad demanded respect or there was corporal punishment. So he kind of like got imprinted this idea of respect is absolutely needed all the time. And so, you know, part of what's been helpful in learning about this just in the last couple,

you know, months for me, is it allows me to put words to something that it's like I've heard from different types of therapies, but it gives me like, oh, there's a number to that. You know, that's a low reflective. He's starting with a low reflective function stance. As a therapist, I'm trying to help him deepen his reflectiveness on this, which is essentially what EFT does well for couples. And I think Sue Johnson did a great job of chariomatically convincing,

people of that. Yeah. Sure. And of course, it's a validated model for work with individuals as well. And mining the emotions

and asking people to think about what else might be going on. What else might you be feeling? And suggesting that complex blended emotions are very common. And to the extent that we can acknowledge

that, we can come around to an appreciation for ways of changing, ways of evolving, ways of being more available to others that we love. Yeah. I'm curious, okay, so kind of moving back into, and you know, do you think, okay, so one of the areas of research, I definitely want to highlight was that you have actually done is you've looked at the diads between the mother's reflective function and the child's attachment. And I was wondering if you could talk about the main studies that you did on that, and what were the findings?

Sure. Well, the principal first study on that was the interviews we did with expecting parents, mothers and fathers expecting their first child. And we found that reflective functioning in the mother's interviews and reflective functioning in the father's interviews was a powerful predictor of child outcomes. but it was most powerful, most compelling, most strong, when there was some notable adversity that the parent had dealt with, come to terms with, overcome in the context of valuing relationships where it was strongest. So, for example, we at one point sorted the maternal

interviews into two groups. Groups who experienced low levels of deprivation during their childhood and others who experienced high levels of deprivation during their childhood. And if they had high levels of deprivation and had acquired and shown reflective functioning in their interview, 100% of the infants were securely attached. You've probably had previous speakers discuss what secure attachment is all about at one year of age? Yes. Hold on. Let me just, did I hear that correct?

So if you had a person who was, so they're scoring their adult attachment interview of this adult, and they've been through really hard things, but they've overcome it and they're now, like, they're like secondarily able to talk about it in a nuanced way that's, like, they're not, like not scattered, it's like a cohesive narrative. Is that what we're talking about? That is what we're talking about. And in fact, I can show you a slide that details this. So I was talking about the image on the right. Mothers who experienced high levels of deprivation. And look at the sharp contrast. On the one hand, 10 mothers who experienced deprivation but showed high reflective functioning, all of their children at one year of age had a secure attachment to them.

And I'll define a secure attachment as the following. A child who's securely attached, when they're distressed, they have only one question in mind. Where's mother? Where's the caregiver? I'm going to get back to her. The insecurely attached child has at least two or three questions. I'm troubled, but what's going on for my parent? Are they available?

Are they going to be someone I can confidently turn to? Or should I deal with this on my own? Or should I kick up a big fuss? Or should I be afraid? Those are the kinds of questions that insecurely attached children ask. The green are children who know where their safe base is, where their safe haven is, where to go when you're distressed. And that's essential in life to know where. your safe base is. Securely attached children and securely attached adults know this. And they manage on

their own a lot of the time. After, once we get to school age years, we have to manage on our own. And it becomes an issue across the lifespan. But, as John Bolby said, we're dependent on others from the cradle to the grave. So the pursuit of independence is a false goal. Anyways, deprived, look at the other one, people who, mothers who experienced deprivation and they were low in reflective functioning. Sixteen mothers,

15 of them had insecurely attached children. So against the background of deprivation, reflective functioning predicts infant mother attachment security 95% of the time. Wow. That's a very high statistic. This is not like a 0.3 correlation, guys.

This is like very, very clear. And remember, it's language in one generation, the parent, the mother, and behavior in the one-year-old infant in the next generation. On the left, my left, the non-deprived group, it's still the case that if they had high RF, the children are more likely to be securely attached, but there are many more mismatches. and the prediction is more in the level of 65, 70%. So that's why in this paper from 1994, we argued that reflective functioning should be seen as an indicator of resilience against adversity.

Yeah, so, and I think I've heard, you know, the best gift you can give your child is to develop, you know, your own psychological blindness before the child comes, you know. This is the why of the importance of therapy for, you know, for people who want to have kids, if they've had especially a really tough childhood, you know, to work out some of those conflicts. What I have found being a parent is that at every age as my kids grow up, it somehow triggers some of the stuff that happened to me at that age. And it's like, I have to simultaneously work through what,

was like, you know? Well, that's right. As parents, we have to acknowledge those moments where we find ourselves automatically unwittingly behaving in a way very similar to our fathers or our mothers or somebody else. And to notice that is the beginnings of changing that pattern. Yeah. It's like I notice a pull towards this type of parenting style, but I'm choosing to do this, you know, like, that's a good way of putting reflective functioning. It speaks to that capacity in all of us to take control, some measure of control over our experiences, our history, and achieve a state of meaning regarding those experiences that is likely to change

over time. But nonetheless, if we can arrive at some valuing of, the present based on a reworking of the past, that's not a bad place to be. One thing, one sort of scoring method of reflective function, which was interesting to me was how if you use cliche terms, it's actually lower reflective function. So it's the highest reflective function people have,

it's kind of like a unique story. It's like a story that you haven't heard before. It's like very specific to them. And I think about literature as well, like good literature. It has that theme of like, you know, this is not just the story that you've heard a thousand times. There's something unique about it. There's something very sort of personal. You know, and I'm wondering if you have any thoughts on that specifically and how that relates

and maybe teach us about that. Sure. Thanks, David. But these days I'm reading a lot of the writings of a psychoanalyst called Edgar Levinson, who writes from the interpersonal perspective. And he argues that imagination is a foundational kind of motivational system. And it's tied in with memory. And in our psychotherapeutic work, we ought to be eliciting a detailed personal story

from our patients. Opening things up. And from that place of digging around and remembering the details of childhood experiences, the roles that different people played, a narrative is developed that has, I would say, the qualities of reflective functioning.

The clichés that you mentioned, We see them very clearly when people are asked, why do you think your parents behaved the way they did? It's a cliche if somebody says, well, it was the Depression years. It was the Trump years. It was the Obama years. It was, you know, it's making reference to some broad, big, wide, painted brush

that applies to millions of people and also applies to me. So we consider that to be a cliche or a generalization as opposed to a particular detailed sensory memory, including sights, sounds, taste. You know, somebody might say, oh, you want some words that described my relationship with my mother during childhood loving. It was a very loving relationship. Well, we follow up and we say, as you think about your relationship, to your mother as a loving one during childhood, from afar back as you can remember through the age of 12, what comes to mind? And somebody might say, well, she just loved us like all parents do.

That's a cliche. That's a cliche. But somebody would say, well, she was there when I got home from school in the elementary. I remember she was always home. And then we would follow up and say, tell me about a time. When you got home from school and she was there, what happened? And then the speaker might say she would have home. homemade cookies and a glass of milk. I talked to her about what happened during the day.

We know, for example, that securely attached children, it's not that they're happy all the time. They have all kinds of adversities during the day, the school day, with peers in the playground, and difficult interacting with a teacher. The question is, when they go home at the end of the day, is there a caregiver that they can talk to about those events and come to some understanding about them? that prepares a child to face the next day with hope and confidence. I'm thinking about just this idea of being a parent, and it's like we're trying to deepen our own kids' reflective function when bad things happen.

You know, like I tell my daughter, look, daddy gets critical remarks about his podcast, about 15% of people will just be unhappy with you in general. You know, like that's always going to be there. You're always going to have critics no matter what. you know and you know maybe you tell stories of your own being bullied or you know you're trying to deepen like what's going on in this person like what why are they unhappy where are they getting these words pathetic where do you think she's hearing this is she hearing it on the television is she hearing it

from her parents you know not to dismiss that these things are mean and uncalled for but it's like I was almost seeing this as like well there's going to be these people when I our life, right, that are mean. It's like this is her first experience of it. It's like, how do we, how do we give her the tools where next time it happens, she has a more reflective function ability to handle it? I don't know. Anything you would, any thoughts on that? You described that very well. I do have thoughts on that. And clearly what you're doing for your daughter is you're giving her the experience of having a father who listens, who believes me and asks good questions.

One way that parents of young children, five, six, seven years of age and older perhaps, can establish a pattern of talking about the day is to borrow from the metaphor of the rose and to talk to the child at the end of the day and say, what was the rose? Was there something good? Was there something kind?

Something memorable? something valuable that you that happened today that you want to hold on to something beautiful like a rose and maybe they mention something and then you ask um what about the thorn because roses if you grab them the wrong way you end up with a thorn what was there anything that was frustrating fearful painful and what finally did you did you see a bud did you see something that's beginning to grow that can be followed tomorrow next week. So you orient them to thinking about the day and the past in terms of the best and the worst thing and make them aware of the potential to grow in a new direction with the bud. I mean, not all children will warm to that idea, but the general principle, I think it's a general

principle informed by what you said about your creative way of responding to know what for you must have been a painful realization that your cherished 10-year-old is now exposed to some of the, some of the evil in the world. And there is, there is, there are such processes around and they're related to harsh experiences. So certainly it's linked in with the value of reflective functioning. Yeah, I think, okay, so kind of want to see if we if covered all the things you want to cover well i think the talk to do david is briefly mention um some of the difficulties that people get into that is low reflective functioning because we mentioned we mentioned rejection we mentioned hostility like you know why do my parents

behave the way they did you're the psychiatrist you tell me when is this over i got to go um some of the other indicators of low reflective functioning are disorganization, bizarre, atypical remarks. I mean, I have had some experience with patients who are very disorganized. It's hard to follow. My countertransference experience is one of confusion, some despair, wondering why they clever people, accomplish people. But when they're asked to talk about relationships and what's going on in the life, they're not very organized.

Now that's what's called unintegrated. And of course, with therapy, our goal is to help patients arrive at a sense of wholeness and integration. The other is disavowal where someone just says, I don't know, but they're out, you know,

were you maybe feeling, you say you were feeling sad? Was there some fear there as well, perhaps? And they said, I don't know. So it's kind of like, I don't, disavowing. That's a low example. And then there's something called distorting self-serving. Okay.

You defined distorting self-serving as those people who elevate themselves. I'm fine. The other people, they don't matter. They disappointed me. I asked, I interviewed one expecting father many years ago. I said, what was your relation with your father like? And he was an idiot. I knew it by the time I was 11.

When I was in my teens, I tried to be nice to him. I gave him a job and I had to fire him. So what's this person doing? It's kind of a cold dismissal of the parent and an elevation of the self. I asked that same man, if he was ever sick as a child. No, I was never sick. Oh, I had TB once. I said, how did you get over that?

I got over it on my own. So there are these, you know, inflated narcissistic, if you like, individuals who praise themselves and put others down. We call that distorted self-serving. We don't quite believe the attributions to others. It seems distorted. And there's also a distorted sense of the importance of the self. And then we have those naive simplistic replies, general. Why do my parents behave the way they did?

All parents love their children, don't they? It was the depression years. And then finally, and we see this in people with borderline symptoms, a kind of intense interest in relationships, but they don't go well. And the RF is hard to track because it's overactive, hyperactive. And before, this is like somebody who's got their wheels stuck in the sand. and they're spinning.

They're often angry these people. You know that they had some difficulty experiences in childhood, but you're not quite sure what they are because they're... And clinically, the goal there is to slow down the narrative, like some structure. Whereas in the people who are disavowing, the goal is to kind of warm things up and ask lots of questions so that they get comfortable telling their story.

The person with hyperactive RF has an intense interest to tell their story, but they're not organized, and it's they're rushing. And so, interestingly, Bateman and Fonagy and mentalization-based treatment, you might have talked about this in previous podcasts, they draw on the metaphor of the remote control, pause, rewind, review, and they use that language with patients. You know, can we pause? Can we just rewind a little bit? Tell that story again, and a little slower so I can follow better? Yeah, I was thinking about somatization as well. You know, like not feeling emotions,

not having a narrative because it's almost too painful. They just feel it in their body. I'm wondering if that would be low reflective function. That would be a form of low reflective functioning. Definitely. And with those patients, of course, I imagine what you do is you ask them to talk about their body. And where's the pain? Where is the defeat?

What are you feeling as you think about that pain in your leg, your arm, and so on, to kind of open things up a little bit. I think the somatization is a little bit like disavowal. Can't talk about it with words. So I experience it in my body. And we know that trauma work is very much focused on the body. As Vessel, Commander Cook has said, the body keeps the score. Yeah. Okay, so the somatization, the disavow, it's like I had a patient who said,

and they were describing how horrible their body pain was. And I said, would you rather have the body pain or feel emotion? and they said, I'd rather have the body pain because the emotion was so painful. And it was probably a motion of loss of a relationship, loss of an attachment. Sure. It was so painful.

I think this also applies to self-harm as well, non-suicidal self-harm and suicidal thoughts as well. I was thinking about that with not self-harm, but violence in the prison population, the reflective function being so low, you know, it seems to me that that is a way of expressing emotion in a very sort of outward physical way. And rather than like putting its words, processing what it might be,

or just someone's impulsiveness to violence might be a much higher if they're misreading people, if they're not seeing the world accurately, if they feel like people are after that. I think that's a great example, and we talked about it earlier, and I think that these are people who don't fully appreciate that speech is a form of behavior. They think that behavior is something you do with your feet and your arms. And we know, of course, that when people are angry, blood goot rushes to the hands. When they're afraid, blood rushes to the feet to help you run.

But when you are high in reflective functioning, the blood is distributed evenly throughout the body, and there's a flexibility of thought and feeling. One thought that I had, which I don't know if you've thought about this, is there's an idea of sensorium like brain function, and brain function naturally fluctuates. You know, probably the extreme version of this is an old person who gets an infection and gets delirium, where they're now psychotic. They're seeing things that aren't there for the first time. They don't have a history of psychosis.

There's also something called hypoactive delirium, which is more they're just stuporous, can't focus, can't concentrate. But when I think of sensorium, I think about myself. And there's certain parts of the day, especially if I'm sleep deprived, especially if I haven't eaten well, especially if I've been stressed out for a couple weeks, where I may not be my normal brain.

you know and i think in those moments i have lower reflective function i don't know have you thought about like reflective function as like a something that shifts throughout the day potentially even for normal people for sure it shifts throughout the day um it um tends to disappear in those moments when we're most tired or most hungry and um nursery school teachers know this they do their instruction in the morning when children are we're meeting in the morning maybe that's why you wanted to meet so early in the morning, you would benefit from... My audience can benefit from a higher reflective function. Yeah, but they, Anna Freud remarked on this, that children are engaged with the most intense,

challenging learning experiences in the morning. And in Germany, until seven years of age, you only go to school in the morning. The afternoon is for running around and playing. And my mother was a elementary school teacher and something she felt fiercely to be important was recess. Absolutely. Running around and releasing one's energies so that you come back a little more settled for some more learning before the lunch break. So yes, there are fluctuations in reflective functioning. And as I said, there's this paradox that when we need it most, when we're threatened,

we tend to draw inward and reflective functioning leaves us. And it hopefully is something that we regain later in the day through conversation with a family member or supportive person or the next day. So we have to nurture reflective functioning and make it a kind of habit, a habit of mind that we can recover quickly. we need to. Yeah, and I think probably the extremes of this in human behavior is someone with borderline per size disorder, Funigan-Bainment, call it psychic equivalence mode. It's basically when they're losing their ability to mentalize accurately someone else's state or their reflective function probably drops. Indeed, this is their speculation about what precedes reflective functioning. Because reflective function, because reflective function,

is not really observable until 11, 12 years of age, 10, 11, 12 years of age, and then it takes off and grows. In young children, one, two, three years of age, Bateman Fonagin and Targe, Mary Targe and Peter Fonaget suggested that the one-year-old is governed by psychic equivalence. I'm not so sure of that. We don't know what's going on in the mind of the one-year-old, but we do know how frustrated they may be if they don't get what they want in the moment that they want it. And so they ascribe this state of psychic equivalence. And that is, just because I want something, we know in adulthood, just because I want something doesn't mean I should have it or can get it as quickly as I want it.

But for the one-year-old in the moment of want, it's connected with the belief that what you desire should be right there. We think about four or five-month-old infant's crying. because they want to be fed. They're crying because they can't wait. The three-year-old can wait. The three-month-old can't. Or they're communicating directly their needs in the moment

without filter, right? Without filter and without the ability to delay gratification. Without the, yeah, without the ability to delay gratification. So the thing about psychic equivalence mode, which I find helpful is that when someone is in that state, and I think we all can enter into that state when we're stressed and hungry and tired. But in that state, your reality is the reality

that is the truth, right? So there is no other reality. So if someone hates you, if I'm sitting here thinking, which I'm not, that Howard Steele hates me, he does hate me. And that is 100% true. It's not perhaps he hates me. It's no, he really does. And so there's no question in my mind that my mind may be inaccurately giving me messages, right?

Well, that's well put. And it strikes me that somebody in a florid psychotic state is vulnerable to that same phenomenon. Oh, yeah. And I question it a little bit because we have so much information data now from the infancy researchers that, we come into the world for the capacity to hear, seeing comes online, and we have a rudimentary understanding by two, three months of age of how gravity works. And I'm not entirely sure that the two, three, four month old

is completely unable to manage without, depending on psychic equivalence. But it's a, you know, it's a tradition in the, psychiatric psychoanalytic literature to interpret infancy in terms of what we know from adult psychopathology yeah and that's and that's where i think attachment literature and the work that you do and being an editor makes you so unique it's because you are really in more of an observation capacity you know you're trying to observe what's actually happening and i think that's why we have to

ground ourselves as clinicians in that research, right? That, yeah, if you're a mother that has done her own work and done her own therapy, and maybe you came from a very deprived childhood, but now your reflective function is high because you've done a lot of work on yourself, you can be confident that that's right. And for the person with moderate to high reflective functioning, when we listen to them, when we listen to the speaker with moderate to high reflective functioning, the conclusions we draw about their experience are likely to be the same as the speaker. There's a kind of consensual reality that is achieved.

That's a term that Harry Stack Sullivan used for his goal of therapy to arrive at a consensual reality. That what the patient understands and believes about their experience agrees more or less with what the therapist or psychiatrist understands. Now, this is related to John Bowlby's assumption about the internal working model, because he said in the securely attached individual, the internal working model of self and others provides a tolerably accurate model of the outside world, a tolerably accurate model, not a completely accurate model, a tolerably accurate model. And of course, when we start out our work with patients, their models often. going to seem muddled and confused, and it's unclear what happened to them, how they think and feel, and we entertain all kinds of hypotheses about maybe this happened, maybe that happened, and most we don't say, but over time, there's a kind of coming together and an increase in reflective functioning for the patient facilitated by a therapist with high reflective functioning, and a consensual reality might

emerge that the patient feels gratified by. And yeah, I think this is why the adult, even if they had a fairly deprived childhood, with higher reflective function, has a securely attached child because they're able to enter into the mind of the child to some degree to see what that child is feeling, thinking, reflect it back to them. So the child then understands what they think or feel. you know, it's like the opposite of that is that the child is always only experiencing the parent's world. The parent is not reflecting back anything about the child's world to the child. So it's only no, it's only in relationship to a parent that is in their own, stuck in their own

experience, so to speak, which I think I have had, several patients that I feel like I've successfully been able to help through that, but it's taken years because you're basically, you may be the first attachment in that person's life that has attuned to them in a stable way over years in an on-coing repetitive way and in a reflective way. And you're interested as a therapist into their internal experience. I'm curious about their kind of deepening their own reflective capacity, reflecting back their experience to them. Sure, there's an attachment piece that we have to take account of in those cases that we work with. And as you said, it takes years.

And I think one reason why it takes years is that people are very reluctant to give up their thoughts and feelings about family members, mother, father, siblings. And those are very important to everybody. And we, the therapist, were a stranger. This is one of Ebyo Levinson's points that therapy fails. You pointed out that therapy fails because therapists may not have sufficiently high reflective functioning. But all therapists face the dilemma or problem that we are outsiders, strangers to the patient's experiences, and the very familiar people that they deeply love are mother, father, however they were treated by those people. And so we have to gently, over time, establish and maintain trust and persuade the patient that we're not here to trouble them in any extreme or overwhelming way,

and that we invite them to tell their story again and again and again. that the story takes on the characteristics of belonging to the past, freeing the patient to respond in new ways in the present. Yeah. And sometimes I think what I've found is that you can have very well-intentioned parents that do not have the communication abilities that I possess. So I'll point that out to the patient, you know, like despite your dad or mom's, mom's best intentions. It sounds like they really had a difficult time in this instance communicating warmth or caring to you, you know, and I think that's been helpful as well to kind of not go all bad on the parent. Yeah, I'm sure that's a very clever, adaptive way

to go and to... The parent could have great intentionality, but poor execution on the intentionality. And as the same go, the road to hell is paid with good intentions. And can lead to a lot of suffering sometimes when that's the case. Okay, so kind of wrapping up our time together, what do you feel are some of the gaps that, like, if you had a PhD candidate right now and you were to say, here are some of the things that we don't know yet that we should know about reflective function, about attachment, are there any things that jump in your mind right away?

Well, we say in the reflective functioning manual that it's not yet clear what are the distinctive reflective functioning difficulties that particular patient groups show. So I currently have a PhD student who's looking at a community sample of adolescents and young adults with varying levels of borderline symptoms, not people with borderline pathology, borderline personality disorder, but there are questionnaires that measure extent of borderline symptoms. And she's engaged in a study

trying to understand what types of reflective functioning are most associated with borderline symptoms. And the preliminary work suggests that it's the hyperactive. Oh, wonderful. I mean, the functioning. Let me specify.

Not wonderful, like, that's a great thing that they're hyperactive. but it's just helpful. It's helpful for me to be able to think in that category and to be able to help people. So it's wonderful in that way. Yeah, and I would welcome other students who might want to study people living with chronic depression

or people living with, I have another student studying obsessive-compulsive disorder and we'll look at levels of reflective functioning in that group. So if we can, can know what the distinctive reflective functioning troubles are of particular patient groups, we might be better able to engage with them and help them. Yeah, I really, really like that. Well, Dr. Howard Steele, it has been a true pleasure. I want to have you back on for sure. I feel like we could spend another six hours talking about this and getting super granular. And I think

I will put a link in the show notes and in the article that will go up with this, the link to your training that you do on Reflective Function and to your website. And I encourage anyone who's listening to this to go check that out. Thank you. You can include my email and people could reach out to me by email if they have an interest in any of the trainings that I do online. I do them all on Zoom like this experience was. Great.

And then there's also some books you can. check out by Howard Steele on attachment, deep dives, his articles, and I'm excited to highlight you and your expertise and the hard work you've done over decades on attachment. I think it's been a real contribution. Thanks very much, David. This was a pleasure. All the best. All the best.