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Mentalizing as Common Ground for Psychotherapy:
Educating Patients and Clinicians
Mentalizing as Common Ground for Psychotherapy:
Educating Patients and Clinicians
Jon G. Allen, Ph.D.
The Menninger ClinicBaylor College of Medicine
Jon G. Allen, Ph.D.
The Menninger ClinicBaylor College of Medicine
Collaboration
Colleagues Peter Fonagy, Mary Target & Anthony Bateman;
Efrain Bleiberg, Pasco Fearon, Toby Haslam-Hopwood, Elliot Jurist, George Gergely, Jeremy Holmes, Linda Mayes, Richard Munich, Lois Sadler, John Sargent, Carla Sharp, Arietta Slade, Helen Stein, Stuart Twemlow, Laurel Williams
Consortium University College London, Anna Freud Centre, Yale
Child Study Center, The Menninger Clinic, Human Neuroimaging Laboratory at Baylor College of Medicine
Books
Fonagy, Gergely, Jurist & Target (2002). Affect regulation, mentalizing, and the development of the self. New York: Other Press.
Bateman & Fonagy (2004). Psychotherapy for borderline personality disorder: Mentalization-Based Treatment. New York: Oxford University Press.
Bateman & Fonagy (2006). Mentalization-Based Treatment for borderline personality disorder: A practical guide. New York: Oxford University Press.
Allen & Fonagy, Eds. (2006). Handbook of Mentalization-Based Treatment. Chichester, UK: John Wiley & Sons.
Allen, Fonagy, & Bateman (2008). Mentalizing in clinical practice. Washington, DC: American Psychiatric Publishing.
Definitions of “mentalizing”
mentalizing is a form of imaginative mental activity, namely, perceiving and interpreting human behavior as conjoined with intentional mental states (e.g., needs, desires, feelings, beliefs, goals, purposes, and reasons)
Shorthand• attending to mental states in self and others• holding mind in mind• holding heart and mind in heart and mind• mindfulness of mind• understanding misunderstandings
Part I
Mentalizing as a common factor in psychotherapeutic treatment
A capsule history of “mentalizing”
First recorded use of the word, 1807First appeared in Oxford English Dictionary, 1906
give a mental quality to; picture in the mind;cultivate mentally
Used in French psychoanalytic literature in late 1960sEmployed in understanding autism in 1989 (Morton)Employed in understanding developmental
psychopathology in 1989 (Fonagy) and extended to treatment of BPD (Bateman & Fonagy)
Advocated as a common factor in psychotherapeutic treatment (Allen, Fonagy & Bateman)
What is the therapeutic alliance if not an attachment bond?
—Jeremy Holmes (2001): The search for the secure base
Much, if not all, of the effectiveness of different forms of psychotherapy may be due to those features that all have in common rather than those that distinguish them from each other.
—Jerome Frank (1961): Persuasion and healing
In advocating mentalization-based treatment we claim no innovation. On the contrary, mentalization-based treatment is the least novel therapeutic approach imaginable. —Allen & Fonagy, Handbook of Mentalization-Based Treatment
Mentalizing is the most fundamental common factor among psychotherapeutic treatments…perforce, clinicians mentalize in conducting psychotherapies and also engage their patients in doing so. —Allen, Fonagy, & Bateman, Mentalizing in Clinical Practice
mentalizing, even if not always explicit in our language, is implicit in many forms of psychotherapy…Allen and colleagues, of course, have already said this, when they suggest: “You’re already doing it.” And indeed we are, if we’re doing our job.
—Oldham (2008), Epilogue to Mentalizing in Clinical Practice
Two broad questions
What is distinctive about mentalizing?as a treatment approach?as a concept?
What’s all the fuss about?
Plakun’s Y model: Generic and specific facets
Plakun’s Y model: Generic and specific facets
psychodynamic
psychodynamic
cognitive-behavioralcognitive-behavioral
mentalizingmentalizing
Treatments for BPD
Implication: extensive overlap between MBT and other treatment approaches to BPD
Implication: extensive overlap between MBT and other treatment approaches to BPD
relatively single-minded focus on mentalizing process: consistency;
a style of psychotherapy
relatively single-minded focus on mentalizing process: consistency;
a style of psychotherapy
Mentalizing: Generic and specific facets
Mentalizing Focus in Psychotherapy
mentalizing
metacognitive approaches
Third-Generation Cognitive-Behavioral
Therapies
Acceptance and Commitment Therapy (ACT)mindfulness practice
The Menninger Clinic: Historical ContextLong-term psychoanalytically oriented hospital treatment
throughout most of its history in Topeka, KansasGradual reductions in hospital stays coupled with
increasing array of partial-hospital and outpatient services
Increasing theoretical eclecticism (e.g., CBT, DBT, psychoeducational approaches)
Downsizing to specialty inpatient treatment programs with 4-8 week lengths of stay
Relocation to Houston, Texas to partner with Baylor College of Medicine
Jump-starting treatment for treatment-resistant patients
Developing the “common factor” approach to mentalizing at The Menninger ClinicWide range of disorders beyond BPD: depression, anxiety,
trauma, substance abuse, other PDsProfessionals in Crisis program emphasizes mentalizing; initiated
psychoeducational interventionClinicians’ resistance to “mentalizing”
sounds foreignalready know it all
Increasing desire for conceptual coherence in a psychotherapeutic culture (integrative function)
Belatedly educating clinicians after educating patientsMentalization-Based Adolescent Treatment Program developed in
consultation with Peter Fonagy, Mary Target, & Anthony Bateman
Complaints
“Mentalization” has an intellectualizing and potentially dehumanizing ring to it and must be humanized: We must keep in mind that the mental states
perceived and the process of perception are suffused with emotion; mentalizing is a form of emotional knowing
A grammatical preference for the verb (or gerund) emphasizes agency, activity, and process; mentalizing is mental action; something we do Aspiring to render “mentalizing” an everyday
word rather than a technical concept
New words
The word in language is half someone else’s. It becomes ‘one’s own’ only when the speaker populates it with his own
intention….many words stubbornly resist, others remain alien, sound foreign in the mouth of the one who
appropriated them and who now speaks them…Language is populated—overpopulated—with the intentions of others.
Expropriating it, forcing it to submit to one’s own intentions and accents, is a difficult and complicated process.
—Wertsch: Mind as action
Mentalizing emotion (“mentalized affectivity”)Mentalizing• transforming non-mental into mental• mentally elaborating primitively mental experienceEmotion includes much that is potentially non-mentalized• non-conscious cognitive appraisals• physiological arousal• action tendencies and motoric activation• expressive motor behavior
Emotion (affect) is mentalized when felt Mental elaboration includes understanding and attributing meaning to
feelings, which includes continuous conscious cognitive appraisals and reappraisals
Mentalizing in the midst of emotion
Mentalizing while remaining in the emotional state1. identifying feelings• labeling basic emotions• awareness of conflicting emotions
• attributing meaning to emotions (narrative)2. modulating emotion• downward and upward
3. expressing emotion• outwardly and inwardly
Two impairments of mentalizing (besides misuse):too little or too much imaginativeness
concreteness, indifference, aversion
grounded imagination
imagination gone wild (paranoia)
nonmentalizingdistorted
mentalizingmentalizing
mindblindness
excrementalizing
Overlapping concepts (hairsplitting)
mindblindness: antithesis of mentalizing; employed originally to characterize autism
mindreading: applies to others and focuses on cognitiontheory of mind: conceptual framework for mentalizing, focuses on cognitive
developmentmetacognition: focuses primarily on cognition in the selfdecentering: observe one’s thoughts/feelings as events in mindreflective functioning: measurement of mentalizing in attachment contextmindfulness: focuses on present and not limited to mental statesempathy: focuses on others and emphasizes emotional statesemotional intelligence: pertains to mentalizing emotion in self and otherspsychological mindedness: broadly defined, the disposition to mentalizeinsight: mental content that is the product of the mentalizing process
Mentalizing as an umbrella termFull range of mental statesSelf and othersImplicit (intuitive) and explicit (deliberate) processesVarying time frame
presentpastfuture
Varying scopenarrow (e.g., feeling at the moment)broad (e.g., autobiographical narrative)
Criticisms of “mentalizing”
Choi-Kain & Gunderson (Am J Psychiatry, in press)• The concept is broad and multidimensional• The core measure, the Reflective Functioning Scale, yields only a single
score, is time-consuming and costly, and has limited research• Research should focus on more limited-domain concepts for which (primarily
self-report) measures have been developed (e.g., theory of mind, mindfulness, psychological mindedness, empathy, affect consciousness)
Semerari, Dimaggio et al., Metacognitive Assessment Scale• Separates self and others• Differentiates four facets
Identifying mental states Differentiating subjective from objective (mental states as representational) Relating mental states to each other and behavior Integrating metacognitive knowledge into abstract narratives
Limitations of emphasizing process over content
Mentalizing: links to other domains of knowledge
ATTACHMENT
EVOLUTIONARY BIOLOGY
PSYCHOANALYSIS
NEUROBIOLOGY
MENTALIZING
THEORY OF MIND
PHILOSOPHYphilosophy of mind
ethics
Mentalizing: links to other domains of knowledge
EVOLUTIONARY BIOLOGY
THEORY OF MIND
PHILOSOPHY
PSYCHOANALYSIS
NEUROBIOLOGY
MENTALIZING
philosophy of mind
ethics
Part II
Attachment trauma and impaired mentalizing:A focus for psychotherapy
Trauma spectrum
Attachment trauma: Two senses
Trauma that occurs in an attachment relationship, in childhood or adulthood
Trauma that adversely affects the capacity for secure attachment—the bane of the therapeutic relationship
Dual liability associated with attachment trauma in childhood (Fonagy & Target)
provokes extreme, repeated stress undermines the development of the capacity to
regulate distress§ insecure (disorganized) attachment
§ impaired mentalizing capacity
§ impaired self-regulation
Intergenerational transmission of mentalizing
A mother’s capacity to hold in her own mind a representation of her child as having feelings, desires, and intentions allows the child to discover his own internal experience via his mother’s representation of it; this representation takes place in different ways at different stages of the child’s development and of the mother-child interaction. It is the mother’s observations of the moment to moment changes in the child’s mental state, and her representation of these first in gesture and action, and later in words and play, that is at the heart of sensitive caregiving, and is crucial to the child’s ultimately developing mentalizing capacities of his own [Slade, 2005]
Intergenerational transmission of mentalizing
mentalizing [is] the mechanism by which (1) the mother-child relationship exerts its influence on the attachment security of the child and (2) the mother-child relationship influences the child’s socio-cognitive development…secure attachment is fostered through accurate and appropriate parental mentalizing of the child, which in turn positively stimulates the development of the mentalizing capacity of the child. As a result, the mentalizing child is able to form a secure attachment to the parent…The parent’s capacity to engage in accurate and appropriate mentalizing may be disrupted by a variety of child characteristics, most notably temperament. The process by which secure attachment is fostered via accurate and appropriate parental mentalizing is therefore likely to be bidirectional. (Sharp & Fonagy, 2008, Social Development)
High parental reflective functioning (mentalizing)
Sometimes she gets frustrated and angry (child mental state) in ways I’m not sure I understand (opacity of child’s mental state). She points to one thing and I hand it to her but it turns out that's not really what she wanted (opacity). It feels very confusing to me (mother's mental state) when I’m not sure how she’s feeing (opacity of child's mental state) especially when she’s upset. Sometimes she’ll want to do something and I won’t let her because it’s dangerous and so she'll get angry (mother recognizes diversity of mother and child mental states). (Slade, 2005)
Model of intergenerational transmission and developmental psychopathology
psychosocial functioning
emotion regulation
child mentalizing
parental mentalizing
of child
child attachment
securityparental attachment
security
parental mentalizing in
relation to childhood
attachment
adapted from Sharp & Fonagy (2008) Social Development
Intergenerational transmission of trauma
Disturbed and abusive parents obliterate their children’s experience with their own rage, hatred, fear, and malevolence. The child (and his mental
states) is not seen for who he is, but in light of the parents’ projections and distortions. The infant
then takes on the parent’s hatred and aggression, a primitive form of identification with the aggressor
[Slade 2005]
“Trauma” broadly construed
AFRAID
unbearable emotional
states
++
ALONE
absence of experience of
being mentalized
feeling abandoned neglected,
unloved, invisible
IMPAIRED IMPAIRED MENTALIZINMENTALIZING CAPACITYG CAPACITY
Mentalizing failure in traumatizing behavior
AFRAID
unbearable emotional
states
+
ALONE
absence of experience of
being mentalized
feeling abandoned neglected,
unloved, invisible
IMPAIRED IMPAIRED MENTALIZINMENTALIZING CAPACITYG CAPACITY
mindblindterrorizing
traumatizer
Non-mentalizing modes of experience
psychic equivalence: world=mind; mental representations are not distinguished from the external reality that they represent, such that mental states are experienced as real, as in dreams, flashbacks, and paranoid delusions. [clinical example: “dead”]
pretend: mental states are separated from reality but maintain a sense of unreality inasmuch as they are not linked to or anchored in reality
teleological: an action-oriented mode in which mental states such as needs and emotions are expressed in action; only actions and their tangible effects—not words—count.
mentalized: actions are understood in conjunction with mental states (as contrasted to the teleological mode), and mental states have neither an exaggerated sense of reality nor unreality but rather are appreciated as representing multiple perspectives on reality (as contrasted with the psychic equivalence and pretend modes).
PTSD and psychic equivalence
psychic equivalence
mind represents
world
REEXPERIENCING flashbacks & nightmares
mind=world
mentalizing
REMEMBERING as painful
experience
The pretend mode: bullshitting
This is the crux of the distinction between [the bullshitter] and the liar. Both he and the liar represent themselves falsely as endeavouring to communicate the truth. The success of each depends upon deceiving us about that. But the fact about himself that the liar hides is that he is attempting to lead us away from a correct apprehension of reality; we are not to know that he wants us to believe something he supposes to be false. The fact about himself that the bullshitter hides, on the other hand, is that the truth-values of his statements are of no central interest to him; what we are not to understand is that his intention is neither to report the truth nor to conceal it. This does not mean that his speech is anarchically impulsive, but that the motive guiding and controlling it is unconcerned with how the things about which he speaks truly are.
Frankfurt: On Bullshit
An ironic mentalizing perspective on self-knowledge
There is nothing in theory, and certainly nothing in experience, to support the extraordinary judgment that it is the truth about himself that is easiest for a person to know. Facts about ourselves are not peculiarly solid and resistant to skeptical dissolution. Our natures are, indeed, elusively insubstantial--notoriously less stable and less inherent than the natures of other things. And insofar as this is the case, sincerity itself is bullshit.
Frankfurt: On Bullshit
Applications to BPD
Persons with BPD often mentalize adequately but are highly vulnerable to losing mentalizing, especially when attachment needs are activated in the context of insecure attachments (e.g., distrust; threat of loss or betrayal)
frantic responses to perceived abandonment can be construed as posttraumatic reexperiencing of painful emotional states in the context of non-mentalizing attachment relationships
the core “trauma” in BPD might be the failure to develop robust mentalizing capacities stemming from relative deficiency of mentalizing in early attachment relationships (with or without abuse)
this trauma is associated with impaired affect regulation and impaired social cognition, especially in attachment contexts (i.e., when attachment needs are evoked), including in psychotherapy relationships, which have the potential to undermine mentalizing if too stimulating
Mentalization-Based Therapy for BPDBateman & Fonagy, American Journal of Psychiatry, 2008
Effectiveness of MBT Day Hospital vs. Treatment as Usual• 8-year follow-up (5 years post-termination of MBT)• 23% versus 74% of patients made suicide attempts• fewer ER visits and hospital days; less medication use• 13% versus 87% met criteria for BPD at end of follow-up• Significant differences in impulsivity and interpersonal functioning
(including marked improvement in intense-unstable relationships and frantic efforts to avoid abandonment)
• three times longer periods of good vocational functioning
Minding the Baby: Sadler, Slade, & Mayes
High-risk, first-time inner city parents and infantsExtends from pregnancy to child’s second birthdayNurse home visitationInfant-parent psychotherapy
promote mother’s mentalizing re: the self (e.g., verbalizing feelings about pregnancy)promote mother’s mentalizing re: the infant (e.g., speaking for the infant)
Mentalization-Based Adolescent Treatment Program:Efrain Bleiberg, Laurel Williams, Carla Sharp
Develop assessment and treatment for emerging personality disorder
Assessment• Diagnoses• Mentalizing capacity• Executive and cognitive functioning• Trauma history• Emotion regulation and risky behaviors• Family functioning (parenting style, attachment, mentalizing)
Part III
Promoting an alliance through psychoeducation
Psychoeducational ApproachPurposes
• promote a therapeutic alliance• draw patients’ attention to a natural process
Curriculum• understanding mentalizing and its development• psychiatric disorders and mentalizing impairments• how treatment modalities promote mentalizing• mentalizing exercises (projective, metaphors, role-playing, etc.)
Incorporating “mentalizing” into other psychoeducational groups• Coping with trauma• Coping with depression
Articles for patients and family membersAllen, Bleiberg, & Haslam-Hopwood (2003). Mentalizing as a compass for treatment.Allen, Fonagy, Bateman (2008). What is mentalizing and why do it? (Appendix in Mentalizing
in clinical practice)
Broad scope of mentalizing
othersothers
feelingsfeelingsthoughtsthoughts
selfself
empathyempathy
Holding mind in mind
Holding mind in mind in emotional states
Part IV
Cultivating mentalizing in psychotherapy:Mentalizing begets mentalizing
what good therapists do with their patients is analogous to what successful parents do with their children
—Jeremy Holmes (2001): The search for the secure base
Mentalizing as the engine of attachment: Therapist’s contribution (in caregiving role)
Fostering an attachment relationship; emotional proximity Attentiveness to distress (empathy, attunement, responsiveness) “Marked” emotional responsiveness: representing the patient’s emotion to
the patient rather than becoming fully immersed in it Emotional self-awareness and self-regulation Providing support, encouragement and help while appraising and
respecting the patient’s competence and autonomy Questioning and challenging the patient’s perspective while providing
alternative perspectives Understanding how attachment patterns are reenacted from childhood to
adulthood and in the transference with the caveat that process (mentalizing capacity) is emphasized over content (specific insights)
Note parallels to a secure base in supervision
Core mentalizing competencies for therapists (and patients)
Affective competence (Diana Fosha) How affect is handled relationally The capacity to feel and deal while relating Neither overwhelmed nor hostile to emotion in patient or self Requires affect tolerance and affect regulation Allows therapist to provide an affect-facilitating environment Note: entails “mentalized affectivity” or mentalizing emotion
Narrative competence (Jeremy Holmes) Psychological equivalent of immunological competence Collaborative and coherent discourse (e.g., as in secure/autonomous AAI
narratives) Balancing prose and poetry, stories and images Evident in story telling, story listening, story-understanding; story making and
story breaking
Secure attachment is marked by coherent stories that convince and hang together, where detail and overall plot are congruent, and where the teller is not so detached that affect is absent, is not dissociated from the content of her story, nor is so overwhelmed that her feelings flow formlessly into every crevice of the dialogue. Insecure attachment, by contrast, is characterized either by stories that are over-elaborated and enmeshed, or by dismissive, poorly fleshed-out accounts…[there are] three prototypical pathologies of narrative capacity: clinging to rigid stories, being overwhelmed by unstoried experience, or being unable to find a narrative strong enough to contain traumatic pain.
—Jeremy Holmes (2001): The search for the secure base
Narrative competence
Our Humanity: The art of mentalizing
Appeal to special abilities of analysts must not violate the following principle: It must be possible to show that the claimed capacities are refinements of ordinary human capacities, and it must be made plausible why under specified circumstances such refinement can actually occur. This can be called the continuum principle, because it postulates that the abilities claimed for analysts must be on a continuum with ordinary human abilities.
—Carlo Strenger Between hermeneutics and science: An essay on the epistemology of psychoanalysis
Mentalizing as the engine of attachment: patient contribution to attachment relationships
Selection of attachment figures and appraisal of trustworthiness Self-awareness regarding needs and feelings Expression of emotional distress (affective competence) and context
(narrative competence); associated emotion-regulation skills Appraisal of the attachment figure’s receptiveness, attunement,
responsiveness (i.e., the caregiver’s mentalizing) Appraisal of the effectiveness of strategies to influence the caregiver’s
responsiveness Ability to manage conflicts, understand misunderstandings, and repair
ruptures Correcting and updating mental representations of self and others (internal
working models) Reciprocating caregiving
Mentalizing in maintaining an internalized secure base
Jeremy Holmes: “the secure base can be seen not just as an eternal figure, but also as a representation of security within the individual psyche”
Activating mental representations and memories of secure attachment experiences
Relating to oneself in an empathic manner, for example, protective, encouraging, reassuring, accepting, compassionate, approving (mentalizing stance)
Engaging in comforting and self-soothing activities
Parallel contributions to mentalizing: Meeting of minds in therapy
A patient’s perspective on Bowlby
John Bowlby: the role of the psychotherapist is “to provide the patient with a secure base from which he can explore the various unhappy and painful aspects of his life, past and present, many of which he finds it difficult or perhaps impossible to think about and reconsider without a trusted companion to provide support, encouragement, sympathy, and, on occasion, guidance.” [A Secure Base]
Jon Allen: “The mind can be a scary place.”Patient: “Yes, and you wouldn’t want to go in there
alone!”
The ability to think and talk about past pain is a protective factor leading to secure attachment, no matter how traumatic a childhood may have been. This inspiring finding is in itself an endorsement of psychotherapy, on of whose main functions, it can be argued, is to enhance reflective function [mentalizing].
—Jeremy Holmes (2001): The search for the secure base
Challenges: Simone Weil
At the bottom of the heart of every human being, from earliest infancy until the tomb, there is something that goes on indomitably expecting, in the teeth of all experience of crimes committed, suffered, and witnessed, that good and not evil will be done to him. It is this above all that is sacred in every human being.
Affliction is by nature inarticulate. The afflicted silently beseech to be given the words to express themselves. There are times when they are given none; but there are also times when they are given words, but ill-chosen ones, because those who choose them know nothing of the affliction they would interpret.
Thought revolts from contemplating affliction, to the same degree that living flesh recoils from death. A stag advancing voluntarily step by step to offer itself to the teeth of a pack of hounds is about as probable as an act of attention directed towards a real affliction, which is close at hand, on the part of a mind which is free to avoid it.
The Mentalizing Stance (mentalizing mindfully)
Psychological aspects inquisitive, curious, playful, open-minded “not knowing” (cleverness as cardinal sin) not creating the capacity but rather promoting attentiveness to
the activity of mentalizing
Ethical aspects (as in parenting, for example) good will and compassion acceptance and forgiveness respect for autonomy love
Therapeutic paradox activating attachment needs undermines
mentalizing for patients with insecure attachment
psychotherapy activates attachment needs patient must learn to mentalize in the context
of intense emotional states in attachment relationships
note contrast with mindfulness practice
General tips on mentalizing in psychotherapy
You are doing it alreadyCultivate alternative perspectivesBalance focus on self and othersMaintain an optimal level of emotional arousalChallenge patient’s assumptions about your mental statesFocus on mental states in the here-and-now, in current
relationships and in the transferenceAvoid attributing mental states to patients of which they are
unaware; liable to be taken in as alien or rejected outright [extremely common in our setting with “anger”]
Use “I” statements
Example of “I” Statements (Bateman & Fonagy)
“You are angry with me”
versus
“The way you are frowning makes me think that you may be feeling angry about something and I am wondering what that may be about”
Mentalizing the transference
validating the patient’s experience of the patient-therapist interaction
exploring the current patient-therapist relationshipaccepting and exploring enactments, including the
therapist’s own contribution and the therapist’s distortions
collaborating in arriving at an understandingpresenting an alternative perspectivemonitoring and exploring the patient’s reaction
Transference work: transparency
The patient has to find himself in the mind of the therapist and, equally, the therapist has to understand himself in the mind of the patient if the two together are to develop a mentalizing process. Both have to experience a mind being changed by a mind (Bateman & Fonagy)
