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Cited by 144Psychoanalysis and Psychopathology ResearchAttachment and Relationship DynamicsMaternal Mental Health During Pregnancy and Postpartum

Another step closer to measuring the ghosts in the nursery: preliminary validation of the Trauma Reflective Functioning Scale.

Open access
Ensink, Karin, Berthelot, Nicolas, Bernazzani, Odette, Normandin, Lina, Fonagy, Peter·2014·Frontiers in Psychology
DOI 10.3389/fpsyg.2014.01471PMC PMC4269108
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Abstract

The aim of this study was to examine preliminary evidence of the validity of the Trauma Reflective Functioning Scale and to investigate reflective functioning (RF) and attachment in pregnant women with histories of trauma, with a particular focus on the capacity to mentalize regarding trauma and its implications for adaptation to pregnancy and couple functioning. The Adult Attachment Interview was used to assess attachment, unresolved trauma and mentalization (measured as RF) regarding relationships with attachment figures (RF-G) and trauma (RF-T) in 100 pregnant women with histories of abuse and neglect. The majority (63%) of women had insecure attachment states of mind and approximately half were unresolved regarding trauma. Furthermore, the majority of women manifested deficits specific to RF-T. Their RF-T was significantly lower than their RF-G; the findings indicate that women with histories of childhood abuse and neglect do not manifest a generic inhibition of reflectiveness, but a collapse of mentalization specific to trauma. Low RF-T, indicative of difficulty in considering traumatic experiences in mental state terms, was associated with difficulty in investment in the pregnancy and lack of positive feelings about the baby and motherhood. In addition, low RF-T was also associated with difficulties in intimate relationships. Results of a regression analysis with RF indicated that RF-T was the best predictor of investment in pregnancy and couple functioning. In sum, the study provides preliminary evidence that RF-T can be reliably measured and is a valid construct that has potential usefulness for research and clinical practice. It highlights the importance of mentalization specifically about trauma and suggests that it is not the experience of trauma per se, but the absence of mentalization regarding trauma that is associated with difficulties in close relationships and in making the transition to parenthood.

AI snapshot

Written from the paper’s full text.

TL;DR

This preliminary validation study examined the Trauma Reflective Functioning Scale in 100 pregnant women with histories of childhood abuse and neglect, finding that reflective functioning about trauma (RF-T) was significantly lower than reflective functioning about attachment relationships (RF-G). RF-T was the best predictor of investment in pregnancy and couple functioning, suggesting that mentalization specifically about trauma, rather than trauma exposure per se, is linked to adaptation.

Key findings

  • RF-T was significantly lower than RF-G (M = 2.78, SD = 1.96 vs. M = 4.14, SD = 1.95; paired t(63) = 4.93, p < 0.001, d = 0.70), although the two were correlated (r = 0.61, p < 0.001).
  • In multiple regressions, RF-T was the best single predictor of engagement in pregnancy (β = –0.42, p = 0.01), positive feelings toward pregnancy (β = –0.37, p = 0.03), commitment toward maternity (β = –0.35, p = 0.03), and overall quality of relationship with partner (β = –0.57, p < 0.001).
  • Attachment distributions: 37% secure, 21% dismissing, 5% preoccupied, and 37% unresolved; compared with normative samples, the sample had significantly lower secure attachment (z = 3.46, p < 0.01) and higher unresolved attachment (z = 4.28, p < 0.01), but compared with clinical/high-risk abuse samples it had higher secure attachment (z = 4.71, p < 0.01) and less unresolved attachment (z = 10.95, p < 0.01).
  • No association was found between dose of maltreatment and RF-T (β = 0.07, p = 0.64) or RF-G (β = –0.04, p = 0.67); number of maltreatment types was associated with increased risk of unresolved classification (β = 1.14, Wald = 9.59, p < 0.01, OR = 3.13).

Methods

  • Prospective participants (n = 809) were screened with the Parental Bonding Instrument; 131 were eligible, and 100 pregnant women with histories of abuse and neglect consented to complete the Childhood Experience of Care and Abuse interview.
  • The Adult Attachment Interview was used to assess attachment, unresolved trauma, RF-G, and RF-T; the Contextual Assessment of Maternity Experience assessed pregnancy investment, maternal commitment, feelings toward the baby/motherhood, and couple functioning.
  • Analyses included Pearson correlations, paired-samples t-tests, linear and logistic regressions, multiple regressions, z-tests, and chi-square tests.

Limitations

  • The paper states that findings require replication and that demonstration of the reliability of the RF-T coding manual needs to be repeated.
  • The paper states that the best test of RF-T validity will be whether it predicts infant attachment disorganization and explains more variance than unresolved trauma, and that further research is needed on RF-T, unresolved trauma, dissociation, defenses, and PTSD.
  • Evident from the text: RF-T could only be coded for childhood abuse, not neglect or other potentially traumatic incidents; the sample was a specific community sample of pregnant women with abuse/neglect histories, limiting generalizability.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.3389/fpsyg.2014.01471

Cites

69 of 69 references verified0 citation errors · 0 not checkable

Statistics

Claims the paper makes

0 of 25 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    In 100 pregnant women with histories of abuse and neglect, the majority (63%) had insecure attachment states of mind.

    “The majority (63%) of women had insecure attachment states of mind and approximately half were unresolved regarding trauma.”
    Quote in the paperNot a substantial claim
  • Findingown data

    In these women, RF-T was significantly lower than RF-G.

    “Their RF-T was significantly lower than their RF-G; the findings indicate that women with histories of childhood abuse and neglect do not manifest a generic inhibition of reflectiveness, but a collapse of mentalization specific to trauma.”
    Quote in the paperSubstantial claim
  • Findingown data

    The majority of the women manifested deficits specific to RF-T.

    “Furthermore, the majority of women manifested deficits specific to RF-T.”
    Quote in the paperSubstantial claim
  • Findingown data

    Low RF-T was associated with difficulties in intimate relationships.

    “In addition, low RF-T was also associated with difficulties in intimate relationships.”
    Quote in the paperSubstantial claim
  • Findingown data

    In a regression analysis with RF, RF-T was the best predictor of investment in pregnancy and couple functioning.

    “Results of a regression analysis with RF indicated that RF-T was the best predictor of investment in pregnancy and couple functioning.”
    Quote in the paperSubstantial claim
  • May combine two claims. 40
  • Classified as probably not a substantial claim. 31

  • May combine two claims.

    Findingown data

    Low RF-T was associated with difficulty in investment in the pregnancy and lack of positive feelings about the baby and motherhood.

    “Low RF-T, indicative of difficulty in considering traumatic experiences in mental state terms, was associated with difficulty in investment in the pregnancy and lack of positive feelings about the baby and motherhood.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Fifty percent of participants had RF-T scores from -1 to 2, 28% had scores of 3 or 4, 17% had scores of 5 or 6, and 5% had scores between 7 and 9.

    “Fifty percent of participants had RF-T scores ranging from –1 to 2, 28% had scores of 3 or 4, 17% had scores of 5 or 6 and 5% had scores between 7 and 9.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Eighteen percent of participants had RF-G scores from -1 to 2, 38% had scores of 3 or 4, 31% had scores of 5 or 6, and 13% had scores between 7 and 9.

    “Eighteen percent of the participants had RF-G scores ranging from –1 to 2, 38% had scores of 3 or 4, 31% had scores of 5 or 6, and 13% had scores between 7 and 9.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Mean RF-T was significantly lower than mean RF-G, as confirmed by a paired t-test [t(63) = 4.93, p < 0.001, d = 0.70].

    “Although RF-T scores and RF-G scores were significantly correlated (r = 0.61, p < 0.001), mean RF-T was significantly lower, as confirmed by a paired t-test [t(63) = 4.93, p < 0.001, d = 0.70].”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    In our sample, 37% of women with CA&N had secure attachment states of mind, 21% were dismissing, 5% were preoccupied, and 37% were unresolved.

    “In our sample, 37% of women with CA&N had secure attachment states of mind, 21% were dismissing, 5% were preoccupied and 37% were unresolved.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    RF-G scores were normally distributed, with a mean around 4 (M = 4.14, SD = 1.95).

    “The RF-G scores were normally distributed, with a mean around 4 (M = 4.14, SD = 1.95).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Of the 12 women who described abusive childhood experiences during the CECA interview but did not report abuse during the AAI, five reported some physical abuse from biological parents and seven reported extra-familial sexual abuse.

    “Of the 12 women who described abusive childhood experiences during the CECA interview but did not report abuse during the AAI, five reported some physical abuse from biological parents and seven reported extra-familial sexual abuse.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    RF-T scores were normally distributed, with a mean of 2.78 (SD = 1.96).

    “RF-T scores were also normally distributed, with a mean of 2.78 (SD = 1.96).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    RF-T was strongly related to the quality of interpersonal relationships, including the quality of the relationship with their partner, and difficulties in thinking about past traumatic experiences were associated with poor relationship quality.

    “In addition, the relationship between RF-T and the quality of interpersonal relationships was strong, and showed that difficulties in thinking about past traumatic experiences were associated with poor relationship quality.”
    • Also stated in: § DISCUSSION · plain
      “The findings of this study showed that RF-T was linked to adaptive functioning in two important areas, including the women’s commitment to pregnancy and positive feelings about the baby and motherhood, as well as the quality of the relationship with their partner.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Dose and severity of abuse were linked to the risk of being unresolved with regard to trauma, but not to RF-T.

    “Furthermore, the dose and severity of abuse were linked to the risk of being unresolved with regard to trauma, but not to RF-T.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    RF-T was linked to women's commitment to pregnancy and positive feelings about the baby and motherhood.

    “The findings of this study showed that RF-T was linked to adaptive functioning in two important areas, including the women’s commitment to pregnancy and positive feelings about the baby and motherhood, as well as the quality of the relationship with their partner.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    Informed consent for study participation was obtained from all the women.

    “Informed consent for study participation was obtained from all the women.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    Women with histories of childhood abuse and neglect do not manifest a generic inhibition of reflectiveness, but a collapse of mentalization specific to trauma.

    “Their RF-T was significantly lower than their RF-G; the findings indicate that women with histories of childhood abuse and neglect do not manifest a generic inhibition of reflectiveness, but a collapse of mentalization specific to trauma.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Study design and conductreasoning

    To ensure reliable rating of RF regarding trauma, a manual with different levels of RF regarding trauma was developed and qualified judges rated a series of transcripts for trauma-specific RF.

    “Furthermore, to be sure that we were rating RF regarding trauma reliably, we developed a manual with different levels of RF regarding trauma and asked qualified judges to rate a series of transcripts with regard to trauma-specific RF.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Premisenone given

    The separate coding of trauma was consistent with the practice for rating attachment, whereby a transcript could be rated for security as well as for the subject being resolved or unresolved regarding trauma.

    “This separate coding of trauma was consistent with the practice for rating attachment, whereby a transcript could be rated for security as well as for the subject being resolved or unresolved regarding trauma.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationreasoning

    For pregnant women with histories of CA&N, RF regarding traumatic interactions with their attachment figures is likely to be especially important for maintaining trust and satisfactory intimate relationships.

    “Furthermore, for pregnant women with histories of CA&N, RF regarding traumatic interactions with their attachment figures is likely to be especially important for maintaining trust and satisfactory intimate relationships.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    The CECA is a semi-structured interview designed to retrospectively measure adverse childhood experiences, including antipathy from parents, neglect, physical abuse, and sexual abuse.

    “The CECA (Bifulco et al., 1994) is a semi-structured interview designed to retrospectively measure adverse childhood experiences.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Bifulco et al., 1994 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationnone given

    The investigator-based format of the CECA has the advantage of not depending on participants to have previously categorized their own childhood experiences as abusive.

    “The investigator-based format of the CECA has the advantage of not depending on participants to have previously categorized their own childhood experiences as abusive.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Interpretationown data

    RF-T is a valid construct that has potential usefulness for research and clinical practice.

    “In sum, the study provides preliminary evidence that RF-T can be reliably measured and is a valid construct that has potential usefulness for research and clinical practice.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    The PBI has good retest reliability, internal consistency, and validity, with demonstrated stability over twenty years.

    “The psychometric properties of the instrument have been extensively evaluated and it has been shown to have good retest reliability, internal consistency, and validity (Parker, 1989, 1990), with demonstrated stability over twenty years (Murphy et al., 2010).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites Parker, 1989, 1990

      Not checked in the free run.

    • cites Murphy et al., 2010 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The PBI is a 25-item self-report questionnaire developed to assess adults' perception of the level of parental care and protection/control they received during the first 16 years of childhood.

    “The PBI (Parker et al., 1979) is a 25-item self-report questionnaire developed to assess adults’ perception of the level of parental care and protection/control they received during the first 16 years of childhood.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Parker et al., 1979 source

      Not checked in the free run.

  • May combine two claims.

    Interpretationown data

    It is not the experience of trauma per se, but the absence of mentalization regarding trauma that is associated with difficulties in close relationships and in making the transition to parenthood.

    “It highlights the importance of mentalization specifically about trauma and suggests that it is not the experience of trauma per se, but the absence of mentalization regarding trauma that is associated with difficulties in close relationships and in making the transition to parenthood.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Interpretationreasoning

    Pregnant women who are able to think about trauma and have developed an account of traumatic experiences in mental state terms can be expected to find the transition to motherhood less fraught.

    “With regard to RF, pregnant women who are able to think about early attachment relationships that have been difficult in mental state terms and who are able to mentalize about traumatic experiences can be expected to find the transition to motherhood less fraught.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    The study was approved by the ethics committee of the Maisonneuve-Rosemont Hospital.

    “The study was approved by the ethics committee of the Maisonneuve-Rosemont Hospital.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    The RF manual's psychometric properties include high inter-rater reliability and good discriminant, divergent, and predictive validity across a number of samples.

    “The psychometric properties detailed in the manual include high inter-rater reliability, as well as good discriminant, divergent, and predictive validity across a number of samples.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Fonagy et al., 1998

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    RF raters were blind to CECA scores.

    “RF raters were blind to CECA scores.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductown data

    After 9 hours of training, excellent agreement between raters was achieved, and the four raters' ICC of 0.87 on 20 protocols suggested excellent reliability.

    “After 9 h of training, excellent agreement between raters was achieved. The four raters then rated 20 protocols, and the intraclass correlation between the four raters was 0.87, suggesting excellent reliability.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Study design and conductnone given

    In the present study, RF was rated by two qualified raters trained by the developers of the RF coding system with more than 10 years of experience in rating RF of adults, parents and children.

    “In the present study, RF was rated by two qualified raters who were trained by the developers of the RF coding system and have more than 10 years of experience in rating RF of adults, parents and children.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Lack of resolution manifests in lapses in the monitoring of reasoning or discourse when individuals discuss traumatic experiences.

    “Lack of resolution manifests in lapses in the monitoring of reasoning or discourse when individuals discuss traumatic experiences.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Main et al., 2002

      Not checked in the free run.

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    This is consistent with the approach used when coding attachment: participants who manifest lapses specifically when discussing loss or traumatic experiences can still be globally coherent and secure-autonomous while also having an unresolved classification.

    “This is consistent with the approach used when coding attachment: participants who manifest evident lapses in the monitoring of discourse specifically when discussing loss or traumatic experiences can still be considered to be globally coherent and be classified as secure-autonomous, while also having an unresolved classification (Main et al., 2002).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Main et al., 2002

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    RF is scored on a scale of -1 to 9, with every score representing a different level of mental state explanation.

    “RF is scored on a scale of –1 to 9, with every score representing a different level of mental state explanation.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Fonagy et al., 1998

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    The AAI has good psychometric properties, as evidenced in high test-retest reliability, validity, and stability over time.

    “The AAI has good psychometric properties, as evidenced in high test–retest reliability, validity, and stability over time (Bakermans-Kranenburg and van IJzendoorn, 1993; Benoit and Parker, 1994; Sagi et al., 1994).”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites Bakermans-Kranenburg and van IJzendoorn, 1993

      Not checked in the free run.

    • cites Benoit and Parker, 1994

      Not checked in the free run.

    • cites Sagi et al., 1994 source

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    The CECA has good psychometric properties including good inter-rater reliability and validity as determined by agreement between sisters' independent accounts.

    “The CECA has been demonstrated to have good psychometric properties including good inter-rater reliability and also validity as determined by agreement between sisters’ independent accounts (Bifulco et al., 1994).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Bifulco et al., 1994 source

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning

    Where a respondent manifested low mentalization only when discussing abuse experiences, this would be captured in the RF-T score and would not lower the global RF-G score.

    “This means that where a respondent manifested low mentalization only when discussing abuse experiences this would be captured in the RF-T score and would not lower the global RF-G score.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    Current convention is to combine the U/d and CC classifications because of potential commonalities in etiology and sequelae, and this convention was followed in the present study.

    “Current convention is to combine the U/d and CC classifications because of potential commonalities in etiology and sequelae (Bakermans-Kranenburg and van IJzendoorn, 2009), a convention that was followed in the present study.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Bakermans-Kranenburg and van IJzendoorn, 2009

      Not checked in the free run.

  • Classified as probably not a substantial claim. May combine two claims.

    Premisecitation

    Lack of resolution is coded on a scale from 1 to 9, with scores of 5 and higher considered to reflect lack of resolution.

    “Lack of resolution is coded on a scale (1–9) with scores of 5 and higher considered to reflect lack of resolution (Main et al., 2002).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Main et al., 2002

      Not checked in the free run.

  • May combine two claims.

    Study design and conductown data

    Inter-rater reliability was computed on the 10 cases (10% of the total sample) considered most difficult, and an ICC of 0.79 suggested good reliability even with challenging transcripts.

    “The inter-rater reliability was computed on the 10 cases (10% of the total sample) considered to be the most difficult.”
    • Also stated in: § MEASURES · hedged
      “Intraclass correlations of 0.79 obtained for the RF ratings of these 10 cases suggested good reliability even with challenging transcripts.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The CAME interview was developed to assess the psychosocial context relevant to a pregnant woman's experience during the transition to motherhood, including her perception of the quality of her relationship with her partner, maternal commitment, and her feelings toward pregnancy, motherhood, and the baby.

    “The Contextual Assessment of Maternity Experience (CAME; Bernazzani et al., 2005) interview was developed to assess the psychosocial context relevant to a pregnant woman’s experience during the transition to motherhood, including her perception of the quality of her relationship with her partner, maternal commitment, and her feelings toward pregnancy, motherhood, and the baby.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Bernazzani et al., 2005 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The AAI categorizes participants as secure-autonomous, insecure-dismissing, insecure-preoccupied, or cannot classify using Main et al.'s coding manual.

    “Based on their general strategy evident in discussing attachment relationships, participants are categorized as secure-autonomous (F), insecure-dismissing (Ds), insecure-preoccupied (E), or cannot classify (CC), using Main et al.’s (2002) coding manual.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Main et al., 2002

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The AAI is a semi-structured interview designed to assess adults' state of mind with respect to their attachment relationships with their parents during childhood.

    “The AAI is a semi-structured interview designed to assess adults’ state of mind with respect to their attachment relationships with their parents during childhood (George et al., 1985).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites George et al., 1985

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S4 (based).

    Premisereasoning

    The questions used to rate RF-T are exactly the same as the questions used to assess unresolved trauma in the attachment coding system.

    “(Essentially the questions that are used to rate RF-T are exactly the same as the questions used to assess unresolved trauma in the attachment coding system).”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Interpretationreasoning

    Given that the AAI provides questions regarding childhood abuse but no such detailed questions regarding childhood neglect or other potentially traumatic incidents, only childhood abuse can be coded for RF-T.

    “Given that the AAI provides a set of questions regarding childhood abuse, but no such detailed questions regarding childhood neglect or other potentially traumatic incidents, only childhood abuse can be coded for RF-T.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    The RF coding system has been demonstrated to have good psychometric properties.

    “The RF coding system has been demonstrated to have good psychometric properties (Fonagy et al., 1998; Taubner et al., 2013).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites Fonagy et al., 1998

      Not checked in the free run.

    • cites Taubner et al., 2013 source

      Not checked in the free run.

  • Classified as probably not a substantial claim. May combine two claims.

    Study design and conductnone given

    In the present study, AAI transcripts were coded by a rater trained to be reliable to the Berkeley coding standards and blind to abuse and neglect as assessed by the CECA, to the goal of the study, and to the composition of the sample.

    “In the present study, transcripts were coded by a rater who was trained to be reliable to the coding standards of the Berkeley laboratory of Mary Main and Erik Hesse.”
    • Also stated in: § MEASURES · plain
      “The coder was blind to abuse and neglect as assessed by the CECA, to the goal of the study, and to the composition of the sample.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    The CAME has good concurrent and predictive validity, and its dimensions have good internal consistencies in different samples.

    “The CAME has been demonstrated to have good concurrent and predictive validity and the dimensions have been shown to have good internal consistencies in different samples (Bernazzani et al., 2005).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Bernazzani et al., 2005 source

      Not checked in the free run.

  • May combine two claims.

    Interpretationown data

    These findings suggest that individuals with CA&N histories have been able to develop accounts of their difficult early attachment relationships in mental state terms, but find it particularly difficult to develop adequate mental state accounts of abusive experiences.

    “These findings require replication, but suggest that individuals with CA&N histories have been able to develop accounts of their difficult early attachment relationships in mental state terms, but find it particularly difficult to develop adequate mental state accounts of abusive experiences.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    The findings provide further evidence suggesting that RF-T is a valid construct and can be meaningfully differentiated from RF-G.

    “The findings provide further evidence suggesting that RF-T is indeed a valid construct and can be meaningfully differentiated from RF-G.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    RF-T was the best and only predictor of women's engagement in pregnancy, positive feelings toward the pregnancy and engagement in motherhood, as well as the quality of their relationship with their partner.

    “RF-T was the best and only predictor of women’s engagement in pregnancy, positive feelings toward the pregnancy and engagement in motherhood, as well as the quality of their relationship with their partner.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    The pregnant women in this sample had a capacity to mentalize about early attachment relationships that was greater than expected, and we did not observe a global deficit in mentalization.

    “However, their capacity to mentalize about early attachment relationships was nonetheless greater than expected, and we did not observe a global deficit in mentalization.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    The findings add to, but are broadly consistent with, extensive research evidence of avoidance and dissociation of traumatic memories and difficulties in accessing and putting into words memories that have been stored as experiences rather than as narratives.

    “The findings add to, but are broadly consistent with, extensive research evidence of avoidance and dissociation of traumatic memories and difficulties in accessing and putting into words memories that have been stored as experiences rather than as narratives (Brewin, 2011; Allen, 2013).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites Brewin, 2011 source

      Not checked in the free run.

    • cites Allen, 2013

      Not checked in the free run.

  • May combine two claims.

    Interpretationown data

    The findings are in line with and extend Fonagy's (1993) conceptualization of the "ghosts in the nursery" as an absence.

    “The findings of the present study can be seen to be in line with, and to extend, Fonagy’s (1993) conceptualization of the “ghosts in the nursery” as an absence.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Fonagy’s (1993)

      Not checked in the free run.

  • May combine two claims.

    Interpretationown data

    Compared with their RF regarding attachment relationships, women with CA&N histories manifested striking difficulties in mentalization regarding trauma, with RF-T being significantly lower than RF-G.

    “Compared with their RF regarding attachment relationships, women with CA&N histories manifested striking difficulties in mentalization regarding trauma, with RF-T being significantly lower than RF-G.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    There is a dose-response relationship between early adversity and unresolved trauma, in terms of both the severity of trauma and the number of traumatic experiences.

    “This adds to the evidence that there is a dose–response relationship between early adversity and unresolved trauma, in terms of both the severity of trauma individuals have been exposed to and the number of traumatic experiences.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    RF-T is a valid indicator of mentalization regarding trauma with potentially good predictive value.

    “The finding that RF-T was related to functioning in two different domains suggests that it is a valid indicator of mentalization regarding trauma with potentially good predictive value.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S4 (based).

    Study design and conductnone given

    RF-T was reliably coded.

    “While we went to considerable lengths to ensure that RF-T was reliably coded, and elaborated an RF-T coding manual especially for this purpose, the findings require replication, and demonstration of the reliability of the RF-T coding manual needs to be repeated.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationown data

    The RF-T coding manual and scale are an important contribution that can facilitate the reliable rating of RF-T.

    “In sum, the findings of this study suggest that the RF-T coding manual and scale are an important contribution that can facilitate the reliable rating of RF-T.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given

    The findings require replication, and demonstration of the reliability of the RF-T coding manual needs to be repeated.

    “While we went to considerable lengths to ensure that RF-T was reliably coded, and elaborated an RF-T coding manual especially for this purpose, the findings require replication, and demonstration of the reliability of the RF-T coding manual needs to be repeated.”
    Quote in the paperNot a substantial claim
57 of 57

  • The paper relies on this without support.

    There is little research regarding the long-term implications of CA&N for adult attachment and reflective functioning.

    “In spite of the growing body of research on the impact of abuse and neglect on infant attachment, there is surprisingly little research regarding the long-term implications of CA&N for adult attachment and reflective functioning (RF) to inform prospective parents and mental health professionals.”

  • The paper relies on this without support.

    Few empirical studies have examined the relationship between CA&N and the development of mentalization capacities.

    “Furthermore, despite extensive theoretical writings on the impact of CA&N on the development of mentalization capacities (Fonagy and Luyten, 2009; Allen, 2013), few empirical studies have examined this relationship.”

  • The paper relies on this without support.

    Little previous research has examined the relationship between maltreatment, attachment and reflective functioning.

    “Given how little previous research has examined the relationship between maltreatment, attachment and RF, we chose to examine the impact of abuse also including women who had experienced some maltreatment (severity rating of 3).”

  • The paper relies on this without support.

    The mean RF-G in low-risk populations is 5.00.

    “The mean RF-G of women in this sample (4.14) was somewhat lower than the mean (5.00) reported in low-risk populations.”

  • The paper relies on this without support.

    Developmental research shows deficits in capacities broadly overlapping with mentalization, such as children’s self-representation, theory of mind, and emotional understanding, associated with abuse and neglect.

    “This is consistent with developmental research showing deficits in capacities broadly overlapping with mentalization, such as children’s self-representation, theory of mind, and emotional understanding associated with abuse and neglect.”

  • The paper relies on this without support.

    Individuals with a history of childhood abuse and neglect are very likely to face additional anxieties and threat during pregnancy.

    “While for most prospective parents pregnancy provokes mixed feelings, including both joy and apprehension, those with a history of CA&N are very likely to face additional anxieties and threat.”

  • The paper relies on this without support.

    Mentalization has important implications for the quality of interpersonal relationships.

    “Furthermore, at a theoretical level, the proposition is frequently made that mentalization has important implications for the quality of interpersonal relationships, but to our knowledge this is the first direct evidence to support this theory.”

  • The authors state this as an assumption.

    The absence of the contingent marked mirroring response creates an unmentalized alien core around the child’s experience.

    “We have assumed that the absence of the contingent marked mirroring response, the product of the mother’s reflection of her empathic response, creates an unmentalized alien core around the child’s experience.”

  • The paper relies on this without support.

    There is an absence of data on the attachment of adults with CA&N histories in the community.

    “Given the unique opportunity of gaining attachment data on a relatively large number of pregnant women, all with histories of abuse and neglect, and the absence of data on the attachment of adults with CA&N histories in the community, we were also interested in the pregnant women’s state of mind with respect to attachment.”

  • The paper relies on this without support.

    The infant’s distress is the most probable trigger for brief but dramatic failures of mentalization with the activation of the mother’s memories of trauma.

    “As the infant’s distress is the most probable trigger for such brief but dramatic failures of mentalization with the activation of the mother’s memories of trauma, it is indeed these experiences in the infant which will remain without adequate second order representation that we believe is created from the mother’s mirroring response.”
10 of 10

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • It is specifically the ability to mentalize one's traumatic experiences rather than the general ability to mentalize that impairs parenting.

    “Ensink and colleagues [61] found that it is specifically the ability to mentalize one’s traumatic experiences rather than the general ability to mentalize that impairs parenting.”

    From Psychoanalytic Interventions with Abusive Parents: An Opportunity for Children’s Mental Health (2022) · cites this paper as [61]

    The Discussion reports no global mentalization deficit, and the Conclusion reports marked trauma-specific deficits in prospective mothers with histories of childhood abuse and neglect. But the Introduction frames the link to parenting as a question, and the Conclusion describes parenting implications as possible risks requiring further research—not as a finding that trauma-specific mentalization deficits impair parenting. (LLM, conf=0.88)

    Experimental — accuracy not yet measured

  • In a sample of 100 pregnant women who had suffered from childhood abuse and neglect, reflective functioning about the traumatic experiences was lower than the general mentalization about their childhood.

    “In a sample of 100 pregnant women who had suffered from childhood abuse and neglect, they found that reflective functioning about the traumatic experiences was lower than the general mentalization about their childhood”

    From Mentalizing makes parenting work: a review about parental reflective functioning and clinical interventions to improve it (2017) · cites this paper as Ensink et al., 2014

  • Abused mothers mostly had low reflective functioning and more than one third of the mothers in their sample were classified on the AAI as unresolved regarding trauma.

    “Ensink et al. (2014) also noted that abused mothers mostly had low reflective functioning and that more than one third of the mothers in their sample were classified on the AAI as unresolved regarding trauma.”

    From Mentalizing makes parenting work: a review about parental reflective functioning and clinical interventions to improve it (2017) · cites this paper as Ensink et al., 2014

  • Low mentalization about the traumatic experiences was the best predictor of the difficulty to invest in the pregnancy as well as of the lack of positive expectations about becoming a mother.

    “and that low mentalization about the traumatic experiences was the best predictor of the difficulty to invest in the pregnancy as well as of the lack of positive expectations about becoming a mother.”

    From Mentalizing makes parenting work: a review about parental reflective functioning and clinical interventions to improve it (2017) · cites this paper as Ensink et al., 2014

Statistics recomputed

Every reported test result, recomputed from its test statistic and degrees of freedom. A result shows as not adding up only once an independent check has confirmed it.

  • Consistentt(63) = 4.93reported p < .001 · recomputed p < .001

    “t(63) = 4.93, p < .001”

  • Consistentt(35) = 0.48reported p = .64 · recomputed p = .634

    “t(35) = 0.48, p = .64”

  • Consistentt(55) = -0.43reported p = .67 · recomputed p = .669

    “t(55) = -0.43, p = .67”

  • Consistentz = 3.46reported p < .01 · recomputed p < .001

    “(z = 3.46, p < .01”

  • Consistentz = 4.28reported p < .01 · recomputed p < .001

    “(z = 4.28, p < .01”

  • Consistentz = 4.71reported p < .01 · recomputed p < .001

    “(z = 4.71, p < .01”

  • Consistentz = 10.95reported p < .01 · recomputed p < .001

    “(z = 10.95, p < .01”

  • Consistentz = 4.47reported p < .01 · recomputed p < .001

    “(z = 4.47, p < .01”

  • Consistentz = 2.3reported p < .05 · recomputed p = .021

    “(z = 2.30, p < .05”

  • Consistentt(98) = 3.58reported p = .001 · recomputed p < .001

    “t(98) = 3.58, p = .001”

  • Consistentt(98) = 1.08reported p = .28 · recomputed p = .283

    “t(98) = 1.08, p = .28”

  • Consistentt(62) = 0.68reported p = .5 · recomputed p = .499

    “t(62) = 0.68, p = .50”

  • Consistentt(62) = 1.15reported p = .25 · recomputed p = .255

    “t(62) = 1.15, p = .25”

13 of 13

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Reported insecure-group RF-G mean does not match Table 4

    Major

    The 57 non-secure participants in Table 4 have a mean RF-G of approximately 3.37 when its group counts and means are combined, not the reported 3.63. Even using only the dismissing and preoccupied groups gives approximately 3.41.

1 of 1

Cites

Flagged first, then by citations

Research works printed but not linked: 14

  1. Allen, 2013, Mentalization in the Development and Treatment of Attachment Trauma.
  2. Ammaniti, 2014, “Transition to parenthood: studies of intersubjectivity in mothers and fathers,” in, Early Parenting and Prevention of Disorder: Psychoanalytic Research at Interdisciplinary Frontiers, 129
  3. Berthelot, 2012, La dissociation comme médiateur entre l’agression sexuelle et la symptomatologie clinique chez l’enfant., Rev. Québéc. Psychol., 33, 37
  4. Bion, 1962, The psychoanalytic study of thinking., Int. J. Psychoanal., 43, 306
  5. Briere, 2002, “Treating adult survivors of severe childhood abuse,” in, The APSAC Handbook on Child Maltreatment,, 175
  6. Cloitre, 2011, Treating Survivors of Childhood Abuse: Psychotherapy for the Interrupted Life.
  7. Godbout, 2013, Childhood trauma and couple relationships., Integr. Sci. Pract., 3, 14
  8. Knauth, 2000, Predictors of parental sense of competence for the couple during the transition to parenthood., Res. Nurs. Health, 23, 496, 10.1002/1098-240X(200012)23:6496::AID-NUR83.0.CO;2-1 · DOI
  9. Luyten, 2012, “Assessment of mentalization,” in, Mentalizing in Mental Health Practice, 43
  10. Main, 2002, Classification and Scoring Systems for the Adult Attachment Interview.
  11. Slade, 2009, “The psychology and psychopathology of pregnancy,” in, Handbook of Infant Mental Health, 22
  12. Steele, 2009, “Treating dissociation,” in, Treating Complex Traumatic Stress Disorders: An Evidence-Based Guide, 145
  13. Stovall-McClough, 2008, “Adult attachment and posttraumatic stress disorder in women with histories of childhood abuse,” in, Clinical Application of the Adult Attachment Interview, 320
  14. Winnicott, 1967, “Mirror-role of the mother and family in child development,” in, The Predicament of the Family: A Psycho-Analytical Symposium, 26

Cited by

Sorted by citations

Related

Authors
Ensink, K., Berthelot, N., Bernazzani, O., Normandin, L., & Fonagy, P.
Affiliations
  • Université Laval (CA)
  • Université du Québec à Trois-Rivières (CA)
  • Université de Montréal (CA)
  • Anna Freud Centre (GB)
Corresponding author
Fonagy, Peter
ORCID
Venue
Frontiers in Psychology
Publisher
Frontiers Media SA
Published
2014-12-17
Volume
5
Pages
1471-1471
ISSN
1664-1078 (ISSN-L)
DOI
10.3389/fpsyg.2014.01471
PMC
PMC4269108
OpenAlex
W2065151296
Semantic Scholar
31820b199ab0cf8190f754e491ef41e587be3b85
Cited by
144
References
69
Citations by year
2026: 14 · 2025: 10 · 2024: 12 · 2023: 20 · 2022: 10 · 2021: 11 · 2020: 11 · 2019: 14 · 2018: 16 · 2017: 10 · 2016: 7 · 2015: 9
FWCI
10.26
Type
journal article
Language
en
Open access
Licence
cc-by
Locations
  • Frontiers in Psychology (publishedVersion, cc-by)
  • Europe PMC (PubMed Central) (publishedVersion, cc-by)
  • PubMed Central (publishedVersion, cc-by)
  • PubMed (publishedVersion)
  • DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
  • UCL Discovery (University College London) (submittedVersion)
Funders
National Institute for Health and Care Research (NF-SI-0510-10228)
Topics
  • Social Sciences › Psychology › Clinical Psychology › Psychoanalysis and Psychopathology Research
  • Social Sciences › Psychology › Social Psychology › Attachment and Relationship Dynamics
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Maternal Mental Health During Pregnancy and Postpartum
Keywords
reflective functioning, mentalization, unresolved trauma, childhood abuse and neglect, pregnancy, attachment, insecure attachment, couple functioning, transition to parenthood, scale validation, Adult Attachment Interview

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-09.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-09.

Statistics and arithmetic are recomputed, not judged.

Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.

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