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This study examines how reflective functioning (RF) can be assessed in analytic sessions and throughout psychoanalytic psychotherapy. The goals are to replicate in part a study by Josephs and colleagues (2004) by applying the RF Scale to analytic sessions and to study fluctuations of RF within each session. Additionally, RF based on sessions was compared with the RF ratings based on the Adult Attachment Interview (AAI) during the course of two psychoanalytic psychotherapies with a duration of 240 hours. RF changes based on 10 sessions per patient, assessed at baseline and after 80, 160, and 240 hours of therapy, and RF changes based on AAI ratings measured at baseline and after 240 hours of therapy, and in one case at follow-up, were related to changes of symptoms and attachment classifications over time. Results showed that in both cases RF fluctuated within sessions. The average RF rating per session increased over the course of treatment, while the AAI-based RF rating needed longer to increase. Rather good correspondence was found between session-based RF ratings and independent AAI-based RF ratings. In both cases, changes in RF over time were compared to changes in attachment classification based on the AAI and to symptomatic change. Better correspondence between symptomatic and attachment changes was found with the AAI-based RF rating. It was tentatively interpreted that session-based RF ratings may represent a state of RF that is strongly influenced by the therapist-patient interaction, whereas AAI-based RF can be considered to have more trait characteristics.

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This article demonstrates the utility of a theory-guided psychodynamic approach to the assessment of personality and personality pathology based on the object relations model developed by Kernberg (1984). We describe a clinical interview, the Structural Interview (SI; Kernberg, 1984), and also a semistructured approach, the Structured Interview of Personality Organization (STIPO; Clarkin, Caligor, Stern, & Kernberg, 2004) based on this theoretical model. Both interviews focus on the assessment of consolidated identity versus identity disturbance, the use of adaptive versus lower level defensive operations, and intact versus loss of reality testing. In the context of a more clinically oriented assessment, the SI makes use of tactful confrontation of discrepancies and contradictions in the patient's narrative, and also takes into account transference and countertransference phenomena, whereas the more structured approach of the STIPO incorporates clinical judgment informed by clinical theory into a well-guided interaction with the patient. Both interviews have good interrater reliability and are coherent with the alternative model for personality disorder diagnosis proposed by the Diagnostic and Statistical Manual of Mental Disorders (5th ed.), Section III. Finally, they provide the clinician with specific implications for prognosis and treatment planning and can rationally guide clinical decision making.