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What is mentalising?

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What is Mentalizing and Why Do It?

Jon G. Allen, PhD
Director of Psychology, The Menninger Clinic as well as Professor of Psychiatry, Menninger Department of Psychiatry and Behavioral Sciences at The Baylor College of Medicine



From Mentalizing in Clinical Practice byJG Allen, P Fonagy, & AW Bateman (2008): , Washington, DC: American Psychiatric Publishing
 

You are mentalizing when you’re aware of what’s going on in your mind or someone else’s. You’re mentalizing when you puzzle, “Why did I do that?” or wonder, “Did I hurt her feelings when I said that?” Your ability to mentalize enables you to make sense of behavior. You hear a car door slam shut and it draws your attention. Then you see the man who slammed the car door reaching into his pockets and coming up empty handed. He starts to get agitated, tries unsuccessfully to open the door, looks through the car window toward the ignition, and starts cussing. All this behavior would be bewildering if you didn’t automatically infer that he’s frustrated because he locked his keys in the car.

Mentalizing, you automatically interpret behavior as based on mental states, such as desires, beliefs, and feelings. The man wanted to be able to drive his car, believed that he’d have a hard time getting back into it, and felt frustrated—perhaps also helpless. Sometimes you need to mentalize to interpret your own behavior: “How could I have been so gullible as to loan him money when I knew full well that he’s totally undependable?” Often you need to mentalize to understand your emotional reactions: “Why am I this upset about her not calling me back right away? Why am I so sensitive right now? I’ve been feeling like a lot of people have been letting me down lately…”

Such questions are merely the launching point for how you might explain things to yourself. Seeing the man become frustrated about locking himself out of his car might stimulate your own memories of being locked out and a recognition that this happened when you were distracted. Using this further understanding from your own self-exploration will enhance the interaction if you go over to sympathize with the man and to see if you can help.

A shorthand idea for mentalizing: keeping mind in mind. Mentalizing requires attention and takes mental effort; it’s a form of mindfulness, that is, being mindful of what others are thinking and feeling as well as being mindful of your own thoughts and feelings. Thus mentalizing is similar to empathy. But mentalizing goes beyond empathizing, because it also includes awareness of your own state of mind—empathizing with yourself. Thus, you’re mentalizing when you’re going in to ask your boss for some time off and you’re thinking, “I’m feeling anxious. It makes sense that I’d feel anxious right now, because he might feel put out. Well, I can tolerate that.” If your boss unfairly gives you grief about taking some time off, you’d be mentalizing in thinking, “I’m getting frustrated, so I need to choose my words carefully. I need to acknowledge that this makes his life more difficult and let him know how important the time off is to me.” Thus you are mentalizing when you demonstrate your understanding of your boss’s annoyance and try to address it while simultaneously explaining your own point of view.

The following situations call for mentalizing:

 

·                     Comforting a friend in distress

·                     Clearing up a misunderstanding with a friend

·                     Calming down a child who is having a tantrum

·                     Developing strategies to refrain from overeating

·                     Persuading an employer to give you a raise

·                     Proposing marriage

·                     Describing symptoms and problems to your psychiatrist

 

As all these examples attest, mentalizing is common sense; we are all natural psychologists in trying to understand behavior and figuring out why people think and feel the way they do. Mentalizing is like language in being innate: we all develop the capacity to mentalize, barring genetic conditions such as autism. Yet, like language, mentalizing develops best in an environment conducive to learning.

Like using language, you mentalize naturally; most of the time you don’t need to think about it. You don’t need to be a linguist to use language, and you don’t need to become a professional psychologist to mentalize. Yet mentalizing is a skill that can be developed to varying degrees. Failing to mentalize can contribute to serious problems in relationships. Your friends, family members, or spouse will be unhappy if you’re oblivious to their needs and feelings or you continually misinterpret their actions. Psychiatric disorders such as depression and substance abuse notoriously interfere with mentalizing, because they compromise the capacity for flexible thinking, lead to distorted views of the self, and undermine attention to others’ experience. When such disorders develop, you can benefit from learning about mentalizing, paying greater attention to doing it, and becoming more skillful at it.

Developmental psychologists have been researching mentalizing over the past few decades, so we now know a lot about how it develops and how we can improve it. This article describes different aspects of mentalizing, conditions that affect mentalizing, the nature of skillful mentalizing, and the benefits of mentalizing. We conclude by revealing our main goal: to influence your attitude toward mentalizing.

 

Aspects of Mentalizing

 

Mentalizing involves awareness of yourself as well as others. Our colleague, psychiatrist Jeremy Holmes at the University of Exeter in the UK, puts it this way: mentalizing is seeing yourself from the outside and others from the inside. Mentalizing with regard to others takes effort: you cannot merely assume that others think and feel the way you do, although they might; you must shift perspectives and try to take their point of view. Thus the more you know about another person, the more accurate your mentalizing will be. For example, you are probably better at understanding a person with whom you have an intimate relationship and others who are close to you than you are at grasping the motives of more distant acquaintances. Yet, as we will discuss below, you might be aware that you also have greatest difficulty mentalizing when you experience conflict with those to whom you are closest. Each of us runs into circumstances that interfere with our ability to mentalize, usually when we feel threatened or find ourselves in the throes of intense emotional arousal.

You cannot take for granted your ability to mentalize with respect to yourself: even though you live in your own mind, you don’t necessarily always know how your mind is working. All of us are capable of self-deception. It’s common for others to see aspects of ourselves to which we are blind. Often, we know ourselves best through dialogue with others: you might start out just feeling vaguely “upset” and, over the course of the conversation with a trusted friend, come to recognize that you’re feeling hurt, ashamed, and resentful. Thus others, seeing us from the outside, can help us see ourselves more clearly from the inside.

You can mentalize in different time frames. You can mentalize about specific mental states in the present: “I’m getting all worked up for nothing.” “She’s starting to get impatient with me.” Also, you can reflect on past mental states: “Now that I’ve calmed down, I can see that she intended her criticism to help me, not to belittle me.” In addition, you can mentalize by anticipating future mental states: “If I don’t let her know that I’ll be late, she’ll worry and then I’ll feel guilty.”

Most important, you can transform hindsight into foresight: mentalizing about problems in the past can enhance your ability to mentalize in the future. “I know I’m extremely sensitive to criticism and I get so defensive that I can’t listen to her point of view. Next time, I’ll try to think about where she’s coming from, listen carefully to what she’s saying, and avoid another blow up.”

Just as you can mentalize about the present, past, or future, you can mentalize with a narrower or broader perspective. You can focus narrowly on a person’s feelings at a given moment: “She looks irritated.” In addition, you can be aware of the broader context of her mental state: “She thinks I lied to her.” You can even take into account a broad swath of the person’s history: “She’s extremely sensitive to any sign of betrayal because of her father’s recurrent untrustworthy behavior.” Thus, expanding the scope of mentalizing may take into account a broader time frame as well as the wider network of interactions and relationships that influence an individual’s mental states.

The same applies to your own mental states: self-understanding often requires you to consider the wider context beyond the present moment. You might wonder, “Why am I so upset that he didn’t acknowledge how much work I did on this project?” Mentalizing, you might realize that you’ve been feeling unappreciated for a long time, and not having this particular project recognized was the last straw. You can take this line of thinking all the way back to your childhood, for example, connecting your current feelings with repeated disappointments in the past, when a parent routinely failed to attend school plays or sports events. Your feelings about the present invariably are colored by your past experiences, and mentalizing involves being aware of this coloring—the “baggage” from the past—so that you can see the present for what it is.

You can mentalize more or less consciously. Mentalizing explicitly is a conscious process in which you think deliberately about the reasons for actions—often when you are puzzled: “Why would she have said that?” “How could I have forgotten to do that when I knew it was so important to him?” You mentalize explicitly when you put your feelings into words, whether you’re trying to make sense of yourself in your own mind or needing to express what you’re feeling to someone else.

Most often, however, you don’t have time to mentalize explicitly when you’re interacting with others; you’re mentalizing implicitly, that is, spontaneously and intuitively, without thinking about it. Mentalizing implicitly, you’re guided by your gut feelings. When your friend tells you about a major disappointment, you automatically adopt an expression combining sadness and caring, leaning forward to make emotional contact. Thus the natural empathy you have for others is based on your ability to mentalize implicitly. You also mentalize implicitly when you engage in conversation, keeping the other person’s perspective in mind and taking turns naturally without having to think about it. You’re likely to find conversations annoying when others fail to mentalize, mentioning names of people you don’t know without taking into consideration that you have no idea who they’re talking about.

When all goes well, you can get by with mentalizing intuitively and implicitly. Using language naturally, you don’t need to think about your choice of words until you’re misunderstood. Similarly, you need to mentalize deliberately and explicitly when you hit a snag in a relationship. Much of your explicit mentalizing takes the form of narrative, through which you make your own and others’ actions intelligible. You ceaselessly create stories involving thoughts and feelings. Think of a time when you had to justify your actions to someone, such as asking your boss for time off. Think about how you explain your emotional reactions to someone else’s behavior. Think about how squabbling children behave when a parent confronts them. Each one comes up with a different story. Then the parent needs to mentalize to sort it out and intervene appropriately.

You begin learning to mentalize early in life by creating stories to account for your actions. And you do this in your own mind. For better and at times for worse, you continually tell yourself stories about yourself, and these stories influence who you are. Self-critical stories, for example, can undermine your self-confidence. “Nothing I do ever turns out right, no matter how hard I try. I’m useless. If anything goes wrong, I’m always the one to be blamed. The story of my life…”

Ideally, mentalizing, like story telling more generally, is creative: mentalizing, you come up with fresh perspectives, seeing yourself and others from more than one point of view. Thus you’re mentalizing when you wonder, “I’m really irked at him. What else might I be feeling? I guess he hurt my feelings.” Similarly, you’re mentalizing when, after you think, “What an idiot I am,” you reconsider and think, “I made an understandable mistake; I was trying to do too much at once.” Jeremy Holmes insightfully construed psychotherapy as a “story-making” and “story-breaking” process. Mentalizing, you move out of old ruts in the stories you create about yourself and others.

 

Conditions for Mentalizing

 

Children learn language best in a language-rich environment, by hearing speech, being spoken to, and being listened to and responded to when they are learning to speak. Similarly, children learn to mentalize best when their family members are sensitive to their states of mind, especially their emotions. Children learn to mentalize by being mentalized, that is, when others have their mind in mind. Mentalizing will not flourish in emotionally neglectful relationships. Rather, mentalizing develops best in trusting and safe relationships—what we call secure attachment relationships. Moreover, once children begin to acquire language, talking openly with them about their own and others’ needs, feelings, fears, and reasons for actions gives mentalizing a great boost. As with all other skills, mentalizing is learned through practice, and learning continues throughout the lifetime.

Developing the ability to mentalize is one thing; using it consistently is another. Some conditions are more conducive to mentalizing than others. Your level of emotional arousal is a major factor in being able to mentalize at any given moment. Mentalizing goes best when your level of emotional arousal is neither too high nor too low. You need to feel relatively safe to mentalize. If you’re feeling threatened—angry or frightened—you’ll be more concerned with self-protection than with taking the time and effort to mentalize. In states of high emotional arousal, the instinctive fight-or-flight response takes over, and mentalizing falls by the wayside. You can feel so panicky or infuriated that you can’t think straight, much less consider what someone else is thinking or feeling.

As we already indicated, you’re generally likely to have most difficulty mentalizing in emotionally close attachment relationships when conflicts arise and feelings run high. Catch-22: mentalizing is most difficult when you most need to do it. That’s why much of our mentalizing takes place after the fact; fortunately, you can translate hindsight into foresight and thereby turn your misunderstandings into understandings, much like you might do with your partner after a falling out. And you may need professional help in the form of individual or couples therapy so that you can learn to mentalize when you’re experiencing conflict or feeling threatened in your attachment relationships. Mentalizing enables you to be aware of your feelings as well as those of your partner. To engage in constructive problem solving, each person needs to keep their own mind as well as the other’s mind in mind. And the best way to engage another person in mentalizing is to be doing it yourself.

Either too much or too little emotional arousal can interfere with mentalizing. If you’re too depressed or lethargic, you won’t be inclined to mentalize. Mentalizing takes effort, and you must be motivated to do it. If you’re indifferent to others’ needs or feelings, you won’t be inclined to mentalize.

 

Skillful Mentalizing

 

The two hallmarks of skillful mentalizing are accuracy and richness. Mentalizing accurately means seeing others for who they really are as well as seeing yourself for who you really are. Mentalizing requires imagination, for example, being able to project your own experience into others, putting yourself in their shoes, and imagining how you might feel if you were in their situation. But projecting from your own experience can be a slippery slope; your imagination can lead to distorted mentalizing. For example, feeling ashamed and inadequate or being excessively self-critical, you might wrongly imagine that others look down on you or judge you harshly. In so doing, you would be mentalizing, but you would be mentalizing inaccurately.

We are often asked, “Can you mentalize too much?” Frequently, this question reveals ineffective or inaccurate mentalizing such as obsessing or worrying about what someone else is thinking or ruminating about your past failures and deficiencies. Skillful mentalizing, on the contrary, is flexible and exploratory; you’re not stuck in a rut. Of course, as with all else, health lies in balance; there’s more to life than mentalizing.

As problems with worrying and ruminating illustrate, mentalizing accurately means grounding your imagination in reality; you might do this by asking others what they think and feel instead of relying solely on your assumptions or projections. If you think someone is put out with you or critical of what you’ve done but you’re not sure, you can ask. If you’re unsure of your interpretation of a situation, you can check out how others saw it. Often, different people interpret the same situation in different ways. This brings us to the essence of mentalizing: recognizing that there are many mental perspectives on the same outer reality. That’s mental reality.

Richness in mentalizing refers to the process of mental elaboration—making the effort to use your imagination and think beyond the surface. A father is failing to mentalize when he dismisses his son’s tears as showing that “he’s just a spoiled brat” rather than considering the basis of his son’s disappointment or frustration. Similarly, thinking that a co-worker is “just a jerk” is a non-mentalizing view. You might think of yourself in the same non-mentalizing way: “I’m just lazy” or “I’m just impulsive.” The word, “just,” is a tip-off to non-mentalizing; it closes off thoughtful exploration of the potential multitude of reasons for behavior.

In her book, The Sovereignty of Good, novelist and philosopher Iris Murdoch provided a now-celebrated example of a mother-in-law’s shift in perspective regarding her daughter-in-law, a shift in viewpoint that illustrates a transformation from inaccurate to accurate mentalizing. Initially, the mother-in-law found her daughter-in-law to be crude, unrefined, and juvenile; she thought her son had married beneath him. Outwardly, she treated her daughter-in-law with impeccable kindness but, inwardly, she felt scorn. Yet the mother-in-law was uncomfortable with her attitude and wondered if she were being snobbish. She put her mind to seeing her daughter-in-law accurately, justly, and lovingly. She was determined to see her daughter-in-law for who she really was. Through a concerted effort of attention and imagination, she came to see her daughter-in-law not as vulgar but rather as refreshingly simple, spontaneous, and delightfully youthful—a dramatic shift of perspective.

Because mentalizing is inherently open-ended, allowing for multiple perspectives, you know you’ve stopped mentalizing whenever you have a sense of certainty. You’ve stopped mentalizing when you declare, “I know you really don’t want me here!” You’ve shifted into mentalizing when you say, “I’m thinking you really don’t want me here—is that so?”

 

The Benefits of Mentalizing

 

The most obvious benefit of mentalizing is engaging in fulfilling relationships with others, particularly those with whom you are emotionally attached. Mentalizing—each person having the other’s mind in mind—lies at the heart of intimacy. Mentalizing skillfully also enables you to influence others effectively, taking their point of view into account while respecting their individuality. When you fail to mentalize, you tend to impose your point of view and your will on others, trying to force them to comply with your wishes, needs, or beliefs. Conflict, antagonism, and resentment are bound to ensue. And mentalizing not only allows you to influence others but also opens you up to being influenced by others. You could not learn from others if you were unable to have their mind in your mind. Healthy relationships depend on it.

Ironically, while mentalizing develops best in secure attachment relationships in childhood, one advantage of secure attachments is that you typically don’t have to put too much conscious effort into mentalizing as long as things are going smoothly. You will need to put effort into mentalizing, however, when you are in competitive relationships as well as when you are not sure of another person’s trustworthiness. If you are naively trusting—not making the effort to discern the other person’s true intentions or motives—you can put yourself in danger. Thus, in a new relationship, cautious appraisal as well as being attuned to your gut reactions is essential. Failing to mentalize can be even more calamitous if the other person senses your naiveté through their own mentalizing but then exploits your innocence for personal gain. Such misuse of mentalizing becomes a way of gratifying oneself or furthering one’s own interests rather than a self-reflective process or joint project of mutual understanding. Of course, some leaders of organizations climb the competitive ladder in this way, and con-men also must understand others’ minds of they are to be successful. Like any other skill, mentalizing can be misused.

Mentalizing not only is essential to good relationships with others but also to your relationship with yourself. Just as you need to influence others, you need to be able to influence yourself, for example, when you want to change your feelings, attitudes, thought patterns, or behavior. To influence yourself, you must know yourself and be attuned to yourself, keeping your own mind in mind. If you’re struggling with an addiction, for example, you need to anticipate situations that will tempt you and then steer clear of them.

Mentalizing your emotions is most important and most difficult. You can be immersed in an emotional state without mentalizing. You can be emotionally agitated and appear tense and edgy to others without being aware of your feelings. Or you may be dimly aware of feeling “out of sorts” but not be clear about just what you are feeling or why. Mentalizing emotion requires feeling and thinking about feeling at the same time, clarifying your feelings and their basis. Your feelings are your gut-level guide to your needs and to how your relationships are going. You feel annoyed when someone invades your space, and your annoyance prompts you to stand up for yourself. When you’re aware of your feelings through mentalizing, you’re in the best position to get your needs met effectively. You can express your feelings to others accordingly and thus solve the problems that your feelings are signaling: “I don’t like it when you just barge in without knocking.” Even when it’s not a good idea to express your feelings outwardly to others, you can at least express them inwardly to yourself. Ideally, you can take an understanding and compassionate attitude toward your feelings, just as you would wish others to do. You might not want to tell your boss how angry you are about his being unreasonable, but you might say to yourself, “I can’t believe how aggravating this is—no wonder I was anxious about asking him for time off!” And you might express your feelings later to a trusted friend as well.

Mentalizing your emotions also enables you to refrain from impulsive and self-defeating behavior—storming out of your boss’s office. Mentalizing is like pushing a pause button—not merely “counting to ten” but also giving yourself time to think about your needs and feelings and the best way to manage them rather than employing desperate measures to quell them. For example, mentalizing enables you to recognize, tolerate, regulate, and express your feelings of frustration rather than having to drink to the point of intoxication to get rid of them.

 

A Mentalizing Attitude

 

To repeat, mentalizing is like language: short of rare genetic abnormalities or extreme deprivation, we all learn to talk and we all learn to mentalize. Yet all of us can learn to speak and write more articulately, and all of us can learn to mentalize more effectively and consistently. The most frequent problem with mentalizing is not lacking the basic ability but rather failing to cultivate it and put it to use. When you’re having trouble in close relationships or difficulty managing your own emotional states, you’ll need to pay more attention to mentalizing and put more effort into it. You may need professional help. We’ve said that the best way to influence another person to mentalize is to do it yourself. This is what we therapists aspire to do: by mentalizing, we help our patients to mentalize. In fact, we believe that the success of all forms of therapy rests on mentalizing on the part of patients and their therapists.

As therapists, we wrote this article to inspire what we call a mentalizing attitude, that is, an attitude of openness, inquisitiveness, and curiosity about what’s going on in others’ minds and in your own. This mentalizing stance requires tolerance for ambiguity—comfort with not knowing. Mentalizing involves exploring possibilities with an open-minded attitude, a sense that there’s always more to the story. Accordingly, this article is a mere introduction.


Copyright © American Psychiatric Publishing, Inc

We're very grateful to the APPI for their permission to include on this website the above feature from the book Mentalizing in Clinical Practice, byJG Allen, P Fonagy, & AW Bateman. To quote from another psychotherapy guru, Jeremy Holmes:
"How often in our field is one able to recommend a book written with wit and grace, expounded with clarity and scholarship, deftly structured, illustrated with memorable tables and diagrams, research- and clinically-oriented, and relevant across the range of psychotherapeutic disciplines? Here is a strong authorial voice on a vital psychotherapeutic theme. This exceptional volume helps therapists, from analytic to cognitive and beyond, to open minds and hearts to mentalizing as a meta-concept, underpinning—and often spearheading—all worthwhile psychotherapeutic enterprise."--Jeremy Holmes, M.D., Professor of Psychological Therapies, University of Exeter UK

All this and a fascinating chapter on mentalising within social systems which doesn't stop with an inspiring account of the Peaceful Schools project in the American mid-West. Jon Allen boldly applies the "inescapable ethical texture of mentalising" to consider its potential role in preventing global conflicts. It's a great book - buy it now from Amazon!
http://tiny.cc/mentalizinginclinicalpractice



 

Mentalizing as a Compass for Treatment (White Paper: Houston, TX: The Menninger Clinic, 2003)

Jon G. Allen, PhD, Efrain Bleiberg, MD, and Tobias Haslam-Hopwood, PsyD

 
This article is based on a patient education program the authors are conducting in the Professionals in Crisis program at The Menninger Clinic. This program is designed to foster a therapeutic alliance by helping patients understand a central aim of treatment, namely, fostering mentalizing, the awareness of mental states in self and others. The educational material is based on research in the Child and Family Program. The educational sessions are conducted like seminars in which the leaders and patients collaborate in understanding these concepts and their application to treatment. Patients in the program are provided with this article as background material for the seminar.


 

Many persons with serious psychiatric disorders require intensive treatment. Medication or individual psychotherapy alone—or even their combination—won’t always do. Patients who have not benefited sufficiently from less intensive outpatient treatment may require inpatient treatment that provides for comprehensive assessment and combines a wide range of interventions—not just medication and individual psychotherapy but also group therapy, family work, educational groups, therapeutic activities, and a specialized milieu. Crucial to such treatment is a social environment that provides support, a feeling of belonging, and ample formal and informal opportunities to confide in peers and learn from them.

Such a rich array of therapeutic interventions confronts us with a problem: How does it all work? It is no small challenge to understand how medications work or to understand how individual psychotherapy helps. Researchers have been studying these interventions for decades. When we combine these standard interventions with many other therapies, understanding the basis of our treatment’s effectiveness becomes even more challenging. We all subscribe to the “biopsychosocial” model of treatment, believing that we must integrate the biological, psychological, and social domains as well as the spiritual domain. But this is a vast territory to cover.

If we mental health professionals must struggle to understand how our complex treatment works, and we’ve devoted our whole professional careers to it, how much harder must it be for patients to understand what we’re doing and why? As one of our mentors, psychologist Irwin Rosen used to say, we need a compass for treatment. A compass is not enough to get you anywhere, and no single concept could begin to explain how all of treatment works. But we need a general direction. Working with our colleague, British psychologist Peter Fonagy, we have identified a concept that provides a sound orientation to treatment: mentalizing. We believe that helping patients understand how we are thinking about treatment—our conceptual compass—will help them make the best use of it.

Educating patients about our understanding of treatment can make an important contribution to establishing a therapeutic alliance, and we know from extensive experience and research that a therapeutic alliance is crucial to a positive treatment outcome. The therapeutic alliance entails active collaboration between patients and their treaters, and such collaboration is based on a sense of working together toward shared goals. This collaboration requires shared understanding, and the concept of mentalizing provides a focal point.

 

I. Understanding Mentalizing


 

Mentalizing refers to the spontaneous sense we have of ourselves and others as persons whose actions are based on mental states: desires, needs, feelings, reasons, beliefs and the like. Normally, when we interact with others, we automatically go beneath the surface, basing our responses on a sense of what underlies the other person’s behavior, namely, an active mind and a wealth of mental experience. Thus we are natural mindreaders, and mentalizing entails accurate and effective mindreading. By virtue of being human, this process of mentalizing comes so naturally to us that we easily overlook its significance. To understand psychiatric treatment, however, we must pay careful attention to mentalizing and the conditions under which this basic human capacity becomes impaired.

We mentalize in relationships with other persons, not in interactions with inanimate objects. A brick is a static object, inert and unresponsive, always behaving in the same way. A person’s behavior is based on mental states that are always in dynamic flux, which makes understanding other persons (and ourselves) the most complex problem solving of which we are capable. Evolutionary biologists now argue that the reason we developed such fancy brains is the sheer complexity of making sense of each other for the sake of our cooperative—and competitive—living.

 

Mentalizing explicitly and implicitly


 

Sometimes we mentalize consciously. When we are puzzled about another person’s actions, we may wonder, “Why was he so abrupt with me? Is he irritated because I didn’t return his call right away?” And we mentalize consciously when we are puzzled by our own actions—“How could I have binged on that ice cream when I was so resolved to stick with my diet?”

The majority of our social conversations revolve around gossip, in the benign sense that we mostly talk about ourselves and others—what we are doing and why, and what they are doing and why. Mainly, we seemed to be interested in making sense of our social world and our place in it. We are busy practicing mentalizing.

But thinking and talking about what is going on in our own mind and the minds of others is only part of our mentalizing activity, perhaps just the tip of the iceberg. When we interact with others, we mentalize intuitively, just as we ride a bicycle by habit. Thus we don’t just mentalize at an intellectual level; we mentalize at a gut level. When interactions go smoothly, we need not think explicitly about states of mind—our own or the other person’s. We can respond automatically, mentalizing implicitly. For example, we often respond to others’ emotions without thinking about it, for example, nodding sympathetically with a concerned look on our face as we listen to a friend talking about her child’s frightening accident. Another example: we naturally take turns in conversation, being sensitive to pauses, and unthinkingly keeping our conversational partner’s point of view in mind.

 

Mentalizing and mental health  

Mentalizing is crucial to our well being in several respects. First, mentalizing implicitly and explicitly is the basis of self-awareness and a sense of identity. Importantly, when we mentalize, we have a feeling of self-agency, being in control of our own behavior. Thus mentalizing provides us with a spontaneous sense of ownership and responsibility for our actions and our choices, rather than feeling that our behavior just “happens.”

Mentalizing allows us to have an intuitive as well as an explicit sense of ourselves that has coherence and continuity. When all is well, we have a spontaneous sense that our different roles, attitudes, states of mind, and modes of experiencing fit together coherently like the pieces of a puzzle. We maintain a sense of continuity throughout different patterns of relating—as serious professionals, concerned parents, and playful participants in friendly banter. We maintain a sense of continuity throughout different emotional states—feeling angry, elated, anxious, triumphant, and vulnerable. These various experiences form a whole—a self—that we feel and believe is “me.”

Second, mentalizing is the basis of meaningful, sustaining relationships. When we mentalize spontaneously we cannot help but empathize, that is, putting ourselves in the other person’s shoes and seeing things from their perspective. While empathizing, we retain self-awareness, a sense of where we are coming from. Such intuitive empathizing—with ourselves and with others—is the cornerstone of healthy relationships and ordinary human interactions. It makes possible the moment-to-moment adjustments we make effortlessly to the verbal and emotional signals we read in other people’s behavior. For example, when we sense boredom, frustration, or approval, we adjust our own behavior accordingly to convey our perspective and sustain the give-and-take that defines reciprocal human exchanges. Under ordinary conditions of mentalizing, we make these adjustments without much conscious reflection.

At their most fulfilling, relationships involve a meeting of minds. We feel affirmed and validated when we sense that the other person has our mind in their mind. We are not alone. We not only feel heard and understood, we feel felt. We connect through reciprocal mentalizing, when we are thinking explicitly about each other or, more often, when we are interacting intuitively, by feel.

Third, mentalizing is the key to self-regulation and self-direction. Mentalizing allows us to develop a sense of self that includes a sense of coherence, continuity and responsibility for our choices and behavior. At the same time, mentalizing makes possible our engagement in reciprocal, sustaining relationships. By integrating a sense of self and a sense of connections with others, mentalizing enables us to manage losses and trauma, as well as distressing feelings such as frustration, anger, sadness, anxiety, shame, and guilt. Mentalizing, we manage these feelings without resorting to automatic fight-or-flight responses or efforts to cope that are ultimately self-destructive or maladaptive. Instead, coping and self-regulating responses based on mentalizing preserve flexibility and choice. They give us the tools to set goals for ourselves, to define the steps we need to take to achieve our goals, and to imagine ourselves as the person we want to become. From these capacities we generate the two most basic protective experiences human beings can produce: hope and meaning.

Our focus on mentalizing in psychiatric treatment is based on a growing body of evidence that points to mentalizing as the key to resilience—the ability to adapt successfully to adversity, challenges, and stress. By promoting resilience, mentalizing promotes coping with vulnerabilities, including the genetic vulnerability to psychiatric disorders such as depression, bipolar disorder, anxiety disorders, and addictive disorders. Research is demonstrating, for example, that persons who can mentalize in the face of trauma—including childhood trauma—are less vulnerable to psychiatric disorders. Research is also demonstrating that adjustment and quality of life of people with various psychiatric disorders is ultimately determined by abilities that result from mentalizing.

Here are some of the abilities that mentalizing promotes:

 

q                      the capacity to make meaning of adversity;

q                      the capacity to sustain a positive outlook with hope, initiative, and acceptance;

q                      the capacity to experience the mastery derived from feeling responsible for our own behavior;

q                      the capacity to have a sense of purpose and engage in healing and inspiring rituals based on shared values;

q                      the capacity to communicate and solve problems by seeking clarity and speaking the truth;

q                      the capacity for flexibility and humor;

q                      the capacity to feel connected and to give and receive support;

q                      the capacity for open emotional expression and sharing of a full range of feelings; and

q                      the capacity for mutual empathy which allows us to see both our own and the other person’s perspective.

 

Mentalizing and flexibility  

As we will discuss shortly, failure to mentalize in relationships may leave one stuck in rigid, repetitive patterns of interaction. Conversely, mentalizing actively affords flexibility and choice, yielding options rather than being confined to automatic stimulus-response patterns. For example, when we mentalize, we are able to consider another’s behavior—and our own—from multiple perspectives. Even a four-year old can be capable of mentalizing in this way. Sensing his mother’s irritation, he might think he’s to blame. Mentalizing, he also can consider other possibilities: she’s frustrated with his sister or with her own inability to find her car keys. He’s not confined to blaming himself for all her distress and feeling guilty in the process.

Flexibility may be the key to how we know when we’re mentalizing. The hallmark of mentalizing is seeing oneself and others from a fresh perspective, with an inquisitive and open-minded attitude. Making rigid and untested assumptions and projecting our own feelings and needs onto others interferes with mentalizing. Thus mentalizing entails seeing oneself and others realistically. British philosopher and novelist Iris Murdoch, made endearingly famous in the film Iris, captured the challenge: “The difficulty is to keep the attention fixed upon the real situation.”

Mentalizing is also evident in humor and play. Humor always involves a shift in perspective, for example, the capacity to laugh at one’s foibles. And telling a joke well requires mentalizing, gauging the other person’s understanding and reaction, timing the punch line just right. Humor is one form of play, and play is a step toward mentalizing, taking an “as if” attitude toward reality. The capacity to play with ideas, to imagine what might be on another person’s mind or in another person’s heart (or one’s own) is prototypical of mentalizing.

In sum, mentalizing, we see human reality for what it is. To see reality rightly, we must be able to play with imagination and alternatives, actively testing out our perceptions rather than operating on fixed assumptions. Fresh perspectives replace stale habits. A plain example: when you fear your friend misinterpreted what you said or did, you can check it out.

It is important to appreciate that, while our brain is designed for mentalizing, it is also designed to turn off mentalizing in response to danger. Research into neurophysiology is showing that the activation of the fight-or-flight system—a brain system that activates the psychological and neuro-hormonal responses triggered by signals of danger—also leads to the inhibition of mentalizing.

Evolution has prepared us to fight or flee when our survival is in danger; we respond in a fairly automatic, procedural way, unencumbered by reflection or empathy. In fact, it appears likely that we human beings are capable of violent or destructive acts against one another only when we go into the fight-or-flight mode and momentarily stop mentalizing. Psychiatric disorders reflect maladjustment associated with the persistent inhibition of mentalizing. Such inhibition may be triggered by internal states or interpersonal situations—such as feeling close and dependent. The inhibition of mentalizing leads to inappropriate responses that impair our interpersonal relationships and perpetuate maladaptive cycles of experience and coping.

 

How we learn to mentalize  

Given its importance, we must give high priority to understanding the conditions under which mentalizing flourishes. Fortunately, we have a strong head start, because considerable research has been devoted to understanding how mentalizing develops, as well as the developmental factors that interfere with mentalizing. We aim to use what we have learned about the development of mentalizing to guide our treatment efforts.

The single most important factor in fostering mentalizing is a secure attachment relationship—a close emotional bond. An infant who confidently reaches out to an attachment figure for comforting in times of distress displays secure attachment in its prototypical form. The secure attachment figure—a mother, father, or other caregiver—provides a safe haven. Contact with the attachment figure yields a feeling of security.

But there is another aspect to secure attachment that is every bit as important for development: the secure base. Having confidence that the attachment figure can be relied upon if needed, the securely attached infant eagerly explores the world. For decades, attachment researchers have observed securely attached infants in a playroom with their mother, happily exploring all sorts of toys. More recently, we have come to appreciate that secure attachment does not just foster exploration of the outer world; it also fosters exploration of the inner world, the world of the mind, the mind of the self and the mind of other persons.

Thanks to attachment research, we now have a view of development that seems utterly backwards from what our intuition would suggest. That is, based on our adult mind, we might think that we first become aware of our own mind, and then we come to realize that other persons are similar—they also have a mind like ours. This incorrect intuition about development is based on our experience of empathizing with others: we actively imagine ourselves in their shoes. But developmental research shows that we learn about our own mind from the outside in: it is through the mind of another person—ideally a secure attachment figure—that we become fully aware of our own mental states.

The clearest example of this seemingly backward developmental progression is learning about our emotions. We know that the sensitive caregiver is attuned to her infant’s emotions. She mirrors these emotions in her face and her tone of voice. Seeing her infant’s distress, she shows a mixture of distress and concern on her face—she is mentalizing intuitively. Seeing her infant’s frustration, she may screw up her face in an expression of mock frustration, showing her infant that she knows how he feels. The infant sees his distress or frustration on his mother’s face; he feels felt. And two things happen. First, feeling felt, he finds his mother’s empathic response to be comforting. Second, he begins to understand his own feelings. He sees how he feels in the face of his mother. She has his mind in mind. He discovers his mind in her mind.

Our colleague, Hungarian psychologist George Gergely, characterizes this process of emotional learning as social biofeedback. In standard biofeedback, we hook ourselves up to a measuring device that provides information about our physiological state. A finger thermometer, for example, measures the blood flow to the periphery of the body. When we are frightened, the blood flow goes to the heart and internal organs. We are ready for fight or flight, and our hands get cold. When we are relaxed, the blood flows more evenly throughout the body, and our hands warm up. In the thermometer, we can gauge our state of relaxation, which may not be so evident to us from the inside. Similarly, other persons provide social biofeedback: through their facial expressions and other responses, we can see outside what we feel inside. As in standard biofeedback, we get in touch with our feelings in the process of making the link between our internal states and the information we get from the outer world—other persons who are mentalizing.

Thus we learn to mentalize by being mentalized in secure attachment relationships. Two aspects of attachment security work together in this regard. First, we feel safe and calm, eager to explore. Second, we feel connected, open to seeing our mind in the mind of the other. And, just as secure attachment can foster mentalizing, insecure attachment can inhibit mentalizing. Imagine the child who finds contact with his attachment figure to be frightening. He will turn away from the mind of the attachment figure, feeling frightened rather than calm. He will not be inclined to explore the mind of the attachment figure, and he will be deprived of the opportunity to learn about his feelings through the eyes of another person. Similarly, his internal experience may be distressing, and he may learn to avoid self-awareness as well.

Of course, we have many opportunities to learn about the mind—our own mind and the minds of others—in early development. We learn about minds not just through our primary attachment relationships but also through all our other relationships as well. Children learn about minds from their parents, siblings, extended family members, and peers. This learning continues throughout life. We all continue to need social biofeedback, not only to affirm what we feel but also to recognize our emotions when we are out of touch with our feelings. Just as we do when we are infants, we will learn best about our own mind and the minds of others when we feel safe in a secure attachment relationship.

Perhaps the most common form of mentalizing in therapeutic interactions is identifying and labeling feelings. Peter Fonagy and his colleagues introduced the concept of “mentalized affectivity” to refer to a skill we all need: the ability to mentalize emotionally, that is, to feel and think about feeling at the same time. Of course, this ability requires comfort and familiarity with your emotions. Thinking about our feelings while we are feeling them is essential to regulating and controlling our emotional states effectively, rather than doing something impulsively to shut off the emotions. Ideally, we learn to identify our emotional states and their various combinations (for example, feeling frightened of our anger); we learn to control their intensity and duration (either increasing or decreasing them); and we learn to express our feelings effectively to others and to ourselves. This is a tall order, and these are skills we develop and refine over a lifetime—not without help.

 

II. Mentalizing and Mental Illness  

Mentalizing is basic to our human nature, but we cannot always take it for granted. For example, owing to a failure of brain development, persons with autism do not develop the normal capacity to mentalize. Many autistic persons, because of their failure to connect with the minds of others, do not learn language. Even those with autism who are able to learn language may find other persons’ actions baffling. They remain out of step to a great degree. They lack the intuitive understanding of others that naturally guides social interactions.

The vast majority of us who are spared the ravages of autism develop the ability to mentalize—to understand ourselves and others both intuitively and through deliberate reasoning when we must sort out some confusing incident. Short of autism, our human brains are primed to develop these mentalizing capacities. Mentalizing is a skill and, like other skills such as athletic or musical ability, there are wide individual differences. As with other skills, the interplay of genetic makeup and environmental support will determine an individual’s level of ability. In particular, the development of this natural mentalizing capacity must be nourished and maintained by close and trusting human relationships—secure attachments.

Problems in relationships often contribute substantially to psychiatric disorders, and problems in mentalizing—interpreting our own behavior and the behavior of others—play a large role in this contribution. Although most of us develop considerable mentalizing capacity, we may not be able to use it freely or fully. At bottom, all psychiatric disorders involve persistent or intermittent misinterpretations that give rise to rigid, automatic, and maladaptive patterns of coping, feeling, and behaving.

 

Substance abuse  

Substance abuse is a clear example of failure to mentalize. At the extreme, addicted persons can be so preoccupied with obtaining the substance and getting high that they are oblivious to the impact of their actions on their own life or their relationships. They are flying blind. In this instance, the erosion of mentalizing can be an unwitting consequence of substance abuse. Of course, substances also can be used intentionally to avoid mentalizing, that is, as a deliberate effort to obliterate painful mental states.

Short of extreme addiction, however, we all struggle with impulses that are difficult to control—or perhaps we fail to struggle enough. A person in the throes of alcohol abuse may binge whenever he feels angry or resentful. A frustrating interaction with his boss generates the impulse to drink, and he goes from impulse to action, bypassing thought about what he is feeling and its relation to what he is doing. He may just feel an urge to drink, only dimly aware of the anger that evoked it. Unaware of his chronic problem with self-restraint, he may rationalize: “I’ll have just one.” Without self-awareness, there is little possibility of self-control.

To their frustration, others who are close to the alcoholic may understand him better than he understands himself. And they are also likely to be frustrated with his lack of attunement to the impact of his behavior on them. In this instance, the failure to mentalize applies to both self and others.

 

Depression  

Depression also erodes the ability to mentalize. Everything goes gray—or black. Captured by the depressed mood, the depressed person may lose sight of the impact of the depression on her thinking. She makes a mistake at work and thinks, “I’m a complete failure. I never do anything right. I’m worthless. What’s the point in living?” She cannot see past her depressed state, and she may not be able to remember times when she was not depressed. Her depression seems never-ending. She cannot appreciate that her extremely negative thinking is a reflection of her current state of mind. She does not question her beliefs but rather considers them to be the absolute truth. If she were able to mentalize, she could appreciate that her thoughts are based on her mood: “I’m depressed and that’s why everything seems so black today.”

Depression also interferes with a person’s capacity to mentalize in relationships. The depressed person, like anyone else who is ill and suffering, is likely to be self-preoccupied and disengaged. It takes energy and interest to interact and to be aware of others’ needs, feelings, and desires. We all desire to be mentalized by others with whom we are interacting. We want others to be aware of us: it’s painful to feel invisible. Thus the depressed person’s sense of isolation may be fueled by others’ tendencies to withdraw.

It is important to interrupt this cycle because, being unable to mentalize on her own, the depressed person needs the help of others. Other persons can see past her depression and help her to see past it as well. They can remind her, for example, that she has pulled out of depression before and can do so again. They can see what she cannot: she is in a depressed mental state, and that state can change.

 

Trauma  

Symptoms of posttraumatic stress disorder also illustrate the failure of mentalizing. Posttraumatic stress disorder seems a particularly cruel illness in the sense that the core symptom is reliving the trauma, for example, in the form of flashbacks or nightmares. Owing to the illness, the person not only has suffered through the experience of extremely stressful events but also, perhaps long afterwards, continues to reexperience these events in his mind. Reliving the trauma, it seems as if the memories—mental events—are real. Hearing the backfire, the Vietnam veteran literally dives for cover. Failing to mentalize, he has lost sight of the distinction between memory and current reality. Like the depressed person, he may need the help of others to mentalize—to become aware that he is safe in the present and that he is experiencing a posttraumatic flashback.

We all should be able to identify with the plight of the traumatized person. Just recall what it’s like to wake up after a nightmare: mentalizing again, we think gratefully, “It was just a dream.”

Trauma, and posttraumatic stress disorder in particular, is the most glaring example of problems with extreme emotional arousal--hyperarousal to put it technically. Like other mammals, we evolved to respond to threat and danger with the fight-flight-freeze response. This automatic reflex is adaptive: those who deliberated in the face of a charging tiger did not survive to pass on their genes. When physically threatened, you may need to run, not mentalize.

High levels of arousal tend to turn off the part of the brain that enables us to mentalize, the frontal cortex. Mentalizing and high arousal are in a reciprocal relationship: activating either one tends to deactivate the other. Persons who have a history of trauma may be quick to switch off mentalizing when their arousal increases. Learning to mentalize emotionally in the face of anxiety—if not a charging tiger—can help with emotional control.

 

Personality disorders  

Problems in mentalizing also are prominent in a broad category of psychiatric disorders termed personality disorders. We must approach the topic of personality disorders with great care, because this can be a pejorative label: being told you have a personality disorder can feel like being told you are a bad person. We need an understanding of personality disorders that is helpfully illuminating rather than condemning.

Although we tend to think of personality as a characteristic of the individual, personality characteristics come to light in interpersonal interactions. Most of us can identify personality characteristics that disrupt our relationships—easy irritability, needing too much reassurance, insensitivity, aloofness, and so forth. Personality disorders involve a persistent and recurrent pattern of problems in interpersonal relationships along with maladaptive patterns of thinking, feeling, and coping. Hence personality disorders reflect rigidity, and smooth interpersonal relationships require flexibility.

Exemplifying the problem of rigidity, many personality disorders involve exaggerations of normal personality traits. Examples include being unrealistically suspicious and distrusting (paranoid), highly fearful of rejection (avoidant), excessively dependent on others for reassurance and guidance (dependent), or extremely self-absorbed and feeling entitled to special treatment (narcissistic). Borderline personality disorder does not correspond to any single trait but involves emotionally intense and unstable relationships, often fueled by an intense fear of abandonment. Persons with borderline disorder also may show black-and-white thinking, evident in dramatic shifts in their perceptions of self and others, switching from all-good (idealized) to all-bad (devalued).

Mentalizing is essential to harmonious relationships, and problems in mentalizing play a significant role in personality disorders, which entail recurrent patterns of problems in relationships. Stable and fulfilling relationships require a balance of autonomy and connection as well as give and take. These relationships depend on a combination of self-awareness and awareness of other persons.

A particularly important facet of personality disorders is a failure to appreciate the impact of one’s actions on other persons, which depends on a combination of self-awareness and awareness of others. At worst, this involves treating others as objects rather than persons. Indeed, we believe that turning off mentalizing is crucial to mistreating others; conversely, mentalizing fosters compassion. To quote Iris Murdoch again: “The more the separateness and differentness of other people is realized, and the fact seen that another man has needs and wishes as demanding as one’ s own, the harder it becomes to treat a person as a thing.”

In many situations, gifted mentalizers will be highly successful in love and work, because both depend so much on interpersonal skill. Ironically, gifted mentalizers may also be at risk for psychiatric disorders. For example, mentalizing can be a burden when hypersensitivity to how you are seen by others leads to self-consciousness, anxiety, and shyness. A particularly problematic combination is this: genetic vulnerability to psychiatric disorders coupled with less than optimal environmental support. Psychiatric vulnerability may include proneness to anxiety or mood disorders. Inadequate environmental support may include emotional neglect or lack of parental responsiveness, sometimes resulting from the parents’ proneness to go into the fight-flight-freeze mode rather than mentalizing in relation to their children’s needs. At worst, in a traumatic situation, mentalizing can be frightening to the child: the parent’s animosity or indifference can be frightening, so the child avoids awareness of the parent’s state of mind.

In such adverse circumstances, the child can learn to inhibit mentalizing. Interactions in adulthood that remind the individual of earlier trauma, or the arousal of certain distressing feelings, serve as a trigger: mentalizing is inhibited. Then behavior becomes rigid. Rather than engaging flexibly in mutual understanding, relationships are undermined by coercive behavior that provides an illusion of control.

For example, one of us worked with a speech and hearing therapist who was extremely sensitive to subtle nuances in conversation. She had been at odds with her husband for a number of years, but she felt extremely insecure and terrified that he would leave her. She coped by remaining emotionally remote from him, and he had come to believe that she had little investment in the relationship. With great encouragement in her therapy, and with much trepidation, she managed to tell her husband in a planned telephone call that she cared for him a great deal and wished for greater closeness. Withher highly attuned ear for speech, she detected a split-second pause before he responded positively to her expressed need. She ignored the content of what he said, experiencing his barely perceptible hesitation as a rejection. She flew into a rage, demanding that he be more responsive and caring. Unable to mentalize, she became coercive. She heard rejection. She felt humiliated but could not tolerate her own emotion. She could not see the situation realistically. She could not consider, for example, that her husband may have been taken aback momentarily by her uncommonly open expression of need.

Rather than being an opportunity for a positive change in the relationship, the failure of mentalizing merely reinforced the old pattern. Her husband, having felt he responded positively, launched into a tirade of his own, feeling his efforts were never enough. His response only reinforced her original assumptions, and they both remained stuck.

This example illustrates the central processes—and the critical dilemma—facing persons with a personality disorder: Their adaptation to their particular history of adversity, to their unique biological and psychosocial vulnerabilities, as well as to their strengths and skills, consists of a special sensitivity to certain interpersonal situations and feeling states. These situations trigger a series of coping responses that entail inhibiting mentalizing and activating rigid, non-mentalizing patterns of behavior, often with an addictive quality. These patterns of rigid, nom-mentalizing behavior are directed toward two goals: first, they create an illusory sense of control and self-regulation; second, they evoke responses from others that sustain at least a semblance of attachment.

Examples of non-mentalizing or addictive patterns are anger and distancing evoked by feelings of vulnerability and bingeing on alcohol that is brought about by loneliness and depression. These patterns succeed in the limited sense that they evoke responses form others that reinforce the person’s maladaptive pattern. Thus such personality patterns tend to be self-reinforcing and self-perpetuating.

Perhaps most tragically, these patterns are typically intensified at times of crisis. When we feel stressed, we all do more of what we know how to do. Consequently, we are less able to respond adaptively to the crisis. Unfortunately, efforts to seek help in treatment relationships can run into the same problems, as the same patterns are likely to be played out.

The ultimate dilemma persons with personality disorders face is the following: however maladaptive, their coping strategies and relationship patterns have been essential to their emotional—and at times physical—survival, as well as to their identity and to their attachments. It is not easy to relinquish these strategies in exchange for uncertain rewards. Thus the process of gaining real mastery and control along with genuine attachments is fraught with immense anxiety and requires tremendous courage.

 


Mentalizing too much

 

One could argue that it is not a good thing to have too much money, but it’s hard to imagine that it’s not a good thing to have too much ability—intelligence, musical talent, or mentalizing capacity. But a gifted musician should not be practicing the piano eighteen hours a day. So too with mentalizing.

Although much of our therapeutic energy goes into fostering mentalizing, we also know that there can be too much of a good thing. There are two ways of coping with troubling mental states in oneself and others—trying not to think about them or being inordinately alert to them, continuously braced for danger.

Exquisite sensitivity to others’ mental states can leave you vulnerable to painful emotional contagion as well as to self-sacrificing efforts to rescue others from their pain. And too much mentalizing can lead to a life out of balance. True, as Socrates famously declared, the unexamined life is not worth living. But self-preoccupation goes too far in the other direction, and the overly-examined life also may not be worth living. Although we can do nothing without it, there is more to life than the human mind. Sometimes we just need to plant flowers or mow the lawn.

And being able to turn off mentalizing is crucial to some interpersonal situations. The dentist who is too attuned to the pain of drilling may be distracted from his task, which ultimately relieves more pain. The executive who must downsize a corporation for the sake of its survival must set aside mentalizing for a time to get the task done—too much empathy can be paralyzing.

 

 

III. Treatment Promotes Mentalizing  

We think of psychiatric treatment as providing developmental help when development has gotten stuck. Serious psychiatric disorders are ways of being stuck in repetitive patterns that are self-perpetuating. As we described earlier, substance abuse, depression, posttraumatic stress, and personality disorders illustrate problems with mentalizing, and all these disorders demonstrate inflexibility. All these disorders, however, are also adaptations—ways of solving problems. Change always brings anxiety, because anxiety is fundamentally a response to novelty and the unknown. Not surprisingly, persons with psychiatric disorders often cannot get themselves unstuck on their own—they need help. For all of us, with adequate help, it becomes possible to do what we cannot do on our own.

Our capacity to mentalize provides flexibility by allowing us to see ourselves and others from a fresh perspective. When we cannot mentalize flexibly, we need others to help us see things from different perspectives. Think of the child freely exploring the toys in the playroom. We need the same freedom to explore our mind and the minds of others. But this exploration can be frightening as well as enticing, and we may need help to do it. We need the same climate that enables children to explore calmly and confidently: a sense of security and safety. If we are to explore our mind in the mind of another person, it is essential that the other person be accepting, interested, and empathic. And we can hardly feel safe in exploring the mind of another when the other is in a state of fear or rage.

Persons with psychiatric disorders frequently have troubled relationships. Emotionally stormy or conflict-ridden relationships are not conducive to mentalizing, which requires a climate of safety and trust. Sometimes that climate of safety can best be found in treatment settings that are designed to foster and maintain it.

In addition, we believe that positive emotions—interest, enthusiasm, joyfulness, and compassion—promote mentalizing. Positive emotions tend to broaden our attention and awareness, in contrast to emotions such as fear and anger, which tend to narrow our attention. Thus, in positive emotional states, our thinking is more flexible and creative. Plainly, psychiatric symptoms and disorders—anxiety and depression, for example—erode our capacity for positive emotion. Hence treatment interventions that restore the capacity for positive emotional states, often in the context of promoting a sense of connection with other persons, will also facilitate mentalizing.

Treatment is designed to promote mentalizing from the point of admission, beginning with the initial assessment. Mentalizing is a skill and, like any other skill, mentalizing requires practice. A number of different treatment interventions, such as various therapies and the inpatient milieu, provide ample opportunities to practice mentalizing in a range of different relationships. In turn, the mentalizing capacities developed through such treatment interventions can put patients in a better position to work on troubled relationships outside the treatment setting, providing their significant others are willing to do so as well. Thus discharge planning is intended to set a platform for the generalization of the skills honed in treatment to the key relationships in life outside treatment.

Consistent with our focus on mentalizing, four broad treatment objectives in the Professionals in Crisis program are as follows:

 

1.
                 to interrupt the vicious cycles and addictive patterns that reinforce and exacerbate maladjustment;

2.
                
to provide pharmacological, psychotherapeutic, and psychoeducational interventions targeting specific psychiatric disorders such as depression, or bipolar disorder, posttraumatic stress disorder, other anxiety disorders, and addictions;

3.
                
to promote and practice mentalizing generally and, in particular, in the context of the specific interpersonal situations and feelings states in which it becomes inhibited; and

4.
                
to initiate virtuous cycles based on mentalizing in therapeutic and family relationships such that individuals who have previously been stuck and incapable of using treatment are able to take advantage of treatment in their community and to benefit from the support afforded by their normal social relationships.

 

Achieving these objectives begins by inviting patients and their family members to form collaborative relationships with members of the treatment team. Mentalizing unfolds only in the give-and-take of reciprocal relationships and is undermined in coercive interactions. When we become engaged in mentalizing, our problems are more amenable to change because of our enhanced ability to use other people’s support. Engaged in mentalizing, patients are in a better position to make choices regarding the ways they use treatment, relate to others, cope with stress, and deal with adversity, challenge, and vulnerability.

The treatment plan for each individual will differ and involve different combinations of individual and group interventions and pharmacotherapy. Yet, all interventions have three aims in common: first, to enhance mentalizing and the sense of agency and choice; second, to strengthen control and capacity for self-regulation; and third, to promote awareness of one’s own and other persons’ mental states.

 

Initial assessment  

Treatment begins with a comprehensive assessment, conducted by members of different professional disciplines, including psychiatry, psychology, social work, nursing, addictions counselors, activities therapists, and rehabilitation specialists. This assessment is intended to reveal significant areas of strength as well as difficulty. In particular, the assessment will be directed toward clarifying the psychiatric disorders and interpersonal contexts or triggers that interfere with the process of mentalizing.

From the start, the assessment process calls on mentalizing—making sense of difficulties in the context of a relationship. The process of mentalizing is going well when patients feel felt, having a sense that their clinician has their mind in mind. Mentalizing is built around communication—not just in words but also in feelings as communicated in facial expression and body posture. Although mentalizing is mainly intuitive, assessment and treatment revolves around putting these intuitions into words. The process is one of dialogue, where mentalizing involves making oneself understood. Clinicians invite patients to join in mentalizing with an invitation like, “If I am hearing you correctly, what you are telling me is….” Plainly, this kind of assessment continues throughout treatment, and all treatment interventions depend on this process of mutual understanding.

 

Rounds  

In rounds, patients and their treatment team members convene to coordinate the treatment process. We consider rounds to be a mentalizing extravaganza. Several individuals are engaged in the process of mentalizing, each from a different perspective. The essence of mentalizing is viewing actions from multiple perspectives, in effect, playing with different possibilities in arriving at a shared understanding. Rounds provides an opportunity for understanding and misunderstanding. Misunderstandings provide a golden opportunity for mentalizing, much of which involves reconciling different perspectives and viewpoints. The goal is not to arrive at the correct understanding but rather to learn to engage in the process of mutual understanding.

 

Psychoeducation  

We participate in formal education beginning in childhood, with most of this education centered upon academic skills and preparation for employment and careers. We also are exposed to some education for other life skills—driver’s education and sex education, for example. We also need to be educated about our physical health, for example, understanding something about proper nutrition. And when we develop a major physical illness, we need to understand the illness and its treatment. If you have a heart attack, you must learn about medication, diet, and optimal activity levels.

Similarly, education plays a major role in psychiatric treatment. Ideally, patients should know their diagnoses, understand their illness, and be informed about treatment options. Understanding mental illness entails mentalizing—making sense of mental experience. The term, mental illness, highlights a problem with mentalizing. Something has gone awry with the mind, and we need to understand it. These illnesses are often frightening and baffling, leaving patients feeling out of control of their mental states. When experience doesn’t make sense, they may feel “crazy.” Just understanding these various illnesses—although it is no small feat—can provide a greater sense of control. Knowing that you are having a panic attack and not a heart attack is mentalizing, and this knowledge is crucial in learning to cope.

And it is crucial not just to understand illness but also to understand treatment. As this article attests, we believe that understanding the process of mentalizing provides an orientation to the various treatment interventions we offer.

  Individual, group, and family therapy  

Individual psychotherapy is perhaps the best analogue of a secure attachment relationship that has the potential to foster mentalizing. Much of psychotherapy is devoted to exploring thoughts, feelings, needs, desires, and conflicts. And psychotherapy will be conducive to this exploration only to the extent that it provides a safe relationship climate. Of course, trust in a psychotherapy relationship, like any other relationship, cannot be taken for granted. Plainly, many persons seek psychotherapy because of problems with trust, and there is no reason to believe that the therapist automatically will be exempt from distrust. For many persons, needed trust emerges only gradually, based on positive experience. And trust will evolve largely to the extent that the climate is conducive to mentalizing, which is the foundation of feeling understood and accepted. Feeling understood stems from the experience of another person having your mind in mind, and much of this goes beyond words. When all goes well, we feel felt.

We might think of therapists and other clinicians as providing social biofeedback. In the process, patients may become aware of previously unrecognized emotions, needs, and conflicts. They may recognize the meaning behind certain states or actions. For example, they might recognize that feeling suicidal expresses some unmet need or unacknowledged feeling.

Group psychotherapy also mirrors earlier developmental opportunities by providing a social network that is potentially conducive to mentalizing. In groups, the opportunities to explore one’s own mind and the mind of others are unparalleled. Group psychotherapy provides an especially rich opportunity to appreciate the impact of one’s behavior on others, which combines self-awareness with awareness of others. Just as we know with individual relationships, however, a group will be conducive to open exploration only to the extent that the group provides a safe and accepting climate. A cohesive group provides a sense of belonging that supports such exploration.

Marital and family therapy provide a unique opportunity to foster mentalizing in relationships with family members—an arena where mentalizing may be especially challenging but also especially crucial. Family therapists universally emphasize the importance of open communication. Ideally, each family member is able to express what is on his or her mind, and other family members are open to listening. Often, we mentalize in relation to our own mind by expressing ourselves; we know what we think only after we’ve said it. And we mentalize others by listening. We achieve mutual understanding through dialogue. The process is the same in individual, group, or family therapy. But the impediments to mentalizing are often most conspicuous in family relationships, and marital and family therapy may provide the best opportunity to facilitate this process. Anxiety, which is a common impediment to mentalizing, is often at its peak in interactions with family members. Intense feelings can escalate rapidly in all family members, resulting in more heat than light. The clinician can serve as a mediator, fostering the process of mentalizing in all family members. And the clinician can also serve as a model of mentalizing in the face of intense emotions. Learning to mentalize emotionally in the context of family interactions provides the most direct opportunity to generalize what is learned in treatment to life after treatment.

 

Addiction treatment and support groups  

Addictions are procedural, automatic patterns of behavior that involve psychological dependence, often along with physiological dependence. It is important to appreciate that addictive patterns can be modified only on the basis of an unequivocal commitment to stop using: one must first “walk the walk,” which requires actions that confront the secretiveness, denial, and self-deception that result from and reinforce all addictive disorders. Thus the Professionals in Crisis program expects patients to agree to stop using and encourages them to attend community support groups such as twelve-step groups. These groups offer support for the commitment to sobriety and call for acceptance of helplessness in controlling addictive patterns. These are crucial steps toward maintaining sobriety and achieving real mastery.

 

Milieu treatment  

Although group therapy is a primary forum for interpersonal learning, group living more generally expands these opportunities enormously by providing innumerable informal interactions and relationships. For example, running into conflicts with others is inevitable in a close living situation. Yet a climate conducive to discussing these conflicts, receiving feedback, and resolving them where possible provides unique opportunities for mentalizing. And developing close relationships with persons of similar backgrounds and in similar straits provides unparalleled opportunities for mutual understanding.

Although opportunities to mentalize abound in the milieu, the potential for interpersonal and psychological problems in which patients need help with mentalizing also abound, day and night. It is helpful to explore these problems in scheduled therapies and groups, but many problems are best dealt with on the spot. Members of the nursing staff play a key role in fostering mentalizing throughout the day and throughout treatment.

 

Medication  

Taking psychiatric medication may seem far afield from mentalizing, but it is often crucially helpful. Mentalizing is the most complex form of reasoning we engage in. In fact, recent evolutionary theory proposes that our complex brain, and the neocortex in particular, evolved because of the sheer complexity of having to make sense of each other and our relationships. To mentalize, we need to be able to think straight. And, as we all know from personal experience, we can’t think straight when we’re highly distressed. Complex problem solving is impossible under those conditions. Thus we need to be relatively calm to mentalize. Plainly, problems with mood, anxiety, and thought processes will interfere with all manner of thinking, mentalizing included. Psychiatric medications are often helpful in regulating mood, anxiety, and thought processes, hence may be crucial in facilitating mentalizing.

 

Discharge planning and wellness


 

We have emphasized throughout that mentalizing is a skill to be practiced. We aim to structure treatment so as to provide a climate conducive to practice. As we have described, mentalizing promotes resilience, the capacity to cope with adversity and challenges.

To a great extent, discharge planning entails preparation for implementing the skills learned in treatment after discharge. This entails using the capacities for self-understanding, understanding others, and establishing the kinds of relationships—more secure attachments—in which mentalizing can flourish. Discharge planning also involves ensuring that needed treatment supports to facilitate this ongoing use of skills is in place.

 

The therapeutic bargain


 

In all individual and group interventions, we aspire to appreciate the adaptive functions served by even the most seemingly destructive patterns of addictive and non-mentalizing behaviors, These behavioral patterns provide momentary relief and an illusory sense of control, safety, and attachment. The choice to attempt to relinquish these patterns of behavior—the choice, for example, to stop responding automatically to feelings of vulnerability with rage or the choice to make a commitment to sobriety—is naturally fraught with uncertainty and anxiety. These are difficult choices to make, particularly for persons who have based their identity, relationships, and adaptation on the selective inhibition of mentalizing as a way to remain unaware of their own vulnerabilities. The treatment program recognizes that, as much as patients wish to change, they are also reluctant to give up patterns of coping and relating that are familiar and have been effective in providing them with a sense of safety, control, and human connection—notwithstanding how much pain and maladjustment they have caused.

Treatment can free patients to examine the price they pay for relying on addictive and non-mentalizing patterns of coping and relating. Such self-examination lets patients struggle with the therapeutic bargain at the heart of the treatment process: the laborious process replacing illusions of control and connection based on addictive and non-mentalizing patterns with real mastery and genuine attachments.

 

Coda: Mentalizing and Insight


 

In focusing on mentalizing, we are emphasizing the cultivation of a skill—skill in understanding yourself and others. We place more importance on using the skill than on attaining any particular understanding or insight. Making sense of ourselves is a lifelong process, and our autobiography is always a work in progress. We are not seeking the answer. Rather, we are hoping to foster the capacity to explore freely in search of ever-changing answers. Perhaps more importantly, we are hoping to foster the capacity for mutuality—meeting of minds—that both stems from secure attachments and makes secure attachments possible. Then development becomes unstuck, and a future direction opens up. Choice and a sense of agency gradually take the place of feeling at the mercy of illness.

  Bibliography  


Allen, J.G. (2003). Mentalizing. Bulletin of the Menninger Clinic, 67, 91-112.

Allen, J.G. (2001). Traumatic relationships and serious mental disorders. Chichester, UK: Wiley.

Bleiberg, E. (2003). Treating professionals in crisis: A framework based on promoting mentalizing. Bulletin of the Menninger Clinic, 67, 212-226.

Bleiberg, E. (2001). Treating personality disorders in children and adolescents: A relational approach. New York: Guilford.

Fonagy, P., Gergely, G., Jurist, E., and Target, M. (2002). Affect regulation, mentalization and the development of the self. New York: Other Press.

Gergely, G. and Watson, J.S. (1996). The social biofeedback theory of parental affect-mirroring: The development of emotional self-awareness and self-control in infancy. International Journal of Psycho-Analysis, 77, 1181-1212.

Murdoch, I. (1971). The sovereignty of good. London: Routledge.



Copyright © 2006 The Menninger Clinic


We're very grateful to The Menninger Clinic for their permission to include this feature. The Menninger Clinic website includes the inspiring history of the Clinic's founders, the eponymous Menninger trio of father and two sons, and it's pivotal role in the development of actvely therapeutic psychiatric hospitals in the US.

www.menningerclinic.com

The Handbook of Mentalization-Based Treatment by Jon G. Allen, Peter Fonagy Interesting chapters on using mentalising within other psychological approaches including Dialectical Behavioral Therapy, with anti-bullying and parenting programmes and to bolster resilience.
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