What is the Relationship between Differentiation Relatedness and Reflective Functioning?

Research in psychodynamic therapy hypothesizes that psychodynamic psychotherapies promote psychological health by positively affecting patients’ understanding and reasoning on their own mental states in relation to their symptoms (Katznelson, 2014).  The emphasis of Psychodynamic Therapies (e.g. TFP) is to promote structural change rather than just symptom reduction. Psychodynamic constructs are complex and difficult to quantify making research of the effectiveness of this type of orientation more challenging (Blatt, 2001). The current study hopes to expand the repertoire of assessing psychodynamic therapy research. Two neighboring psychodynamically oriented constructs, Reflective Functioning and Differentiation Relatedness, offer insight into the possible ways in which therapy helps to promote psychological wellbeing (Huprich et al, 2016). There is no systematic empirical research demonstrating a relationship between the two constructs. The initial study (Method 1) makes use of secondary data from two research studies to establish the existence of a correlation between the constructs. The second study aims to demonstrate that two are related in such a way as to suggest that an increase (or decrease) in one will necessarily influence an increase (or decrease) in the other through a much larger study.

Literature Review

Understanding the structural changes that may occur internally in patients helps to provide a more comprehensive assessment of the nuanced changes that occur over the course of therapy that may not be captured through the relatively unidimensional review of symptom reduction. Part of the difficulty in conducting research of this nature is identifying the constructs of study, identifying valid and reliable measures of these constructs and lastly inter-rater reliability (Blatt and Auerbach, 2003). The possibility of measuring changes in mental representations as part of improving and expanding the manner in which these representations can be used in both clinical and research endeavors. The development of systematic means of measuring these constructs has moved from projective labor intensive methods and towards objective systematic measures that are suitable in both clinical and research settings (Blatt and Auerbach, 2010).

Reflective Functioning

Reflective Functioning grew out of attachment theory and can be understood as the capacity to reflect on one’s own experiences and to develop hypotheses about behavior in oneself and others (Fonagy, 2008). Mentalization is concerned more with the complex affective and interpersonal understanding of oneself and others, reflecting abilities that enable an individual not only to navigate the social world effectively but also to develop an enriched, stable sense of self (Fonagy, 2004). Mentalization is a developmental achievement dependent on the quality of interpersonal interactions and the emotional relationship between the infant and caregivers. A caregiver’s marked and contingent mirroring of the child’s internal states facilitates the child’s development of a capacity to mentalize (Slade, 2001) and is involved in the development of personality functioning.

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High RF would include awareness of the nature of mental states (such as opaqueness of mental states), explicit effort to tease out mental states underlying behavior, recognition of the developmental aspects of mental states, and awareness of mental states in relation to the interviewer (Fonagy, 2016) with lower RF signifying a person’s inability to reflect on mental states which may leave them self-focused with the inability to conceptualize not only their own but other people’s thoughts and feelings.  The RF Scale (Fonagy et al., 2016) is an 11-point scale that evaluates the quality of mentalization in the context of the attachment relationship. The RF Scale assesses the interviewee’s capacity to understand mental states and readiness to contemplate these in a coherent manner.

Previously, RF was assessed using a section of the AAI (Adult Attachment Interview) and was labor intensive, thereby limiting its utility within the research context. Computerized Reflective Functioning (CRF) was developed by Fertuck and colleagues (2012), and is based on AAI transcripts. CRF provides a simple and strongly standardized RF measure. The current study makes use of Computerized Reflective Functioning (CRF) as it is applied to the ORI which Lowyck et al (2010) have demonstrated to be a possible alternative to the use of AAI transcripts.

Differentiation-Relatedness Scale

Diamond et al (1991) developed the DR-S as a scale that can be applied to an ORI transcript.

DR is understood as a range of psychological functioning, from highly impaired or pathological levels characterized by self-other boundary confusion and polarization between positive and negative aspects of self and other, to highly adaptive levels of relatedness and self-definition involving mutuality in self-other development and interaction (Diamond et al, 1991). The Differentiation-Relatedness Scale of Self and Object Representations (Diamond et al., 2011) evaluates both differentiation and relatedness, and can be seen as evolving on two independent, yet interrelated, lines of psychological development (Diamond et al., 2011).

Kernberg’s model of early development indicates that from childhood on, relationships are internalized as mental representations of self–object interactions laden with cognitive, affective, and experimental information about the self, the objects, and their interaction (2003).

Personality development depends on the progressive differentiation between self and object representations and an increasing integration of their bad and good aspects (Kernberg, 2003)

The Differentiation Relatedness Scale (D-RS), is a method for assessing the level of differentiation, integration, and relatedness in open-ended descriptions of self and significant others. A five-minute sample, either spoken or written, where the subject is asked to describe a significant figure (often the self, the mother, the father, or the therapist) in the course of the ORI. No probes are given; rather, the subject is given the opportunity to associate freely. In a spoken sample, an inquiry follows the five-minute sample (Diamond, 2011).

The scoring system is designed to quantify an individual‘s ability to articulate a self that is differentiated from others while at the same time evaluating the individual‘s ability to represent complex and nuanced relationships with others (Diamond et al., 1991). Differentiation-Relatedness is defined as a cohesive and integrated sense of self-definition and empathically attuned, mutual relatedness with significant others (Diamond et al 1991). Lower levels of DR would suggest limited ability to acknowledge the self/other boundary leading to a compromise in boundaries (Diamond et al, 1991). Higher levels of differentiation are signified by a mature self/other appreciation as well as an acknowledgment of the nuanced nature of relatedness (Diamond et al, 1991).

Although these are theoretically neighboring constructs, no empirical data has confirmed a relationship between them.

Method 1

Aims and Hypotheses

The aim of the current study is to explore the relationship between DR and RF with a view to examining how they relate to one another. Based on a review of the literature the main hypothesis for the current study is that there will be a positive correlation between the two constructs.

Participants

Participants for the current study were drawn from two independent research studies.

Study 1

The first study included 87 undergraduates who were recruited via a Psychology Department participant pool at a racially and ethnically diverse, urban public university. The age was between 18 to 42, the mean was 21.37 with standard deviation of 4.6. Just under half of the sample (47%)  identified as Hispanic or LatinX while 29% identified themselves as more than one race. 23% identified as White and 15% identified as Black/African American, 24% identified as Asian and 6% identified other racial categories (e.g., Indian Native or Other Pacific Islander).  The study aimed at investigating impairments in perceptual self-other differentiation in grandiose vs. vulnerable narcissism (Karen & Fertuck, 2018).

Study 2

The second study included 45 female participants between the ages of 18 and 45 years old. The participants were recruited via advertisements and referral through a large, metropolitan hospital as part of ongoing clinical studies in mood disorders, suicidal behavior, and BPD. Mean age: 24.96 with a standard deviation of 3.47. One quarter identified as Hispanic (25.9%) and 74.1% identified as non-Hispanic. Just over half of the participants identified as white (55.6%) with 18.5% identifying as African-American, 14.8% as Asian and 11.1% as more than one ethnicity. None of those with BPD or healthy controls were taking psychotropic medications while participating in the study. Sixty percent of the BPD group had a history of use of psychiatric medication.  Exclusion criteria for the BPD group included a current major depressive episode, psychotic disorder, current substance use disorder, or a recent suicide attempt (in the last 6 months). The healthy control group was matched on demographics (age, ethnic/racial frequency, marital status), education level, and estimated IQ, and was psychiatrically assessed with semi-structured interview to rule out a history of psychiatric (the exception was a current or past simple phobia) or substance use disorder.  The total sample was 31.11% Hispanic, 55.56% White, 17.78% Black, 17.78% Asian, and 8.89% mixed/other race.  Institutional Review Boards at two Universities approved the study.  Fifty-eight participants signed consent, and 45 completed all assessments and the fMRI scan. In the BPD group 30.45% exhibited past substance abuse or dependence, 47.82% had a past major depressive disorder, and none had a current or past Bipolar or PTSD diagnosis.

Procedure

The current study makes use of a correlational design utilizing the following measures to assess for DRS and RF:

Measures Used

1. The Object Relations Inventory was developed by Blatt (date) as a means of assessing the levels of object relations in participants with a view to understanding more closely the ways in which therapy assists in shifting internal object representations (Blatt and Auerbach, 2010). The Object Relations Inventory (Blatt, 1991) is a semi-structured, open-ended interview in which patients are asked to describe their mother, father, self, therapist and pet.
   1. The Differentiation and Relatedness Scale was developed by Diamond et al as a means to identify the levels of DRS(Diamond, et al 1991) based on ORI (Blatt et al. 1991). The DRS assesses levels of differentiation between self and others and the establishment of increasingly mature levels of interpersonal relatedness (DR) using a 10-point scale.
2. The Reflective Functioning Scale (Fonagy et al., 2016) is an 11-point scale that evaluates the quality of mentalization in the context of the attachment relationship. The RF Scale assesses the interviewee’s capacity to understand mental states and readiness to contemplate these in a coherent manner (Blatt and Auerbach, 2001).
   1. Computerized Reflective Functioning is ameasure of Reflective Functioning (CRF) that was developed by Fertuck and colleagues (2012). CRF was developed using the marker approach (Fertuck et al, 2012), which is a consolidated and manualized coding system for data records into a computerized text scoring method.

The aims and purpose of the studies were explained to all participants prior to the commencement of the tasks. The data for both studies was obtained through administering the ORI through asking about their relationships with their mother, father, self, therapist, and pet. Two qualified scorers for the DRS were used, with both scoring all transcripts to ensure inter rater reliability.

Design

The current study makes use of a within subject Correlational Design.

Data Analysis

The bivariate relationship between scores on the DRS and RF will be assessed using Pearson’s correlations.

Method 2

Aim

To assess whether the magnitude of improvement in Reflective Functioning can reliably predict the magnitude of improvement in Differentiation-Relatedness. Those with Low or High Reflective Functioning will respond to a shift in Differentiation Relatedness as a result of Transference Focused Psychotherapy.

Hypotheses

1. The magnitude of change in RF will be similar to the magnitude of change in DRS.
2. Those with higher reflective functioning will have a mean difference between the start of therapy and the end of therapy that is significantly higher than the mean difference for those in the Low RF group, which will map onto the difference in DRS across samples.

Procedure and Participants

Participants will be drawn from an outpatient psychotherapy clinic that provides Transference Focused Psychotherapy for patients identified with personality disorders. Transference Focused Psychotherapy (TFP) is a psychodynamic modality based on Kernberg’s object relations theory of Borderline Personality Disorder and has demonstrated effectivity with regards to the improvement of RF in a relatively short period of time (Levy et al, 2006 & Clarkin et al, 2006, Kernberg, 2008). As the treatment is utilized most frequently with those expressing symptoms related to BPD the inclusion criteria will be based on a diagnosis of BPD prior to commencement of treatment. Further, a baseline of Reflective Functioning will be obtained through the administration of the Reflective Functioning Questionnaire (Fonagy et al, 2016). The participants will be streamed into two groups, those with RF scores 0f -1 to 4 (Negative RF to Questionable RF) and those with RF scores of 5 to 9 (Ordinary RF to Exceptional RF). Inclusion in the analysis will be based on a one year course of twice weekly treatment. To get the required power, 88 participants will be needed in each group as calculated with GPower (Faul et al, 2009).

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Participants with a diagnosis of substance use disorder, a psychotic disorder or any current mood disorder will be excluded from the study. Further, participants needed to be at least 18 years old and not diagnosed with a cognitive disorder. These exclusion criteria were identified to remove any possible influence on the constructs under study. At the time that participants were invited to participate in the study, written informed consent was obtained after all study procedures had been explained.

Therapists

Therapists will be selected based on their training in TFP and will be drawn from the staff at the clinic. The therapists included in the study will be identified by senior staff members at the clinic through the assessment of the adherence the therapist have with TFP. Supervision and case assessment by a recognized leader in the modality will augment and attempt at ensuring the standardization of the treatment across therapists. This supervision will include the review of videotaped sessions by each therapist.

Measures Used

1. SCID 5 RV: Research version of the Structured Clinical Interview (SCID) for DSM 5. The SCID is a semi-structured interview guide used to identify major DSM-5 diagnoses.
2. SCID 5 PD: The Personality Disorders Version is used to evaluate the 10 DSM-5 Personality Disorders.
3. SCID 5 AMPD: The Alternative Model for Personality Disorders is a semi-structured interview that provides dimensional and categorical approaches to personality diagnosis.
4. ORI: As used in Method 1, the ORI is a brief semi-structured interview based on the patients responses to their reflections on their relationships with their mother, father, self, therapist, and pet.
   1. DRS: As used in Method 1, the DRS aims assesses levels of differentiation between self and others and the establishment of increasingly mature levels of interpersonal relatedness (DR) using a 10-point scale.
   2. CRF: As used in Method 1, CRF is a measure of RF using a consolidated and manualized coding system for data records into a computerized text scoring method.

Design

The study will make use of a Repeated Measures Quasi Experimental Design. The identified dependent variables are RF (both low and high) and DRS, the independent variable will be TFP. RF will be measured when they present to the clinic in order to stream into the low or high RF group. At the commencement of treatment both groups will be administered the ORI which will be used to assess RF and DR and then again in the last month of treatment.

Data Analysis

Analysis will assess the variance between the two groups (low and high RF) at time point 1 (commencement of treatment) and time point 2 (within the last 4 sessions of treatment). An ANOVA will be run to analyze the variance between the two groups. The subjects will therefore be compared to themselves at time point 1 and time point 2 across all conditions, further the mean average of the low RF and high RF groups will be compared to one another.

Discussion on the two methods

Method 1 is a basic correlational study utilizing pre-existing data and therefore is an easier study to carry out. The small participant sample may contribute to its lack of rigor but for the purposes of establishing an initial correlation may be sufficient. Method 2 is a more ambitious study which could arguably be motivated for in light of the results of Method 1. That is, the second method would only be embarked upon once a correlation has been established. Method 2 requires a greater sample size, 88 per treatment group, with a total of 176 participants. Considering the length of treatment and the extensive assessment prior to the commencement of treatment, this will be an extended and expensive research study.

Method 2 provides an opportunity to collect data on a number of variables which may help in other research studies, including efficacy studies for TFP, the predictive ability of RF over the course of treatment as well as the utilization of the Alternative Model for Personality Disorders. Combined, these variables offer a rich understanding of the utility of assessing therapeutic outcomes, especially evidence based psychodynamic therapeutic outcomes. Incorporating the Differentiation Relatedness Scale in this research will also further the endeavor to expand the psychodynamic research repertoire. The DSM Alternative Personality model suggests that personality functioning consists of the degree to which there is a cohesive sense of self and interpersonal functioning which demonstrates a capacity for empathy and for mature, mutually rewarding relationships with others (Oldham, 2015). One of the principal concerns with this alternative model is that it would be difficult for clinicians to use it.  Arguably these two identified features could also be measured by DR and RF as it is measured in the current study which combined with CRF and the possible future development of Computerized Differentiation Relatedness may make measuring more manageable in both clinical and research settings.

The limitations of Method 2 may lie within the theoretical understandings of the two principal constructs being studied such that it is not possible to completely isolate the patients receiving treatment or to account for any external sources of possible change that may influence the outcome of the study. The number of participants needed could be unwieldy and difficult to obtain especially in light of the length of treatment and the expected dropout rate.

However, this may also afford an opportunity to further the research regarding the predictive value of RF and DR in relation to TFP. Boldrini et al (2017) have demonstrated that higher levels of RF at the outset of treatment predict more stable and long lasting psychological change. Findings in line with this from the current study may assist in further bolstering the research on the efficacy of psychodynamic approaches to treatment.

References

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