Mentalizing May Enhance Functioning of People With Borderline Personality Disorder

March 20, 2024

Longitudinal research into borderline personality disorder (BPD) has revealed a paradox: symptomatic remission is common, but doesn’t uniformly translate into improved psychosocial functioning.

Psychosocial functioning is the ability to work, build, or maintain a supportive social network, or participate in recreational activities. These, in turn, contribute to building a sense of self and stable means of relating to others, which solidify personality development.

Mentalization-based treatment for BPD focuses on stabilizing reflective functioning, the capacity to consider one’s own and others’ mental states. Reflective functioning encompasses several related social cognitive constructs, including mindfulness, empathy, affect consciousness, and psychological mindedness.

Researchers at McLean Hospital recently examined factors associated with psychosocial functioning in BPD.

In Psychology and Psychotherapy, Lois W. Choi-Kain, MEd, MD, director of the Gunderson Personality Disorders Institute, and colleagues report preliminary evidence that reflective functioning is one of those factors.


The team conducted a secondary analysis of the cross-sectional Attachment, Cognition, and Personality (ACP) Study, which is still unpublished. 53 non–treatment-seeking women ages 18 to 35, recruited from hospital and community settings, underwent rigorous diagnostic assessment and were determined to have BPD (n=23) or not (n=30).

The ACP Study measures used in the current analysis were:

  • The Background Information Schedule, which includes the Hollingshead Two-Factor Index of socioeconomic status and the Global Assessment of Functioning (GAF) published by the American Psychiatric Association
  • The Revised Diagnostic Interview for Borderlines (DIB-R)
  • The Childhood Trauma Questionnaire–Short Form (CTQ-SF)
  • Social cognition measures: the Interpersonal Reactivity Index (IRI), the Psychological Mindedness Scale (PMS), the Five Factor Mindfulness Questionnaire (FFMQ), and the Toronto Alexithymia Scale-20 (TAS-20)

In addition, the Reflective Functioning Scale (RFS) was rated on transcripts of the Adult Attachment Interview, which assesses early attachment experiences.

Trained raters who were blind to group affiliation rated the quality of mentalizing based on the participant’s awareness of the nature of mental states, explicit effort to tease out mental states underlying behavior, recognition of developmental aspects of mental states, and mental states in relation to the interviewer.

Abstract illustration of a data stream and a brain

Dimensions of Psychosocial Functioning

Compared with the non-BPD group, participants in the BPD group:

  • Were less likely to be married (P<0.05)
  • Were more impaired on the GAF (P<0.001)
  • Had more coexisting axis I disorders (P<0.001)
  • Had lower quality of physical health (P<0.5)
  • Had greater symptom severity according to the DIB-R (P<0.001)
  • Reported more traumatic experiences on the CTQ-SF (P<0.01)
  • Were more impaired on the PMS subscales benefits from discussing feelings, access to feelings, and openness to change (all P<0.05)
  • Had poorer scores on the FFMQ subscales acting with awareness and nonjudging of inner experiences (P<0.001 and P<0.01, respectively)
  • Had worse total TAS-20 scores and more impairment on its difficulty identifying feelings subscale (P<0.005 and P<0.001, respectively)

The two groups did not differ significantly on self-rated empathy (IRI) or mentalizing capacity (RFS).

Variables Predicting Psychosocial Functioning

On regression analysis, the most important variables predicting psychosocial functioning were BPD symptom severity (estimated coefficient, -8.64) and BPD diagnosis (8.88).

Next highest in importance were:

  • Childhood sexual abuse (-2.48)
  • Socioeconomic status (-2.16)
  • Housing situation (-1.92)
  • Financial situation (-1.68)
  • Community activities (1.40)

Variables that made small contributions to psychosocial functioning were:

  • Physical health (-0.60)
  • Score on the RFS (0.34)
  • Level of education (0.17)
  • Childhood physical neglect (0.04)

Interpreting the Findings

The ability to reflect about oneself and others within personal relationships or at the workplace may form a foundation to deal with or resolve interpersonal conflicts and enhance social learning and recalibration. In theory, mentalization-based treatment improves the capacity for learning and change and may therefore improve psychosocial functioning.

In this study, social cognitive capacities related to self-awareness differentiated participants with BPD from those without BPD better than RFS scores did. However, reflective functioning predicted psychosocial functioning in the total sample. Reflective functioning buffers the detriments to functioning predicted by high levels of BPD symptom severity or trauma.

What’s needed now is empirical testing of mentalizing as a mediator of change in psychotherapy and investigation of how it’s related to psychosocial functioning outcomes in BPD.

Looking for mental health care for someone struggling with borderline personality disorder? Call us today at 617.855.2820 to refer a patient.

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