Transference-focused psychotherapy was developed by Otto F. Kernberg and is based on his model of borderline personality disorder.1,2 The efficacy of transference-focused psychotherapy has been evaluated in two randomised controlled trials (RCTs) to date. A 1-year RCT 3 with 90 participants with borderline personality disorder compared transference-focused psychotherapy with dialectical behaviour therapy 4 and psychodynamic supportive therapy. All three groups showed significant positive change in depression, anxiety, global functioning and social adjustment in a multiwave design. Transference-focused psychotherapy and dialectical behaviour therapy were associated with a significant improvement in suicidality, transference-focused psychotherapy and supportive therapy improved facets of impulsivity and only the former yielded a significant improvement in anger, irritability and verbal and direct assault. Moreover, only those individuals in the transference-focused psychotherapy group improved significantly in their reflective function and their attachment style. compared transference-focused psychotherapy to schema-focused therapy 8 in a 3-year RCT with 88 participants with borderline personality disorder. The transference-focused psychotherapy revealed a significantly higher drop-out rate (51.2% v. 26.7%) and -despite improvements in all domains of outcome -significantly smaller treatment effects. The American Psychological Association (Division 12) evaluated transference-focused psychotherapy as having controversial research support. Thus, more research is needed before transference-focused psychotherapy can be considered to have modest or strong research support. 9 The present study aims to bring clarity to the field and to determine whether transference-focused psychotherapy can be regarded as empirically supported treatment according to the American Psychological Association (Division 12) criteria.10 This investigation examines the efficacy of transference-focused psychotherapy for borderline personality disorder in an RCT comparing those randomised to transference-focused psychotherapy with those randomised to a group treated by experienced psychotherapists in the community. Method Study designThe study was approved by the ethics commission of the Medical University Innsbruck, Austria, on 24 March 2004 (ID: UN1950) and was registered at Clinicaltrials.gov (NCT00714311). Participants were recruited at the out-patient units of the Departments of Psychiatry and Psychotherapy, Technical University of Munich, Germany, and the Psychoanalysis and Psychotherapy Department, Medical University Vienna, Austria. People who fulfilled the inclusion criteria were given a complete description of the study. Those who gave written informed consent were assessed by trained local research assistants. The results of the first assessments were sent to a researcher outside the two study centres who performed the randomisation. Participants were randomly assigned to either transferencefocused psychotherapy or experienced community...

Depression is associated with profound impairments in social and interpersonal functioning. However, little research has addressed deficits in mentalizing capacity that may underlie these impairments. The aim of this study was, therefore, to investigate the capacity for mentalization in female inpatients with depression in comparison with healthy controls. We assessed 46 inpatients with major depressive disorder with regard to psychiatric diagnoses, severity of depression, cognitive impairment, and verbal intelligence. In addition, 20 healthy controls matched for sex, age, and education were included. Mentalization was scored on the Adult Attachment Interview using the Reflective Functioning Scale. The female inpatients with depression showed a significantly lower capacity for mentalization compared with the healthy controls. Mentalization deficits were not restricted to depression-specific topics. Moreover, deficits in mentalizing capacity were related to illness duration, number of admissions, and cognitive impairment. The results indicate severe impairment in the ability of the female inpatients with depression to identify and interpret mental states of the self and others. Correlations with illness duration and number of admissions suggest that a chronic course of depression results in further mentalizing impairments. The investigation of mentalization may be of particular importance for the development of targeted psychotherapeutic interventions for depression.

Borderline personality disorder is associated with deficits in personality functioning and mentalisation. In a randomised controlled trial 104 people with borderline personality disorder received either transference-focused psychotherapy (TFP) or treatment by experienced community therapists. Among other outcome variables, mentalisation was assessed by means of the Reflective Functioning Scale (RF Scale). Findings revealed only significant improvements in reflective function in the TFP group within 1 year of treatment. The between-group effect was of medium size (d = 0.45). Improvements in reflective function were significantly correlated with improvements in personality organisation.

The Reflective Functioning Scale (RFS) was developed to assess individual differences in the ability to mentalize attachment relationships. The RFS assesses mentalization from transcripts of the Adult Attachment Interview (AAI). A global score is given by trained coders on an 11-point scale ranging from antireflective to exceptionally reflective. Coding procedures rely on a distinction of demand and permit questions during the AAI. Demand questions directly probe for reflective functioning (RF), whereas permit questions do not. Coding focuses on detecting qualitative markers of RF and qualitative markers of absent RF, respectively. Despite its relevant empirical contributions in clinical research, several psychometric properties of the RFS are still unclear. In this article, we present data on the reliability and internal structure of the RFS based on a combined sample of 196 subjects. We were able to show that (a) the global score can be assessed with good interrater reliability, is relatively stable across time, and is significantly reduced in persons with mental disorders; (b) demand questions are based on a single latent factor; (c) demand questions do not differ in terms of difficulty; (d) all demand questions but 1 are incrementally predictive of the global score; (e) 5 permit questions contribute to the global score over and above demand questions; and (f) the number of qualitative markers of RF is also predictive of the global score. Our results have important conceptual and methodological implications for future studies using the RFS.

Relationships between personality organization, reflective functioning (RF), and the number of Axis I and Axis II disorders were examined. Ninety-two female patients with Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV-TR) borderline personality disorder (BPD) were administered the Structured Interview of Personality Organization (STIPO), the Adult Attachment Interview for assessment of RF, and the Structured Clinical Interview for DSM Disorders. Significant correlations were found between the level of personality organization and the number of Axis I and Axis II diagnoses. In contrast, no association was found between RF and the severity of Axis I and Axis II pathology. RF and level of personality organization were moderately associated. The results indicate that the concept of personality organization is related to the descriptive approach of the DSM-IV-TR. The STIPO provides a differentiated picture of the severity of personality pathology and allows di