Enhancing parental reflective functioning: A special tribute to the life and work of Nancy E. Suchman,PhD

Nancy E. Suchman's contributions to the fields of infant mental health, maternal reflective functioning, and attachment-based intervention will have long-lasting impacts. In particular, through the development and dissemination of her intervention program, Mothering from the Inside Out (MIO), she innovated a way of working with mothers with substance use disorders that represented a paradigm shift within the field of addiction. In this introduction to the special issue, written to honor her life and work, we review Nancy's background and briefly describe her academic accomplishments. The special issue contains nine qualitative and quantitative research reports written by Nancy's colleagues and their collaborators. All nine papers pertain to the theme of understanding, measuring, and promoting parents’ capacity for reflective functioning. Four provide findings that advance our understanding of parental reflective functioning. The other five highlight insights from continuing evaluations of MIO, including new adaptations of the model. To introduce the special issue, we provide an overview of the scope of the work done within these projects. Finally, the special issue concludes with two commentaries contributed by Linda Mayes and Arietta Slade, leading scholars within the field who were also Nancy's close colleagues. Both provide insight into Nancy's impact on the field.     

The Association Between Reflective Functioning and Parent–Child Relationship Quality

Research consistently links adult and infant attachment styles, yet the means by which attachment is transmitted is relatively elusive. Recently, attention has been directed to the psychological underpinnings of caregiver sensitivity—originally thought to be the mechanism of transmission—as indicated by caregivers’ ability to keep in mind children’s mental states when interpreting children’s behavior, or reflective functioning. Unfortunately for researchers, extant measures of reflective functioning are time-consuming and require extensive observation and coding. A self-report measure could help facilitate the study and assessment of reflective functioning in research and clinical settings. This study investigated the relationship between parental reflective functioning and multiple aspects of the parent–child relationship, by using a new, self-report measure of reflective functioning. Participants were 79 caregivers (M _age = 31.8 years) who completed self-report measures assessing reflective functioning, parent–child relationship characteristics, perceived rejection in early relationships, attachment anxiety and avoidance in current close relationships, depression, and substance use. The results indicated that reflective functioning is a strong predictor of parent–child relationship quality (i.e., parental involvement, communication, parent satisfaction, limit setting, and parental support), independent of other potential indicators. Findings support parental reflective functioning as a contributor to the quality of parent–child relationship and suggest that a parent’s capacity to reflect on the mental states of his or her child in parent–child interactions may provide a key target for interventions that aim to improve parent–child relationships.     

What Are We Doing There? A Therapeutic Tale

In this paper I try to portray our interpsychic work as reflective of an infinite conversation: an intersubjective dreaming of one’s life, moving between multiple positions/self-states, those of the patient and our own; becoming involved while pondering the movement we are part of, sometimes in our hearts and minds, many times aloud and openly with our patient; recognizing her experience and enabling her to see us, and sometimes not reflecting at all—“the “moving talk.” The dilemma of the therapist’s positioning, internally and interpersonally, is further postulated, especially in regard to the posttraumatic patient who suffered severe childhood abuse.     

Working with patients with disruptions in symbolic capacity1

This article focuses on understanding and working with patients who have poorly developed symbolic capacity, or for whom symbolic capacity has been disrupted due to trauma, particularly as it pertains to the use of reverie and interpretation in the analytic process. Many patients who present for Jungian analysis will initially present with deficits in symbolic functioning. This situation results in necessary limitations or modifications in utilizing traditional Jungian techniques such as dream analysis, active imagination, sand tray and other expressive art techniques. The initial phase of analytic work with these patients requires a focus on developing their symbolic capacity before traditional Jungian techniques can be utilized effectively. During the paper Jung's concept of ‘the symbolic attitude’ will be examined as well as the conceptual models of Wilfred Bion and other post-Bionians who outline theories and method for cultivating symbolic capacity and reflective functioning in patients for whom these capacities are impaired or poorly developed.     

Holding the Baby in Mind: Discussion of Joseph Lichtenberg's “Communication in Infancy”

Joseph Lichtenberg suggests that infants are held in their caregivers' symbolic world before they create one of their own. This idea is addressed from the perspective of parental reflective functioning. This construct offers a means of further understanding how a caregiver's capacity to elaborate upon the mental life of her child sets the stage for the child's internal experiences becoming known and developed or distorted and stunted within the context of the relationship. These ideas both complement and expand upon the research and theoretical work described by Lichtenberg in his consideration of the development of communication with self and other in infancy.     

Mentalisierungsbasierte Psychotherapie bei schizophrenen Psychosen

Recently, there has been growing interest in new methods of psychotherapeutic interventions for schizophrenic patients. Social cognition, social functioning and quality of life are central objectives. Mentalization-based therapy (MBT) is a specific psychodynamic method developed from the fundament of attachment theory and empirical psychotherapy research for the treatment of borderline personality disorder, particularly focusing on attachment relationships, mentalizing capacity and affect regulation. Studies have shown that MBT is able to ameliorate interpersonal experience and social life. The latest neuroscientific findings support this view and encourage the application of a modified form of MBT in the treatment of schizophrenic patients. The authors present a concept for disorder-specific interventions in schizophrenia, including psychoeducational aspects and mentalizing exercises which step-by-step lead to a more reflective work in mentalization-based group psychotherapy.     

An under‐active or over‐active internal world?

This paper explores the dynamics brought into analytic work when there is a symmetric fusion between psyche and soma within the patient. It will consider how such a fusion may emerge from reverberations between physical constitution and a lack of maternal attunement, containment and reflective function. I will describe the work with a patient, Jane, who was diagnosed with Myalgic Encephalomyelitis (ME) during the course of her analysis. The dynamic of her physical symptoms within the analytic work, and the impact of her internal affects and internal 'objects' within the transference and countertransference, indicated a difficulty in finding an homeostatic balance resulting in overactivity and underactivity at both somatic and psychological levels. Using the clinical work with Jane this paper will also examine the interrelationship between mother-infant attachment, an inadequate internalized maternal reflective function, affect dysregulation, unconscious fusion, the lack of psyche-soma differentiation and the impact of the latter in relation to internal regulation systems, or lack of, in patients with Chronic Fatigue Syndrome (CFS) and Myalgic Encephalomyelitis (ME). I will draw on similar work carried out by Holland (1997), Simpson (1997) and Simpson et al. (1997). The paper will also employ the concept of the reflective function (Fonagy 2001; Knox 2003), and consider Matte-Blanco's (1999) concepts of generalization and unconscious symmetry in relation to the patient's internal world. I go on to consider how analysis provides a point outside the 'fusion' that can enable the 'deadlock' to be broken.     

Reciprocity in a Securely Attached Mother-Infant Dyad

This article describes the interactions between a highly attuned, sensitive mother, who had the capacity to achieve primary maternal preoccupation, and her infant during his first four months of life. The evolving secure attachment patterns discerned from weekly observations in a naturalistic setting correspond with Beatrice Beebe’s findings using microanalysis of mother-infant face-to-face interactions to predict the nature of the four-month infant’s emerging internal working model of attachment. Using a series of vignettes, the author illustrates how this mother-infant dyad were adept at coordinating their attention, affective responses, vocal rhythms, and touch in ways that seemed to promote feelings of mutual recognition and enjoyment for them both. The mother’s capacity for reflective functioning enabled her to imagine what her baby was feeling and to consistently comfort him, contributing to the formation of their secure mother-infant bond.     

Mentalizing in psychotherapy: patients’ and therapists’ reflective functioning during the psychotherapeutic process / Mentalizando en psicoterapia: funcionamiento reflexivo de pacientes y terapeutas durante el proceso psicoterapéutico

Abstract

There has been a growing interest in mentalization in clinical research given its relationship with normal and psychopathological functioning and its explanatory potential as a mechanism of psychotherapeutic change. This study uses the Reflective Functioning Scale (RFS) to identify and characterize mentalization manifestations in psychotherapeutic interaction. Method: the RFS was applied to a sample of relevant episodes — 44 sessions from five different psychotherapy processes carried out with adult patients who had different diagnoses. Results: we observed a higher probability of reflective functioning (RF) passages in relevant events than in neutral segments. There were no differences in the RF passages according to episode or actor type, but there were in RF Failures, which is more likely in patients and during rupture episodes. Discussion: although certain modifications are necessary, the RFS can be applied to clinical material, and it is a promising strategy for the study of mentalization within psychotherapy.     

Collected Stories: Play in Four Acts

This article evolved from a group process where members of a psychoanalytic institute were faced with planning workshops for a professional weekend around the theme of “play.” The workshop that evolved consisted of four vignettes of play taking place in the therapeutic sessions of a child, an adolescent, an adult, and an elderly woman. The discussion of these vignettes that began at the conference and then was developed for this article focuses on tracing the development of play from childhood into adulthood (Mayes & Cohen, 1996; Russ, 2004) and on the relationship between play and the development of reflective functioning (Fonagy & Target, 1996). One area of particular interest that was focused upon was the use of play with adults who are described as “concrete,” people who function, at times, at a level of differentiation more typical of a young child. Play is described as being particularly helpful in facilitating a more differentiated and, thus, more reflective mode of psychic functioning for this group of individuals as well as for people at all levels of development.     

What Makes Crohn's Disease Patients Difficult to Manage? The Role of Psychosocial Factors

Most GI clinicians face the problem of a small group Crohn's Disease (CD) patients who function poorly and consume inordinate amounts of service with poor outcome. This study examines the hypothesis that psychosocial factors differentiate the CD patients who function poorly from the typical CD patient. A prototypal sample of CD patients with problems functioning, more typical CD patients (not selected for having problems in functioning), and healthy controls each completed a battery of validated psychosocial measures of disease-specific quality of life, coping skills, social support and life stress, perceived medical symptoms and life history factors. Chart data on hospital admissions, ER, GI, Surgeon, and GP visits were also collected. The CD patients with problems functioning reported more symptoms (GI and non-GI) and had many more ER, GI, and GP visits than the typical group. Psychologically, those with problems functioning had poorer quality of life and were more likely to cope using emotional discharge and support seeking. They experienced significantly more stress and reported a more chaotic family history. No differences on an experimental method of information processing biases were found between the CD groups, however. These results indicated that patients with problems functioning, selected by GI staff because they were best-case examples of functional difficulties, shared little with a matched group of typical CD patients. These patients likely require psychological as well as medical intervention to best manage their illness.     

Initial validation of self-reported trajectories in military veterans

Previous research suggests that functioning after potentially traumatic events tends to follow discrete trajectories. This research is limited in that longitudinal data can be difficult to collect. The aim of the current study was to examine self-reported trajectories in military veterans using an online survey. Consistent with longitudinal work, those who reported chronic distress reported higher symptoms of PTSD and Depression, higher negative affect, lower social support, and less satisfaction with life than those on a resilient trajectory. Two change trajectories demonstrated intermediate scores on relevant measures. These results provide support for a retrospective method to assess trajectories of posttrauma functioning.     

Mentalisierung und externalisierende Verhaltensstörungen in der Adoleszenz

Social cognition creates the conditions for successful human interaction. Externalizing disorders are characterized by a failure of adequate social cooperation. Therefore, social cognition seems to be a key factor in understanding externalizing behavior, its etiology and treatment options. The present article combines the clinical theory of mentalization with the state-of-the-art of empirical data on externalizing behavior and of the theory-of-mind research as well as research on social information processing. Empirical evidence suggests that there are distinct deficits in social cognition depending on the type of aggression (proactive or reactive). However, even though it is known from a neurobiological perspective that social cognition is reorganized in adolescence, research on externalizing behavior and social cognition in adolescence is limited. Hence the analysis of two studies is presented which compared reflective functioning between a group of late adolescent violent offenders and a control group. A total of 42 young men participated in the studies and were interviewed with the adult attachment interview. Interviews were coded with the reflective functioning scale. Results showed that violent offenders scored significantly lower on the reflective functioning scale than age and gender matched controls. This result is independent of intelligence. Instrumental proactive aggression and psychopathic tendencies are also strongly associated with lower reflective functioning. The results underline the importance of therapeutic interventions for externalizing adolescents which enhance reflective functioning.     

Parental reflective functioning is associated with tolerance of infant distress but not general distress: Evidence for a specific relationship using a simulated baby paradigm

Parental reflective functioning represents the capacity of a parent to think about their own and their child's mental states and how these mental states may influence behavior. Here we examined whether this capacity as measured by the Parental Reflective Functioning Questionnaire relates to tolerance of infant distress by asking mothers (N = 21) to soothe a life-like baby simulator (BSIM) that was inconsolable, crying for a fixed time period unless the mother chose to stop the interaction. Increasing maternal interest and curiosity in their child's mental states, a key feature of parental reflective functioning, was associated with longer persistence times with the BSIM. Importantly, on a non-parent distress tolerance task, parental reflective functioning was not related to persistence times. These findings suggest that parental reflective functioning may be related to tolerance of infant distress, but not distress tolerance more generally, and thus may reflect specificity to persistence behaviors in parenting contexts.     

Religion, Meaning in Life, and Change in Physical Functioning During Late Adulthood

This study has two primary goals. The first is to see whether select aspects of religion are associated with meaning in life. The second goal is to see whether change in meaning in life is associated with change in physical functioning. Data from a nationwide longitudinal survey of older people provide support for the following relationships: (1) older adults who attend church services more often tend to develop a closer relationship with God; (2) older people who have a closer relationship with God are more likely to provide emotional support to others; (3) elders who give emotional support to their social network members are more likely to have a stronger sense of meaning in life; and (4) older individuals who have a deeper sense of meaning in life are less likely to experience a decline in their physical functioning over time.     

“矛盾”视角下非体面工作从业者矛盾职业认同形成机制

非体面工作是指那些维持社会正常运转所必需的, 但被社会公众所贬低或不喜欢的职业。非体面工作从业者身份认同过程较为复杂, 很难处于有意识的认同或不认同选择的两端, 他们对自身职业或多或少持有矛盾心理。然而, 现有研究关于从业者何时及如何形成矛盾职业认同尚不明晰。本研究拟基于悖论视角, 提出从业者矛盾职业认同形成机制的研究构想。预期研究成果有助于解决现有文献关于从业者要么职业认同要么职业不认同的研究争议, 指出矛盾职业认同在非体面工作情景中更加贴合实际; 实践上可以帮助和引导从业者构建有尊严的职业身份, 并为组织完善底层工作群体管理提供启发。     

To be in touch

This study examined the constellation of interaction structures – repetitive patterns of interactions between patient and therapist over the course of treatment – that emerged in the psychodynamic therapy (PDT) of a child diagnosed with borderline personality disorder and treated by two doctoral student therapists. Identification of these interaction structures can inform therapists of what might be expected from patients with particular symptom or behaviour patterns and how interactions change over time. This study also examined each session’s adherence to three session prototypes: PDT, cognitive-behavioural therapy (CBT) and reflective functioning (RF) process. The Child Psychotherapy Q-Set (CPQ) is a 100-item instrument that assesses the processes within a single psychotherapy session. Items reflect a wide range of therapist attitudes and behaviours, patient attitudes and behaviours and interactions between therapist and patient. Experts used the CPQ to define PDT, CBT and RF process session prototypes. The results suggested that four distinct interaction structures could be identified and that their constellations differed between the two therapists and also differed over time within each treatment. Therapists were more structured and accommodating early on in their treatments and more interpretive later. Prototypical PDT process was more prominent in the sessions than RF process, which in turn was more prominent than CBT process. Unique therapeutic processes are at work in every dyad, despite holding the patient and theoretical orientation constant. An effective treatment in one dyad might not work in another due to therapist-specific and dyad-specific effects.     

The Analyst's Necessary Vertigo

The euphemistic phrase “the difficult to reach patient” often refers to work with patients who have serious difficulties relating. The author examines the basic construct of “reach,” its pitfalls, and potentials. In the author's view, often we are talking about patients who do not fully experience their own subjective existence or the existence of others. This requires unusual efforts to “reach” the patient in order for the patient to consolidate a sense of self and other, creating the possibility of reflective relating. In contrast to views that see such psychoanalytic “reach” as associated primarily with the analyst's needs or pathology, the author views the analyst's extraordinary efforts as responsive to the patient's need to move the analyst into the foundations of the analyst's own being.     

THE LIFE CYCLE AND DISABILITY: EXPERIENCES OF DISCONTINUITY IN CHILD AND FAMILY DEVELOPMENT

Clinicians are often asked to work with parents who have one or more children with specific disabilities. Disability within the family can have a dramatic impact on family interactions and functioning across the course of the family life cycle. The authors review the potential role of disability within a family system and make specific suggestions for working with a family or the child with the disability.