Something new or just old wine in new bottles?
Q: One of my European colleagues is excited about “mentalization” and Mentalization-Based Treatment. What is it?
A: Mentalization refers to the mind’s innate capacity to make sense of social experiences and implicitly know how to respond to them. Think about the following examples. You arrive home and say, “Hi” as you open the door. Your partner says, "Hi" back. Without a second thought, you’re aware of the tension in his voice that suggests he’s had a hard day. Or after a meeting with an old friend, you experience an uneasy feeling. Reflecting on your time together, you realize that you’re feeling bad because your friend takes a superior attitude with you.
Mentalization enables us to understand the intention or purpose behind other people’s behavior from their tone of voice, facial expression, and body posture. Therefore, when someone comes toward us wearing a grimace and hunched shoulders, we “get” that he or she is upset and perhaps angry. We instinctively recognize that mental states—thoughts, feelings, beliefs, or attitudes—underlie almost all behaviors.
This concept was introduced into the clinical literature by Peter Fonagy of the Anna Freud Centre in London in the 1990s. In a series of papers, including “Thinking about Thinking” in 1991 and “Playing with Reality” with Mary Target in 1996, he explored the theory of mind’s central role in the development of a sense of self. Drawing on clinical studies of borderline personality disorder and violent behavior, he argued that the failure to read and get the implicit meaning of another’s actions led to the loss of impulse control, an unstable sense of self, and problematic relationships. In the last 20 years, the mentalization model of mind has gone from being an obscure aspect of Attachment Theory to the centerpiece of Mentalization-Based Treatment (MBT) for borderline personality disorder. It’s now being integrated into treatments for addiction, trauma, eating disorders, and other conditions. But how does it work?
While mentalization fosters an empathic awareness of the moods and mindsets of others, it also enables us to know what our own states of mind and body mean. Our brain–minds assemble information about the state of our body, the input of our senses, and our associative memories to grasp our own intentionality. We mentalize explicitly by reflecting on experiences, conscious narratives, and empathic communication with others. Our “social brains” have evolved over the eons to become highly specialized in “reading” others’ minds, and our own. Menninger Clinic psychologist and mentalization expert Jon Allen and colleagues believe that mentalization is at the heart of emotional and social intelligence, and is central to all interpersonal experience.
Fonagy asserts that mentalization represents the epitome of human cognitive evolution and is the foundation of all effective psychotherapy. In fact, research has shown that when people lose their ability to mentalize their experience—usually in the context of high affect and threats to emotional security—they have a hard time making sense of other people’s behavior and their own. They become reactive, impulsive, and self-centered, and lack perspective.
Fonagy’s early work examined the development of borderline personality disorder. He found that people who became borderline had fragile mentalizing capacities and were vulnerable to breakdown in close interpersonal situations. The research also revealed that these people had often grown up in families that inhibited mentalization skills. In abusive families, for instance, high levels of frightening feelings overwhelm and shut down children's capacity to think about what’s happening. In addition, children may avoid reflecting on their parents’ intentions, since it could be terrifying to understand their confusing and, at times, hateful feelings toward them.
These findings dovetail with similar data generated by the Adult Attachment Interview, developed by psychological researcher Mary Main. She found that individuals who are able to reflect on their relationships with their parents with perspective and understanding were likelier to be secure in their attachments to others and have securely attached children.
Rather than being an entirely new form of treatment, mentalization-based therapy contributes to our understanding of what happens in many different approaches. Fonagy argues that achieving more stable and robust mentalization constitutes success in most treatments because it enables people to regulate their own moods more effectively and think coherently about themselves and what they want. By focusing on mentalization as a skill, therapists help clients understand more of the connection between how they feel, what they want, and how they act by themselves or with others.
Mentalization encourages a nonjudgmental attitude of curiosity, inquisitiveness, and open-mindedness toward the client’s subjectivity. Rather than assuming a role of expert, the therapist adopts a “not-knowing” stance, founded in the belief that we come to know what it’s like for another by inquiry, not by assumptions or formulations or by explaining clients to themselves. It’s a here-and-now, process-oriented approach. The therapist encourages the client to think about his or her experience, the goal being to learn to “think about feeling, and feel about thinking.” The therapist guides the client to step back and take perspective on their experience together in therapy: “Yes, that’s one possible meaning; what are others?” “How do you imagine it looks from my point of view?” He or she listens to the client’s narrative and seeks to explore the aspects that are being neglected.
Some critics have wondered what’s gained in using the term mentalization as opposed to empathy, psychological mindedness or affect awareness. Some find Daniel Siegel’s idea of mindsight a friendlier term referring to many of the same functions. But in my own practice, a focus on mentalization has deepened my understanding of the balance between affect and cognition and the need to integrate these aspects of experience. Of course, we all know, theoretically, that the therapeutic connection is at the heart of all good therapy, but understanding the moment-to-moment processes of mentalization can deepen a therapist’s understanding of just how shifts in the relationship can lead to lasting therapeutic change.Steven Krugman, Ph.D., is a psychotherapist in Boston. He teaches about Attachment Theory and interpersonal neuroscience, and is on the faculty of the Psychoanalytic Family and Couples Institute of New England. Contact: email@example.com. Tell us what you think about this article by e-mail at firstname.lastname@example.org.