Date of Degree


Document Type


Degree Name





Diana Diamond

Committee Members

Sasha Rudenstine

Adriana Espinosa

Elliot Jurist

Howard Steele

Subject Categories

Clinical Psychology | Counseling Psychology


reflective function, mentalization, therapist, emotion regulation, caregiving system, attachment


This study examined associations between therapist mentalization and patient outcomes in the first year of psychotherapy. Mentalization is the implicit and explicit consideration of mental states—one’s own as well as others’—and how such states mediate a person’s experiences in the world. It is conceptualized as existing on a scale of increasing complexity. This study sought to extend developmental research that has illustrated the positive influence of a parent’s mentalization on a child’s emotional well-being. Specifically, it was proposed that psychotherapy cases with high levels of therapist mentalization would have better patient outcomes than those with low levels of therapist mentalization.

To test this hypothesis, 17 therapy cases at a community clinic were followed for one year. In each case, the therapist completed the Patient-Therapist Adult Attachment Interview—Revised (PT-AAI-R) four months into treatment. From these interviews, each therapist’s level of mentalization was obtained via the Reflective Functioning (RF) Scale, which is a method for assessing the quality of mentalization in a narrative. This yielded a Therapist RF score for each case. Patient outcomes were assessed at baseline and 12 months. The patient outcomes assessed were symptoms that have been related to low mentalization—externalizing symptoms, emotion dysregulation, personality pathology, and attachment insecurity. Changes in these symptoms were expected to relate to Therapist RF scores.

Results indicated that Therapist RF was not related to symptom changes in the full sample. However, for patients with high levels of emotion dysregulation at baseline, high Therapist RF was associated with better outcomes in this symptom area. This was not the case for patients with low levels of emotion dysregulation at baseline. This finding suggests that Therapist RF might be particularly important in therapy with patients who have high levels of emotion dysregulation. Additionally, Therapist RF was elevated in the context of elevated personality pathology in patients, which suggests that high levels of personality pathology might be a catalyst for high Therapist RF, though Therapist RF was not associated with better outcomes for this symptom. A qualitative analysis of the PT-AAI-Rs of two therapists who each completed two interviews was performed. This analysis illustrated that Therapist RF scores were influenced by both the patient and the therapist in the dyads.