Reflective functioning skills mediating the relationship between attachment security and therapeutic alliance in mentalization-based treatment for children.

OBJECTIVES: The therapeutic alliance is a critical predictor of psychotherapy outcomes, yet little is known about the child-specific interpersonal factors influencing its early development in child psychotherapy. This study aimed to examine whether children's pre-treatment attachment security and reflective functioning (RF) skills predict the strength of early therapeutic alliance. DESIGN: The study was part of a randomized controlled trial measuring the effectiveness of Mentalization-Based Treatment for Children (MBT-C). METHODS: Participants were 71 children aged 7-12 who received the MBT-C intervention. Pre-treatment assessments included the Attachment Doll Story Completion Task to measure attachment security, and the Child Reflective Functioning Scale to assess RF skills. Early therapeutic alliance was evaluated at the third week of treatment using the self-report scale of Therapeutic Alliance Scale for Children (both child and therapist forms). RESULTS: Results from the mediation model showed that children's reflective functioning skills significantly mediated the relationship between attachment security and early alliance rated by children. Therapist-rated alliance was found to be insignificant. CONCLUSIONS: Findings highlight reflective functioning as a central mechanism linking attachment security to children's perceptions of therapeutic alliance in MBT-C. This suggests that children's capacity to understand others' mental states is critical for establishing early alliance.