Psychiatry & Psychotherapy Podcast - Trauma-Specific Reflective Functioning (T-RF): 5 Trauma Mentalization Profiles & Impact on Parenting

Episode Date: May 29, 2026

In this episode, Dr. David Puder explores Trauma-Specific Reflective Functioning (T-RF) with researchers Dr. Nicholas Berthelot and Dr. Julia Garron-Bissonnette. Discover how childhood trauma affects mentalization and learn about the five distinct trauma mentalization profiles identified in mothers with histories of maltreatment: identification with the perpetrator, functionally grandiose, absorbed in trauma, global failures in mentalization, and those with no major failures who show remarkable resilience. The conversation examines how these different ways of processing trauma significantly impact parenting, attachment security, and the intergenerational transmission of trauma. By listening to this episode, you can earn 1.25 Psychiatry CME Credits. Link to blog Link to YouTube video

All right, welcome back. I am joined today with Nicholas Bethelieu and Julia Garan B. Sudnet. And we are going to be talking about some of their research. If you remember back to my prior episode where I discussed reflective function in mothers and then they followed the mothers and looked at the children. The study showed that mothers with low reflective function. and specifically their trauma narratives had much higher rates of disorganized attachment almost twice. And so this is going to be a longer form discussion with the researchers who published that article and we're going to be going through trauma-based reflective function

and some of the different narratives that come up, how they score it. We're going to be talking about some of their other research as well. So welcome to the podcast. Thank you. Thank you, David. So let's see. Let's start with, talk to me a little bit about the early research in this,

and then kind of like take me through the history of how you guys got into this and how it started. All right. You think you already introduced it quite well since this today you've been talking. about where we documented trauma-specific reflective functioning was important for mother-child attachment was the very first study on that concept of trauma-specific mentalizing. So that's a work I've been doing at University Laval in Quebec, Canada, with Professor Karen and Sank in the course of my PhD dissertation, where we were working with a quite large simple of praying at women who have experienced child maltreatment, so childhood abuse or

neglect. We were looking at their adaptation to motherhood. How were they doing? And how the relationship with their infant eventually unfold? And we had access in the course of that research to narrative about their experiences with their attachment figures, so generally their two parents. and we were coding attachment and reflective functioning. And one thing that we did notice when doing that work is that surprisingly several mothers were reflective quite reflecting quite well better than we thought at first regarding their past experience of attachment relationships.

But we did notice that when they were coming to discussing child abuse and neglect during that interview, their mentalizing skills kind of felt apart. It was much more difficult for them to organize their tough or to reflect coherently on the impact of these experiments on their current functioning. So we kind of observe and decide that we should give separate scoring to these specific parts of the interview on Abuse and It's Leg

than we were doing for the other parts of the interview. And that's when we start developing that idea that mentalizing trauma is not the same as mentalizing in general attachment relationship. Yeah, so you're scoring them and you're recognizing that in some parts of their narrative, they were scoring well, they were scoring high, and other parts they were scoring lower. This is something that I recognized as well as I'm kind of investigating this in my patients. And in myself, actually, I had my own AAI done. And not all passages of your AAI are the same, right? And so some people, specifically with trauma score lower. Julia, how did you get involved and tell me more about this study?

Yeah. I started working with Nicholas in 2017 as a undergrad. And then we continued together through my PhD. and now we still collaborate as I moved away from the lab, but still am not really far. And then I had a lot of interest in childhood maltreatment and in parenting, and specifically the parent-child relationship and really trying to understand their processes that are happening when people parent and the predictors of attachment security, for example, and got really fascinated when I started working with Nicholas about reflective functioning in general.

And so my own dissertation focused on attachment-based reflective functioning in the adult attachment interview, but really started working on this trauma-specific reflective functioning as well and just thinking about the ways that we measure reflective functioning in general. And so I think the manual, even Funnaggy's manual, really accounts for the fact that there might be drops in some areas. And so the overall score is not just a mean, for example, of scores in different questions, right? So we have to think about the overall functioning and flavor. But I think with this work, what we're trying to do is really to better understand the low end of the scale. And especially in people who've experienced child maltreatment. I think it's going to be part of our time today that we're going to be talking about.

what these actual narratives look like. Because I think that as clinicians, I'm mostly speaking to clinicians, we can start to notice in someone's narrative when they have lower RF in portions of the narrative. And it's something that I have found very helpful and kind of helps me zero into someone's story in a different way.

So I'm kind of applying this primary literature that you guys are working on, to clinicians, and I'm hoping that, you know, the clinicians who listen to this can kind of grow in this ability. You have this 2025 article called characterizing the heterogeneity of disruptions in the resolution of trauma among women exposed to childhood maltreatment. You want to describe this study maybe in general, and then we can get into the specifics on the different types of profiles that came through in the trauma narratives. Yeah, absolutely.

If I introduce the ideas behind that study, that study is based on very general observation. The first one is that we know trauma is quite frequent in general population and in our patients. It represents at least one-third to one-half of our patients who have experience. severe abuse or neglect during our childhood. And we know it's a very powerful determinant of mental health.

And the second thing we know, as we already discussed, is that not only trauma impacts mental health, but it also has an intergenerational transmission. And knowing that, knowing that is a powerful determinant of mental health, Another idea which is very important and led us to that study is the idea of heterogeneity. This idea being that even though it's one of the most powerful risk indicators, childhood trauma being one of the most powerful risk indicators for later mental health problem, about half of people who have experienced severe abuse or an attack during a childhood

are showing striking resilience and are doing quite well. So something is happening during the developmental trajectory that Ariand there is trajectory toward resilience or throughout depression or personality disorder or psychosis or something else. And we know very little about the developmental determinants that are under risk trajectory toward one path or another. And the hypothesis we made is that how people have psychologically processed or resolved their traumatic experiences during development is a core determinant of later functioning. And that's why we try to observe in a large temple of 800 preant women we were working with, all of whom having experienced

some type of abuse on neglect during their childhood, whether we could observe different profiles in the way they were thinking about their traumatic experiences and thinking about the impact of these traumatic experiences. So to do so, we use a questionnaire we develop, since as you already said, I think the very best way to capture trauma mentalizing as a therapist or as a researcher is only to pay attention to what people are seeing about their experiences, to be curious about that, to listen carefully and generally we get a good idea whether they are reflective or not. But in research, it's not always possible to do so at least with a very large sample such as ours so we develop a self-report measure to kind of capture different types of impairments

in reflective functioning so that that instrument is called the failure to mentalize trauma questionnaire is freely available in English and multiple languages and we administered that questionnaire and we're able to identify different five different profiles five different ways people were reflecting or not about their expense of childhood trauma. You want to add something, Julia? No, I think that's a good introduction. And you guys also, because in this article,

you have some narratives that you pull out. And so how many people did you do more of a narrative, you know, a qualitative portion of the interview? Well, I couldn't, I don't know, Nicholas, if you had the number in my, I couldn't tell you the exact number in this specific sample that the paper we're talking about. Include what we have about, I would say, probably 250 across like different studies of, they're called trauma meaning making interviews, which we typically will use to code trauma

reflective, trauma-specific reflective functioning. And we pulled from those, from participants in the paper who were, who had completed interviews to really try to illustrate what that might look like in a conversation or in an interview. Okay, okay, I see. So some of the profiles are like, profile one, identified with the perpetrator. So describe this one for me. Yeah, this group of people that we identified that were expressing two, specific types of disruption in mentalizing trauma, one being justification of trauma. They were explaining that trauma was kind of a good way to behave. The ad abuse was

deserved, for instance. And they were identified with the perpetrator as well, meaning that the seems like they emerged out of a maltreating relationship by defensively identified. with hostile attachment figures, probably in an attempt to cope with the fear involved by trauma. So kind of people who now are probably arshend their relationship

with others, may put themselves and try to be in control in their relationship with others, and by doing so, they are less afraid of being abused or on neglect, again, being the one in control. So that's one group, we did observe,

one type of profile we did observe in that study. Okay, yeah. So this is either there are justifying trauma, they're identifying the perpetrator. And then you have some great example comments, like, and I think this is kind of helpful to talk through. This is the kind of thing that we would hear actually in therapy sessions too, right?

So like one of the questions, does that experience affect you now that you are older? So that maybe you're asking the person this, does this experience the trauma affect you when you're older? No, no. No, but if I see him in the street, I won't hesitate to spit on him. When I was younger, I used to hide from him. Now I'm old enough. If I see him on the street, I'll spit on him or run him over with my, car so talk to me why is that identifying with the perpetrator probably all the

people hearing us already have ideas about that since I think it's quite clear in that example that there's a lot of anger anger toward the the perpetrator which which is something you can absolutely understand I mean people have been experiencing quite severe abuse or an ad-like may still have conflicting thoughts, ideas, and negative emotion regarding people to commit these experiences. The first thing which make it clear that it's not reflective functioning is that when we ask that person, if she thinks that the experience affect her now, that she's older, she says no. If I've said yes, I think it makes me so very angry about this.

experiences, we would have seen it completely differently. But she says, no, it doesn't affect me at all. But if I see him, I will run over him with my car. So we see two different parts here that cannot relate with one another are very conflicting and that make it clear that it's not reflective functioning. The type of disruption we observe here is totally in the form of undergoing anger toward that person and feeling justified to revenge? Yeah, it's, I've thought about this in terms of like the stages of grief, right, where if they're caught in the state of anger, right, still wanting to spit on the person, run them over the car, it's like they're moving from putting to words how it impacted them

to action, right? So it's like it's a denial that it impacts. them, but it's still, they would still act upon the emotion that's underneath that isn't completely processed. Yeah, yeah, absolutely. And what is concerning, when we observe that type of situation, if we let it go and don't do nothing about that, is that we know that this specific profiles, so people having such responses, highly correlates with specific types of symptoms and difficulties in their own life,

including here externalized behaviors, including intimate partner violence, perpetration. So it's not only about the narrative when they think about trauma. It's something that unfold in their own life in their current relationship as well. So because the reflective function is low, they're moving to action, they're moving to violence

when they're having emotions, right? Okay, let me read a couple more of these. these narratives here. I tell my kids, mommy is going to get mad and she can give big slaps, big slaps on the butt. But if it's on the butt or the fingers, it doesn't hurt. It's not that strong. So, you know, she cries, but she cries just because she feels something else, not because, you know, she really's not used to it. Maybe that one, I don't know, does that make sense? Did I read that okay?

Yeah, yeah, absolutely. It's confusing to me. I mean, there's something about the confusing nature, which is a little bit. So tell me what this means or what the, maybe how this makes sense to you, Julia. I think the context is, the question is about how it might influence how the participants, than parents, her kids. So I think that context might be helpful here in understanding this specific citation, right? And so kind of thinking, talking about repetition of child maltreatment behaviors, right, towards her kids now.

And so a different way of seeing perhaps this identification with being a perpetrator, or really this active cycle, even in this case here, which is why I think we had used it as an example of this profile as well. Not fully organized, which I think we see a lot in lower reflective functioning narratives as well, which is why maybe it leaves you, David, a bit of a confusion there. Yeah. Yeah, it's like, I'm like, am I reading this correctly? But there's a little bit of that confusion there, right?

Yeah, I'll read another one. I gave my father a punch. Takah! I gave him a black eye. There's laughter, a little signal there. That was one hell of a show. And so it's kind of like this rejoicing of the violence. It's excitement, flavor, right?

Yeah. Yeah. So that's another good example. So that identification with the perpetrator may take different forms, different colors. And the previous example we just saw was a clear. of the abuse. The mother was saying, I hit my daughter, but she's crying because it turns. She's crying because she's not used to it. So that's what we see as unconscious repetition. But in that current example, it's clearly excitement when talking about difficult life experiences.

So the person is laughing, saying that was one hell of a show, discussing an argument with her father where she hit him. So again, the idea. The problematic aspect here is not that she has experienced that type of situation or that she's angry at her father, is that she's talking about that in a way, which makes it funny experiences, and she's excited to tell us about that and want to tell us more. So that's the main point there.

Interesting. Okay, I'll read another. I pity the next guy who tells me, my lunch is not ready sit down i will give you your lunch i'll fill his lunchbox directly in his mouth you know and then there's laughter i am not your slave no it doesn't work that way i like talking about that i find it fun it lets off the steam so there's i describe what's going on in this story here? Something about it's probably

a situation that she was expressing, explaining an argument which she had with her partner and probably her partner said that his lunch was not ready and she gets very mad and she

expressed it that way that the next time she will feel his lunchback directly in his mouth and she's laughing and she tells us, I like talking about that. So that's another good example, I think, that most people will discuss that type of situation, that type of argument with ambivalent feelings. They would not be excited talking about that. They would be shy about these experiences. They wouldn't certainly not be comfortable, but she's in

totally opposite direction. She's particularly comfortable talking about such experiences, being violent or expressing violent fantasy regarding her partner, which is the thing that makes it partially concerning here. Okay. Yeah, there's a little bit of almost like sadism in the enjoyment of the hurting of the others in this type of persona. Also, I'm thinking like this sounds, the defenses seem a little bit more like grandiose or, you know, like a little bit narcissistic flavor,

a little, you know, psychopathic, like the power, wanting power, wanting control, that kind of like identified with the perpetrator and, you know, put this kind of spectrum of thought process. Yeah, totally. And I want to underline here that these narrative, these examples we're talking about, these are real examples that came from Part two.

we met in our studies, which were not people recruited because they had severe mental health problems. These were people that were recruited only because they were expecting a child. So these are women from the community. But we see from these examples that when we ask about their child trauma, when we ask about these experiences, we have access to something particular. And in clinical practice, it tells us that it. It will be very important at one point in the process to pay attention to these experiences,

pay attention to how the people talk, mentalize, reflect, feel when she's talking about difficult life experiences, since we may observe distinct processes that we do not observe when she's talking or he's talking about other types of experiences. Okay. Let's go on to Profile 2, Functionally Grandios. There's some grandiosity. They develop this kind of representation of themselves that is invulnerable to the effects of the trauma, or having the strength to move on.

There's an avoiding of discussing painful emotions. Tell me about this type. Yeah, these are many people who say trauma doesn't impact me at all. It has no effect. I was strong enough to suffer that. without any impact. It may be true in some instance, but they are characterized by that representation

that it had no effect, no impacts over time, because they were strong enough to undergo it without any types of difficulty. And that profile is especially intriguing since they are distancing from, definitely from trauma, from their emotions. And it reflects when we look at their mental health or their symptoms to the absence of symptoms as well.

So they seem like being, in fact, resilient as they do not express any post-traumatic stress disorder, nor depression, anxiety, which fits with the fact that they are, emotionally distant as well from their experiences. So we still have to understand more about that parts of our subgroup, follow them over time, and to see what happens when the child is there, for instance, since they are all parents who will be partially interested in looking at their parent-child relationship. So because they will be with a child which, of course,

will express vulnerability, and they are definitely a group of people who are not comfortable with vulnerability, so we'll be possibly interested to see what happens when they are confronted with child who's crying, expressing distress, that type of thing. Let me go through some of the narratives here to kind of make this a little bit more real.

So this person said, I remember talking about it with my sister. I used to tell her, I know that if it were you, you would have never been able to make it through. Me, I'm capable of confronting every situation, even the most painful ones, in a positive way, not a negative way.

So it's kind of like there was some abuse, and then this person is talking their sister and they're saying, if it was you, you would have crumbled me. I can confront anything. I can move through it. I can push, I could, I could bear this. Yeah, Julia, what do you think when you hear this? Well, I think, I was thinking about what Nicholas said a bit earlier about how it might be that they are doing well and that they, you know, are in a resilient trajectory. But I think with examples like these, we really see that this is not really a reflective process, right? That the participant is showing us.

They're not really walking us through perhaps how they developed that resilience and how they were able to face those experiences. And so I think that's what's lacking here when we're looking at something like reflective functioning, right? And I think the thing is really helpful for kind of, illustrating that piece. Yeah. It's like there's that jump to resilience

without the ability to mentalize the process, right? Because it's very different if someone was like, you know, yeah, what had happened, I was at first very numb and disconnected from it, didn't think about it. And then I went through a phase where I was angry. And then, you know, I was really sad that it happened. And it felt, you know,

you know, like I had to really rectify my understanding on my father and why he would do that. And then subsequently, you know, I've been able to kind of move past it where it doesn't bother me as much. I don't think about it as much. I have compassion for myself as a child having gone through this. So they're showing kind of the mentalizing journey. Exactly. Yes. And you understand how this adaptation came about.

It doesn't have that grandiosity aspect to it. Absolutely. I think your example is quite great, David. And there are some people who are not able to express that in such nice words, but at least we'll say, I'm surprised that I made it true and that I'm doing well today. And so they will express some kind of curiosity about the process, and they will understand that developing well in the context of arched childhood, it's kind of surprising.

There's something that happened that they have them make it true. But as you said, I think it was the right words. There's a jump from the terminal treatment to the resilience without an understanding of the process. And I think as therapists, what I would say is that it may be that if someone is a little bit more grandiose in the jump, right,

we may think to ourselves like, oh, we don't really need to talk to them about this or this trauma's resolved in their brain, but it might not be resolved. I have this one set of brothers that I know really well. One could tell you about the trauma, could tell you how it impacted them. The other one doesn't even remember.

They're like, I don't remember that happening. But that's in the past. You don't need to do it. even think about the past. The past isn't even important to think about, but they both went through the trauma, right? They both went through the same thing. Let me read the second one here. I put a cross on that. There are other things in my life that I think you have to go on, not live in the past. When you go through such experiences, you have to be able to say, okay, that's enough and put the cross on that. Yeah, Julia, what do you hear when you hear this?

I think this is kind of an active rejection, right? And thinking about those experiences. And so a little bit of a different illustration than the one we just looked at for this specific profile. But I think still this idea of not really going into the vulnerability or going into affects or thoughts or feelings that might arise when they think about experiences. Absolutely, that's a good example of kind of overinvestment in cognitive reasoning. And it's not a good understanding of the human mind. The day you decide that it's enough, it's enough.

And you won't think about that anymore. It won't affect you anymore. It doesn't work that way. But she kind of expressed that people have to have that ability. and she implies that she has that strong ability to just decide to let things go and from that moment that doesn't impact her anymore.

It's a super, in my mind, it's like a superficial spirituality too, right? There's a difference between someone who's really done the work, there's maybe some spiritual aspects that have helped them through the work. This is more of like a hypomanic defense of sorts that's combined with spirituality, where it's like,

you just put a cross on it, that's good, that's all you need to do, you know, no need to feel anything. You can move on from it. Okay, so that's number two, functional grandiose. Number three is absorbed in trauma. Tell me about this one.

Yeah, that bars could our subgroup presents several of the impairments. and mentalizing trauma, we assess through the questionnaires, one being identification with the victim, the other one being disorganization of thought, the other one being absorption in trauma and avoidance. So it's a subgroup of people who have a tendency to take responsibility for the trauma or to consider the abusive behaviors as being deserved. when they think about these experiences, they have very important problems in reasoning that take the form of depersonalization or even destructive behaviors when they are connected with trauma-related emotions. So their discourse and narrative becomes very confused, very disorganized.

There's a clear interference of memories of trauma with the monitoring of thought and behavior. so they may become disregulated highly disregulated they may have the urge to for instance cut themselves when they think about the trauma

and they have very negative thoughts and emotions when they are discussing these experiences so the types of difficulties we see here highly fit with the

diagnostic criteria for post-traumatic stress disorder. So it really relates to people when they think about trauma, they get absorbed in these experiences. Julie, anything you would add to it before we maybe read some of these comments? Really? I think this was a good description. I think it's a little bit. If we think about the scales of the questionnaires,

so the questionnaire includes seven scale. And so this profile shows a little more impairments across different scales than the two we just looked at, which were a little bit more specific in terms of one or two types of impairment. So this one might be a little bit more global. We have one that's even more global, the last profile. I'm sure we'll get to it. But this one includes a little bit more of these disruptions. When I heard, so with the first one, I was thinking like there's a little bit of that almost like sadism with the second one. I'm thinking more of like the narcissism

or narcissistic defenses, you know, narcissistic personality style. With this third one, I'm thinking more depressive personality style, dependent personality style. You know, they blame themselves for the trauma when they are, or dissociative personality style.

And so maybe I'll read one of these. You know, when he took his belt, and then there's like a 10 second pause and folded it in two and made noise with another six second pause, scared, another four second pause. It scared us. But he never hit us with it. It was scary as hell.

And then you want a reason to cry? And he takes his belts and he comes to me and, oh, we cried even more. it scared us. He was really strict. So, yeah, when you hear this, I'm hearing the pauses, you know, is there a dissociation in that? Almost like the telling of it,

it's like so distressing. There's a little bit of that dissociation. Sometimes I'll hear pauses and people's stories when they're going through something like that. There's a lot of fear. What are your thoughts on this one? Yeah, I think your comments were, right, on it, these are probably good examples of illustrations of dissociative processes.

So probably just thinking about trauma was highly painful. And this is a process interfered with the way she talked about these experiences. So as you said, she has difficulty organizing her tasks. She's still quite afraid and we can see it when hearing or reading through the narrative. if there's a long pause, she's switching from past to present. At one point, she's talking in the father's word when she was experiencing the trauma. So that's a good example of that, probably still highly vivid

traumatic representation that comes with dissociative defenses. I don't see this person blaming themselves for the trauma, or for what happened there. No, no, this profile are possibly vulnerable to blaming themselves for art experiences, but you're right, we do not see it in that narrative. Not in this narrative, yeah. And then the other thing I would say is, like,

when I hear a narrative like this, I often think to myself, well, there's more there that's not being said yet, you know? Like this could be, sometimes there's more of a surface, narrative of, you know, there's no actual hitting in this narrative, for example. So, but there's dissociation, there's the fear as if there was going to be hitting. Okay, so that's one of them. Here's the other one.

Talking about verbal abusive stepfather. Okay, so that's the context. I started my period when I was like 10, and I had quite important, important mood swings. I was like around fourth grade and then he really didn't know how to deal with me he really did his best but I was so difficult so probably then you see the tendency to feel that they are to blame for the trauma

that we were not saying in the previous example but it's more clearly here right so there's a little bit of like the blaming, yeah, he was doing his best. There's a little bit of that idealization of him, devaluation of herself, you know, I was the one with mood swings, I was difficult to deal with, I was so difficult.

This is around, this is in the context of maybe before this passage, there was some discussion of his verbal abusive words or something. Okay, yeah. Yes. Yeah. And it's being disconnected from the developmental experience of what it is to be young, 10 years old girl, having her a period. I mean, it's a complex experience.

And when the response you have is verbal abuse, at least we would have expect not her to say that she was the one being difficult and that she deserved her father or stepfather treating her this way. and being more ground in the complex experiences that she had at the time and how she would have expected that the caring parent would have responded. Yeah. Yeah. It's like sometimes I'll hear someone tells something traumatic that happened to them, and then subsequently they're trying to make less of the badness of the person that caused the trauma to them, right?

and it's really hard as a kid having a parent that you don't idealize right that you don't look up to so maybe it was like psychologically easier or maybe psychologically more beneficial in the relationship to take the blame even if the other parent was to blame right let's say the stepfather was to blame he was a jerk he was an asshole, but if she had that narrative of him, life would be so much worse. And so this person figures out ways psychologically to make herself bad and make him good continually, because that makes less trauma coming towards her. But it's not a high reflective function position because she hasn't been able to, as an adult now, kind of see how that was adapted. for her growing up to idealize him

and how it was adaptive for her to go bad on herself. Now it's not adaptive, it's maladaptive, but it was historically adaptive. Yeah, you're totally right. And I think that what you raise here is important that probably we would have the different expectations if we were to assess from a specific reflective functioning, effective functioning with children or adolescents that are still living with their parents.

Then when we are evaluating reflective functioning with adults who are not dependent anymore of their parents for survival. So of course, I totally agree with you that when you're a child in that particular situation, kind of shutting down, mentalizing or taking responsibility on yourself is important for survival. you don't want to have a representation of your parents as being dangerous. Otherwise, you will feel constantly under threat. But once you emerge out of that relationship, you're an adult and it's your turn to become a parent.

If you are still kept in that representation of yourself as being the one to blame, as your parents as having done the best they can in that situation, that may be problematic, and that's when we see that intergenerational cycles of trauma, that if she still have that representation, probably she will repeat that the same way. And I think that what's interesting is that you guys found that it's specifically with trauma, reflective function, right?

And it's because I think also when it's these heightened moments that lead to the mismentalism, sometimes. It's like that a lot of times parents can be completely, you know, normal, you wouldn't be able to see the dysfunction, but then when a big stressor happens, it's like then they may regress into kind of earlier reflective function gaps. Yeah, absolutely.

If I can open the parentheses here, And we did document that through our research that when we evaluate different types of reflective functioning, so attachment-based reflective functioning, parental reflective functioning, and trauma-specific reflective functioning, we see that these different types of RF are correlated, but not that much. They are not assessing the same construct exactly. They are, at some point, independent from one another. and our data are especially surprising since they suggest that it's trauma-specific reflective functioning that most strongly predict parenting and the parental-child relationship,

even more so than parental reflective functioning and attachment-based reflective functioning. So it seems that how people mentalize in these emotionally hot moment when they are where past trauma come to mind seems that it's a special. of how they will be a transparent in emotionally heart moment as well. Okay, so that's the third profile. Maybe we'll jump to the, well, let's jump to the fifth one

and then we'll go back to the fourth one. So this is global failures and mentalization of trauma. And so you're seeing a lot of the different things all at once, is that correct? You're seeing identification with the victim, identification with the perpetrator, disorganization of thoughts,

grandiosity, avoidance, absorption, and trauma, justification of trauma. Tell me about this one. Julia, do you want to try? Again. And so our questionnaire has, just for context, seven scales, and we see all seven scales here in this profile.

So all seven disruptions that can be assessed using our questionnaires are being represented in this profile. And this profile includes, can include a mix of all the things that we've just looked at, basically. And so maybe some grandiosity, maybe some lapses in some absorption,

maybe some disorganized narratives too. So lacking coherence and not really walking us through thoughts and feelings and emotions. contradictions. We can see contradictions as well in either one specific answer or throughout the interview, right, things that don't really add up. And talk about the contradiction, because I think that's a very, that's a very important thing for us as clinicians to catch. We haven't mentioned that one yet. Yeah, I don't think we have an example about that. But we do see those. Then even in adult attachment interviews,

we can see those as well, where people, for example, will at some point kind of deny implications of trauma, right? Say that it doesn't impact them at all, but there might be lapses here and there where, oh, but maybe it does in the end. And so I think that's where interviews are really helpful to catch those brief moments that might not even be fully conscious. Yeah, I don't know, Nickupper see if you want to add something to that.

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

So he did not hit. It never went physical. Okay, so that's the first statement. And then so there's five minutes of interview and going on. And then the person says, it happened once that he hit me. It was with a belt and it was quite bad. I had to go to the doctor.

And then later in the interview, the person once again says, other moments were when he came home drunk. Really, my dad was not a violent person. And so you could see some inconsistencies in that narrative. Part of me wonders of sometimes what I'll see is when the person is new to me, their shame might be so high

or they might be dissociated away from memories. And then as the connection increases, as the shame decreases, they might have a better ability to remember things. But I think that what you're seeing in this narrative is that there's an inconsistency, like, oh, it happened once that he hit me. But then even later in the,

interview, it's oh, really, there are other moments when he came home drunk, you know, so there's like more more there and there's this kind of like lack of memory, lack of consistency in the narrative.

Yeah, I understand what you said, David, I think the example you've been giving that when we see someone for the first time and there's not that alliance so far that that a person don't feel secure enough. A person may be reserved or not fully expressed

difficult life experiences. And I think these are good instances of high order defense mechanism like repression, that kind of thing. But with these narrative, what we see, with people who have global failures in mentalizing trauma, in that after one hour, take your head and just say, what the hell?

What did happen with that person? You cannot understand what she's being saying. She's been saying one thing and definitely the opposite. Like here we see in a few words that she said, my dad never went physical, but a few minutes after she described an instance when she was hit so bad with a bell that she had to go to the doctor. And later she starts discussing a situation

when the father came home drunk and something happened, but she doesn't go into that direction, and she ended up saying, really, my dad, was not a violent person. So it definitely do not make any sense. It go into all directions, and most of the time you end up that interview when you have the feeling that you don't know that person.

You have no clue about her story, what really happened. It was highly confusing, and that's the type of situation since you've been discussing the last profile, as being probably reflecting of people with depressive personality or avoidant personality and the other profiles with sadisms or narcissistic personality. Here that's the type of discourse we see with some people with severe borderline personality disorder

or complex trauma, that kind of fragmented discourse about their life history that's highly difficult to make sense and that we have to pause and reflect on these experiences. Yeah, yeah. It's the, like, a borderline level of functioning in the psychodynamic theory of where you can idealize one moment and then devalue the next.

Or, like, it's almost like in that idealizing of the father that they can have moments of, in the same interview that they have moments where they can disclose stuff. So that's one thing I'm thinking about. The other thing I'm thinking about is it's like with the dissociation, right? If the person you're interviewing is highly dissociative and your countertransference is confusion because you're feeling some of that dissociation as well. So when I'm working with clients like this, I will feel sometimes confused and I'll have to kind of ground.

myself because the confusion I'm feeling is actually the dissociation the dissociation it kind of puts a haze in the room it puts a haze in the conversation and this is a very unprocessed trauma when someone is dissociating like that so it's like as we kind of go back to it again and again I don't feel that same dissociativeness that narrative coherence is there there you know narrative coherence one thing leads to another leads to another leads to another and like this kind of like incongruencies. Yeah, yeah.

Totally. So the dissociation is there. I think what adds with that password profile is that it's not only the association. There is that, but there's definitely something at the level of self and other representation. So these are subgroup. And it's a minority of people. I don't remember the percentage I will look at it. But I think it's something like 6% or something, 6% or something like that.

So a minority of people who have experienced trauma that seems like the trauma has been embedded within self and other representation and in a very consistent fashion. So it interferes generally broadly with the way they think about themselves and others. Whereas people who only dissociate, even though that's quite painful, it doesn't come to confusion all the time to the all the narrative. Right.

Okay, so maybe I would say what you're describing sounds like identity, diffusion, identity, you know, this kind of like what Kernberg talks about with the borderline level of functioning and the, you have the idealization, the devaluation, the projective identification,

the identity, diffusion, this kind of like big, you know, overlapping thing. have different personality styles you can have a dependent person you could have a depressive masochistic you could have various different types of styles of personality it's the way that i understand it but then it's like you have this um fracturing of the self right this this yeah really really really difficult takes a lot longer to do the therapy yeah absolutely and just a confirmation of that in that bascadour study we administered an instrument which is the the self and interpersonal functioning scale which is which is based on a criterion A of the alternative model for personality disorder of the DSM-5.

And we evaluate self and interpersonal functioning. And we did observe severe impairments on both domains in people from that profile, to the point that more than half of people in that profile definitely respond to the criteria for personality disorder. So yeah, I totally agree that that's one element that we did assess with that instrument, the identity diffusion of Kernberg. Definition of identity diffusion totally. This was strongly presenting people of that profile, which was not the case for people

in the previous profile we were talking about that were absorbing trauma, didn't have the same level of identity diffusion. It was more the level of interpersonal. problem that was present in the previous profile. Okay, so you also said here, the participants express unintegrated, bizarre, or inappropriate representations of self and other and a clear misunderstanding of psychological functioning,

and I'll read an example that maybe if she would have loved me, I wouldn't have been good to my children. So it's like a statement that doesn't quite make sense, right? Another one, this was talking about sexual abuse during childhood. This person said he was a man who really, really loved women. So whenever he was in my company, well, so it's like, okay, I could see it. It's a bizarre representation that this person loved women and then sexually assaulted her because of that love.

right? Is that? Yeah, absolutely. And if she has that representation that a man who loves women is normal that he's interested in children as well. I don't know what will happen in her current relationship with her partner,

but it's a highly risky situation. And we might expect what we often see, a repetition of sexual abuse over a generation. And we can understand why when we see that kind of representation about others here. Okay, and then maybe we'll, so that's Profile 5. Let's go to Profile 4, which is no failure in mentalizing trauma. So this is the, you want to talk about this one?

Go ahead, Zed Yes. I can start. These people were low across the board on all the failures of mentalizing trauma that we measured, sorry, and then also experienced fewer symptoms and personality dysfunctions. And so we could think of them as potentially at least by these correlations that we see resilient woman. And so they are, we don't know that from the questionnaire, but with the illustration, we can see that they perhaps have processed, the experience of trauma. They're able to understand mental states in that context.

and to make sense to tie those to behaviors and to really understand maybe develop mental features and the nature of mental states. And so people who are showing a reflective process like we would expect to see for higher scores. So these people were not having identification with the victim, identification with perpetrator. They were not having disorganization of thoughts.

They were not having grandiosity, where they were not being avoidant of their emotional world. They were not having absorption in the trauma or justification of the trauma. They might, just to note, like these are not dichotomous variable. They're continuous, but they presented the lowest levels of all of these.

Doesn't mean that their functioning or their reflective functioning was, like, Per fact, and was if we think about a negative 1 to 9 scale, was a 9 all the time. That wouldn't be the case. But there are levels of those elements were the lowest. Yeah. And most of the time when they present that type of disruption,

they are able to note that and comment on that. So there may be instances where they get quite absorbing trauma, but they will say in the course of the interview, I can see that I'm still much more affected by these experiments that I thought I was, just talking about that, it makes me very emotional. So they are able to comment on these processes, on these defenses we've been talking about during the last hour. They see that happening.

They are conscious about that. They are trying to act upon that. And we think it's very, very interesting. And which I find amazing is that it's the majority of people who is quite surprising. And for me, I'm glad to see that that when the majority of people talk about very severe experiences they have during their childhood, they are quite reflective.

They are saying a very interesting thing and it's very optimistic for us to see that. And since we may expect that they'll be quite good parents, even though they have experience quite severe experiences. What we note, however, is that it's not because you're reflective on your past trauma, that it always protect you from suffering at some point. You may be quite reflective,

see the impact it does on yourself, being able to reflect on that, but still experience pain, experience grief, and feel depressed or anxious, yeah. Yeah, let me read one of these and we'll talk about it. well I thought it was just by seeing how I react to these memories

I thought I had forgotten about it not forgotten because some things leave a mark forever but I don't define my life by that experience you know I always try to do better I know I had a troubled childhood I don't want to replicate it over again

nor with my children, nor with my husband, but still, when I talk about it, I can see I am still sensitive about it. Like, it's still there, you know, because I never really had the chance to sit down and talk about it with someone. That's a good example of what we've been seeing. There's still an issue there.

She has the instinct to be like the people we label functionally grandiose, to say, it's in the past, it doesn't affect me anymore. But she's not doing the same. She's able to see that going, unfolding, and to reflect on that. So as as Julia said, being reflective doesn't mean being, I don't know, free of any types of defense

and free of any types of suffering, but it's being able to connect with that, reflect on that. Right. And be curious, yeah. What would you score this out of the, what would this little passage be scored, do you think? It's not an impressive passage, neither. She's just identifying mental states in the course of the interview. There are some elements that are quite rational here.

Probably we will be at the lowest side of the good mentalization scoring. So I don't know. somewhere between five and six. What do you think, Julia? Yeah, I was thinking you're on a five too. I think we're needing a treasual of reflective functioning,

but we're not seeing a lot of sophisticated, like, for example, developmental stance or freshness elements. Yeah. Yeah, I was thinking five. So I'm glad we're in. We all agree.

We're in agreement here. Negative one to nine. Which Miriam said she's almost never given a nine. A nine is like totally un- So she's usually five plus. It's like there's some passages that are five, that are some that are more than five. I will comment on that, if you permit me, David.

That's an issue we have sometime with the RF scale, since as you said, the scale ranging between minus one and nine, so a 10 point scale. And most, in many studies, what we see is that our scores are between three and six or three and seven. There is not a lot of variability. But what is very interesting when we look at trauma-specific reflective functioning using an interview such as the one we use, a trauma-making interview, is that we do see a lot of variability and we generally use most of the scale from minus 1 to 8.

You're right. I think we never code 9. It's something that most people rarely do. But it's a scale that permits to capture the variability in mentalizing process. That's very interesting. That's good. Of course, when you do my score, it'll come back at a 9. Of course.

Of course. Of course, that's grandiosity. so that'll bring me down a little bit right there. But that interpersonal knowledge might increase me a little bit. But then knowing that I'm doing this to make you laugh, maybe that increases me as well, right? Okay, so being playful with it there. Okay, so here we go.

So here's another passage. I worry too much about what people, particularly my parents, think. and I think it's related to the abuse. I just, I'm not as free as I would like to be. I mean, I'm going to be 39 next week, and I sort of like, in the back of my mind, I'm still thinking, oh, would Dad be okay with this?

Okay, yeah, you could see in this passage, it's the, it's different when the person, is just unaware of their idealization of their father, maybe, when they are, like, they don't have the insight, right? There's a little bit of insight here into how the early childhood abuse maybe plays out in the present. Is that what you're thinking? Yeah, absolutely.

I see three elements in that very short passage. I find very interesting. The first one, when we call reflective functioning, you know, we have to get a sense that the person is aware of the nature of mental states. And here we do see that, that she's recognizing the persistence of certain trauma-related mental states despite the willingness to change. She would like to feel different, but that's the way she feels. And even though she works on it, she sees she still have that emotion, that underlying feeling that is there.

And I think that's a good understanding of the world of mental states that we may change, but it's difficult. And some things are lasting over time. The other thing I think is freshness. She's describing things as they are happening in the moment. I'm not sure she's saying things that she reflect a lot prior to the interview. There's something unfolding here. And the last one is what we often see when we, evaluate reflective functioning, the explicit effort to tease out mental states underlying

behaviors. Here she's describing the impact of trauma on herself, on her mental states, on our thought processes. So that's very interesting. Again, that's not something at the I end of the scale. It's probably around a six, but I think it's totally interesting. Yeah, that's good. Okay, let me read another one. one of these. So you said there are little instances of denial, minimization, or self-blame. When this happens, these speakers are able to identify that it represents an attempt to keep a distance to difficult emotions.

Okay, so one of them is, I laugh, but it's not funny. So it's like they laugh, they recognize that it's not funny. It's like they're recognizing the defense of laughter. Laughter is a humor is a higher order defense. Another one says, I said at the beginning that my dad was not violent, but I realized that he was, in fact, quite violent. I think it's difficult for me to acknowledge that.

No one likes to say or admit that one of your parents is violent. You know, my father was really violent verbally. Yeah, I think we, we, we, try there to give example that reflect more subtle indicators of reflective functioning. Since people on the I end of the scale, people are highly reflective, it's quite easy to observe. Most of the time are like, wow, that's amazing what you said. I don't think I could have said that myself. Probably you could, David, since you're in line on the scale, but being a five or six. I'm impressed. I'm not.

Just kidding, but yeah, so these are examples that are most more subtle. We see people sit on the go, some suffering about trauma. They are still dealing with it, but they can see themselves go and they can look at themselves on the outside, see these processes. And I think that's what will eventually protect them to repeat these. experiences within the relationship where they're a child, even though trauma is not totally resolved. Yeah, I can see here, so it starts out, I said at the beginning that my dad was not violent,

but I realized he was, in fact, quite violent. So it shows a progression, even in the midst of talking about something. They're aware that they are changing their sort of, like, wordage. I think it's a good alternative to the one we looked at the prior profile where there was a lot of contradiction, right, about hitting or ending with really my dad was not violent. And here we see a reflective process that kind of shows that we're reaching maybe a novel interpretation during the process of the interviewer or realizing the implication of abuse on her functional. And I think it's a nice alternative to something that can be quite similar. Or even when this person says, I think it's, I think that it's difficult for me to acknowledge that. There's an awareness of the difficulty to say that her dad is violent.

So it's like there's maybe a propensity to want to imagine her father not as violent. There's an awareness of the difficulty of that, right? And then no one, she says, no one likes to say or admit that your parent is violent, you know? So there's like this kind of like knowledge of the idealization of not wanting to sugarcoat the abuse, to want to not see the abuse, and then there's this acknowledgement.

My father was really violent verbally. So, yeah, you could kind of, it's, it's, you can kind of, it's, it's, you can see this person working through and mentalizing in real time or changing or kind of adjusting, right? Yeah, so what would you score this one? Yeah, it's difficult since when we score,

we have access to the whole response. A big portion. This is just a small portion. Probably that person, from what we see here, is around six or more. since she's quite reflective, and if we would have access to the whole narrative, probably we'll see more complexity to that.

Okay. Okay, and then this last one. Oh, sometimes I would just be studying and she would have a tantrum for no reason, but now I can understand. She was in a frustrating situation with her husband because he was never there, He wasn't taking care of his children, so I was the one who paid the price for it.

That's how I see it today. It's like she took her frustration out on me. So it's kind of like there's an acknowledgement of the mother's displacement, of the mother's anger from the husband onto her. It seems a little bit overly justifying the mother's bad behavior. So I could see why this is a more subtle example, right? Tell me about this one. Yes, I think she's doing what's the most difficult to do when you're mentalizing trauma is to try to tease out the perpetrator's mental state.

So it's much more easier to reflect on your own mental states and reflecting on the perpetrator mental states. Here we took that example again to make the difference between when you're just, defying past abuse, saying it was deserved, a good way to react. Here, she don't take the blame for the abuse. She acknowledged that this was inappropriate, but she can see that the mother was undergoing a conflictual situation. It was not easy for her, and that, as you said,

there was a lot of displacement of the mother on her. She acknowledged that developmental perspective. she can say that's now I see it today implying that when she was younger she didn't see it this way so there's something interesting again here having only that passage is it will probably be around a five

it's not there's something missing but that's that's some interesting yeah interesting response very good so tell me maybe be, you know, I think we're going to probably have to do a follow-up getting more into the detail

of like the different scorings and stuff as you get further along. I know you guys are developing kind of a manual for that, specifically for trauma. I think that there's some, you know, you've, you've shared an early version of this and I know you're working on finalizing it, which I'm excited for you guys to get that out there and start doing trainings and such. And more people hopefully will do research. I people email me, quite often they're like, you know, I'm, I'm undergrad, I want to do a PhD in this, you know, what do you recommend? And I've started to point them towards, you know, like labs that are doing this kind of work because I think it's so important. It's really good. And we need a lot of youthful

energy to do these because it's very time intensive, right, to do the scorings. Yes. I have a lot of youthful energy a little bit less now, but. Oh, yeah. It's like, um, it's like, um, there's a reason why there's only so many studies on reflective function. And it's because it's very time intensive to do an adult attachment interview and then to score it for reflective function, right? It's costly. So hopefully at some point I can do some like some like fundraising for this type of research.

So we'll have to hope that. that I can raise some money for further studies like this. Where do you think that the, like when you think about like where the studies are today, what you would like to see in the future, what are you hoping, Julia, maybe like you're young, you know, you're in your postdoc at Vanderbilt, what are you hoping someday to have as part of your lab

and to see accomplished? Yeah, that's a good question. I think what both of us are hoping, to move forward to is really complementary. And for me, I think really trying to better understand what's happening in those moments of either lapses or good reflective functioning. So we have a study right now in Quebec

that Nicholas is leading that he can talk more about, about really processing and using multimodal information to really better understand our reflective processes. And for me, I'm really interested in how that relates to functioning, for like individual level mental health, for example, but also how that relates to the parent-child relationship. And really in those moments. And so trying to really have more of a microscopic view of those processes.

I think a lot of the theory around mentalizing is that it is somewhat a co-regulatory process, right, when you're in relationship with others, especially with kids who are highly dependent on their parents. And so trying to better understand how that co-regulatory power of reflective functioning occurs in these moments. Interesting, yeah. I'm thinking there was this moment where I took my daughter to this really hard basketball practice. She was young. She was probably a fourth grade. Yeah, fourth grade, end of fourth grade.

And it was so hard. There were a couple balls that hit her in the head. passed too quickly, you know, there were older girls. She's crying. It was like, she got in the car and she's like, I never want to do this again. And it was like, it was really hard to watch the practice. It was like painful.

Like, it was like, I was like suffering watching the practice, you know? And, you know, like the way that I remember talking about it was, yeah, it makes sense. It was really hard. It was a really hard practice. That was the hardest practice you've ever been through. I'm so impressed that you got through the whole practice, despite it being as hard as it was. And then we did like some meaning making

about how like doing hard things is good because, you know, it's like how we grow. And if you want to, I said like look, if you want to continue to do this, it's up to you. I think it's gonna help you be a better basketball player eventually. like it's going to take a lot of work, you know. It's going to take a lot of these things. It could have been almost a traumatic experience,

but I think that the post discussion, and she was completely regulated afterwards, we had ice cream, we went home, she was in a great mood, you know? Yeah. What do you think about that in terms of like, is that an example of like putting words to, is that kind of what you were talking about,

like how we put words to things, how we connect with someone in the midst of distress. Definitely. And I think that's a great example of doing it. I think, unfortunately, in labs and in research, we tend to sometimes miss those moments. So I think it's about finding ways to measure moments that might be ecologically valid for families

or that might in lab kind of lead to negative affact or frustration in kids and how we can then look at how parents adjust. So I think those moments are harder to see in the laboratory. And so that's kind of where I see my, I want to see them in the lab, but that's kind of where I see a lot of work being needed.

And especially if they think about, I tend to study younger kiddos for whom the language of meeting making, like the direct path of how this process that you're illustrating with this experience with your daughter might be less direct, right? If we're thinking about doing this with an eight-month-old kid, then what is it that makes it make sense? I think we still have a lot of work to do there. And I'm sure it is important, but I think we still have a lot of ways that we could better understand

and of the active ingredients almost of this. Yeah, I think about in the psychoanalytic tradition, you often do these like home observations. So they find these families that are okay with you, just basically standing in the home, observing mother, infant interactions. You're not talking, you're just kind of observing, and you're actually just like a fly on the wall, right?

And you might be there for 10 hours, just kind of like watching a day of this person's life, you know? Yeah. And then I'm thinking about like the patients that I have that have had issues with bonding and have the kids. And it's not every day that they're going to have issues, right? It's like maybe they're extra sleep deprived. Maybe they're having an argument with their spouse and they're more dysregulated. And it's in those moments that they're not feeling as connected or

they're having these very, very strong intense emotions. How do you start to capture that in a lab if you're not in that sort of situation where you would get that evocative day, you know? Yeah. Well, I don't want to get us too far from the topic of the podcast, but I think now with technology advancements too, we have a lot more ways to have cameras that are a lot less invasive. I know of people who use kind of like the baby monitors that people put on top of cribs

and then they can have access to the recordings at pretty much any time that someone's in the baby's rooms. And so I think we can try to be to use these technologies in research as well too. So maybe it's not happening in the lab. It's happening in the home. But I think we can have better ways of capturing it now. Love that. Yeah. That's good.

Yeah, and I think the example you gave with your mother is really evocative that the things we're trying to capture. And we think that trauma RF is a good proxy of how parents will respond in such situations. Because I think your example is highly evocative. How complex it is to be to be a parent and how complex it is, especially in a situation where, emotionally a situation. And it's so difficult because as you said,

when you look your child in pain, you feel the pain as well. So you have to accept experiencing that, tolerate that emotion,

contain that, reflect on that and then intervene with your child. And that's why we think trauma RF is so important

because people who have experienced RF have underwent intense pain, intense stress during their life. So when they see their child in pain, it may be much more difficult than other parents. And even in other parents who did not experience trauma, that's a very difficult situation to manage. And I think trauma, IRF, help us to understand that some parents will have kind of very inappropriate reaction under these circumstances. will laugh at the pain of their child or will jump on the field and yell at the coach. But we can understand that from what they went to.

And to respond your initial question, what we want to do next was the future, I think that knowing that, what we can try to do is try to prepare parents as much as we can. And the way we do it, Julie and I and our team, is to intervene from pregnancy based on the same. these principles of trauma-specific or effective functioning and mentalizing. So we did develop an intervention which called the step program, supporting the transition to an engagement in parental program, which is one of the very first intervention,

especially designed for survivors of trauma, where we have nine sessions trying to mentalize about different elements, but especially about themselves as people, as parents, and their experience of trauma, for them to be more comfortable when situation as the one you describe will eventually arise. The child will be there. And how is this, do you have a result of this yet? Has this the step program been?

Yeah, well, we have several results. First, we took the time to develop that program. It's kind of tricky discussing trauma during pregnancy, which is very sensitive life period. So we have good data supporting the acceptability of the program, both from the point of view of expert and from the point of view of parents. And then we evaluate the program with, I think we reach about 80 participants so far, pregnant women who have experienced trauma who participate in the program. And when we look how they evolved during the program, when contrasting with people who had under one trauma but did not receive the program.

we see a decrease in depression, a decrease in anxiety, an increase emotional regulation, a decrease in unresolved trauma as well. So it seems like it's highly beneficial. And now we're following these families over time in trying to see how the relationship with their child unfold. And that's where Julia expertise will be quite important for the future to look at the parent-child relationship. How much do the RF scores change pre and post? We're coding. We don't know that yet. Okay.

Yeah, we're coding right now. Okay. Yeah, so hopefully they did change. We think it's at least a mechanism of change, but it'd be fantastic to see it as an outcome, too. Because I know the changes, it takes time, right? So nine sessions would be, would be surprising almost to me at this point, but I would be happy to see that.

In transfer's focus therapy, we know that twice a week therapy over the course of like a year can improve a change in reflective function. So we do know that there are studies that show there can be an increase. Yeah. So I run cohorts

and we're potentially going to be doing some research to see if, you know, eventually, I've been doing the cohorts, but eventually we'll be maybe looking at pre-and-post reflective function as well. And I would like to see if providers' reflective function can increase a little bit over the course of a year. I think they do from what I read of their responses to questions. We have weekly reflective questions. But this is great. This was a great conversation.

I'm excited to connect with you guys. I'm looking forward to maybe having some further episodes down the line as new papers get published as you get further along in your journey. And if you're incredibly wealthy and you're listening to this, I'm sure they could use some funding so you could find them and provide them for their research teams. All right, yeah. Any other final thoughts or any other final things going through your mind? I'll have links to your articles on my website. People can find you guys, links to your bios. And yeah, it was wonderful having some primary research on here

and getting into the details. So thank you. Thank you very much, David, for the invitation. It was a very nice discussion. It was a pleasure. Thanks so much for having us. It was great. Nice.

Okay. So we'll leave it there for today.