Those readers who are curious about the construct of mentalization might find this newsletter illuminating as well as congenial. Those readers who are fatigued by the hype around mentalization should feel free to skip this newsletter. Or they can try to mentalize their disinterest and consider changing their mind!
Although I have referred to mentalization many times in this newsletter, not to mention featured it in the title, I have not paused and put effort into elaborating upon it. It can be tricky to fathom mentalization, as it is, in part, straightforward and, in part, abstruse, easily coming in and out of focus. Context plays a significant role in its deployment. On the one hand, mentalization theory, research and practice has met with an increasing enthusiastic response throughout the professional world of mental health and heralds a rapprochement between psychoanalysis and the rest of the field. On the other hand, mentalization-based therapy is not yet widely practiced, especially in the US, and many more people have heard of it than understand its full meaning and distinctive uses.
Mentalization is not a static construct and has evolved in many respects over the last 25 years. It has been developed as an evidence-based treatment, Mentalization-based Therapy (MBT), for borderline personality disorder. MBT patients show reduced depressive symptoms, fewer suicide attempts, fewer hospital stays, and better social functioning, in randomized, controlled trials.[i] MBT patients also showed continued improvement 18 months post-treatment.[ii] Moreover, in an 8year, follow-up study, MBT patients still showed more improvement than the treatment as usual group.[iii] MBT has been recognized as a treatment for severe personality disorders internationally and is officially part of national health care systems.
Currently, MBT is being expanded to treat various other kinds of psychopathology, such as depression, trauma, addiction, at risk mothers, and anti-social personality disorders. MBT is being used as a treatment for adults, children, adolescents, families and parents. Indeed, even larger claims have been made about mentalization: that the “essence of psychotherapy is mentalizing” and that “psychotherapy enhances mentalization.”[iv] I will return to discuss this claim.
Where does the contemporary construct of mentalization come from?[v] There are three main sources. The term “mentalization” was first used by French psychosomatic thinkers in the 50s and 60s, primarily as a way to capture certain kinds of patients who seemed concrete and inclined to dementalize, that is, to read their emotions as happening in their bodies. What is distinctive about this use of the term is that it entails a relationship to the self and is strongly affective in nature. The second use of the term comes from theory of mind, cognitive psychology and philosophy of mind, in the 70s, where questions around how we know the minds of others came to be of interest. Mentalization here is cognitive, about others (not the self); accuracy tends to be assumed as the norm. A crucial aspect of this understanding of mentalization emerged from false belief experiments, where it seemed that children under 3-4years old were unable to mentalize compared to children who were older. The third source of mentalization, which served as a catalyst for Fonagy and colleagues’ original formulation was attachment and object relations developmental theories, which stressed that caregivers’ investment in mentalizing children spurred the interest for children to begin to mentalize.
The background of attachment theory was explicitly emphasized in early mentalization theory; Bionian notions of reverie and containment have also been acknowledged, in particular, the parental capacity to take in and give back overwhelming emotions in a manageable form to the infant. As mentalization theory has developed over time, the role of attachment theory has shifted in important ways. Originally, secure attachment was postulated as the basis for the emergence of mentalization (related to the findings from false belief experiments). However, two issues complicated the picture: 1) infant researchers began to use alternative experimental paradigms, which suggested that mentalizing capacities begin significantly earlier than 3-4 years old; thus, attachment and mentalization occur simultaneously and overlap, but not sequentially; and 2) clinically, it became apparent that attachment and mentalization can function antagonistically—for example, when someone’s attachment system becomes activated at work, hearing a boss’s announcement of a strict deadline as the voice of an abusive parent, thereby disrupting his/her/their capacity to mentalize. Mentalization theory made the adjustment from the idea that borderlines cannot mentalize to that their capacity to mentalize is inconsistent and can fail when under stress.
More recently, mentalization theory has undergone a further change, revaluing how attachment is understood and incorporating ideas that come from cognitive evolutionary psychology concerning social communication.[vi] The function of attachment has come to be understood in a more circumscribed way, primarily having to do with the regulation of safety through proximity and distance from the caregiver (which is especially relevant to emergency situations); in no way is this unique to human beings, since many other animals exhibit attachment behavior. Attachment style can influence the unfolding of mentalization, but it is not the sole determinant.
The present understanding of mentalization is that it facilitates social communication. Mentalization depends upon having a curiosity about one’s own and others’ mental states; it is predicated upon the fact that mental states are often opaque, not transparent, and that effort is required, along with an investment in providing information that can justify your beliefs. Mentalization entails that one holds beliefs lightly and is prepared to amend them, when necessary. It is challenging for humans to devote themselves to understanding their own or others’ mental states; it’s easy to fail and to resort to pre-mentalizing phenomena like the psychic equivalence mode (where you assume that if something is in your mind, it must be in the mind of others), the teleological mode (where you recognize only what is physically observable), and the pretend mode (where you allow fantasy to govern your response). From an evolutionary perspective, mentalization is an achievement: it contributes to the fitness of the species by serving to modulate competition and enhance cooperation.[vii]
Mentalizing depends upon the integration of cognition and affect, which I have tried to convey in my construct of mentalized affectivity, an alternative to the conventional model of emotion regulation where cognition prevails over affect. It is possible for mentalization be too cognitive or too laden with emotion; optimally, cognition helps to render the affect to be experienced and communicated effectively. All therapies work on mentalizing emotions and most seek to balance affect and cognition in a flexible that is in accordance with one’s highest aspirations.
The object of mentalizing can be the self or it can be others. At the heart of mentalizing, in my opinion, is an appreciation of how these two things are integrally related, specifically being open to the mentalizing of others, including about the self. Mentalization theory has embraced the construct of epistemic trust, the capacity to receive input from others having to do with social knowledge. Without epistemic trust, one is forced to be fully self-reliant (or to be lost in not only distrusting others but distrusting oneself). Although epistemic trust has been adopted as crucial for mentalizing to develop, it is best conceived as a necessary but insufficient condition.
The other relevant term that has been adopted from cognitive evolutionary psychology is epistemic vigilance, the capacity to weigh the trustworthiness of sources of knowledge.[viii] It strikes me that epistemic vigilance is what is most central to the work of psychotherapy. Epistemic trust is a premise of the work in psychotherapy, but epistemic vigilance is actually how we help to equip patients to live more fulfilling lives. Without epistemic trust, patients are unlikely to be receptive to viewing therapists as genuinely motivated to understand and help them. Epistemic mistrust leaves patients isolated and has been associated with an absence of resilience. However, we must be careful not to imply misleadingly that epistemic trust means that therapists possess expert knowledge that patients would do well to accept. Our ambition cannot be to have patients simply to receive information from us; on the contrary, what we want is for patients to weigh what we say for themselves, and to engage in a dialogue in which both parties are responsive to each other. MBT has always encouraged a stance of not knowing on the part of the therapist and differs from TFP in this respect. I am not sure about all modalities, but, as my colleague Lissa Weinstein likes to stress, psychoanalytic clinicians especially value moments when a patient disagrees with them or exhibits negative transference, as they are often an indication of growing agency and overall progress. Finally, it would be unfortunate to imagine that encouraging patients to trust their therapists ought to be generalized outside of the consulting room, without equipping them to discern whether, if and to what degree others are trustworthy. Mentalization theory needs to be able to address the complexity of social life beyond the matter of trust to include, for example, the reputation that a person possesses, as cognitive evolutionary psychologists have already ventured to do.[ix] We trust according to an evaluation of whether the person is respected as a knowledgeable source, and it goes without saying that such reputations can be well-earned or misleading.
Mentalizing overlaps with a number of other constructs that have been taken up in the mental health world. It certainly bears a close connection with empathy, especially in its cognitive form, which requires understanding as well as a more automatic response. Mentalization also has an affiliation to mindfulness, especially those variations which affirm rather than aim to achieve transcendence of the self. Mentalizing resembles the self-observing ego, with the qualification that mentalizing has an intersubjective basis, which the self-observing ego does not. So, there are related constructs in the literature, although mentalization has distinct merits because of its rootedness in communication.
Mentalization is not, of course, the solution for any kind of problem or suffering. Indeed, while it is crucial to be able to mentalize, rather than act in certain circumstances, it is equally important in other situations to curtail mentalizing. Here’s a dirty little secret: it is often the case that we realize that we need to mentalize, when we have failed to do so. So, mentalizing has both a retrospective and prospective function. What matters the most is embracing the challenge of knowing how and when to mentalize. This requires practice and typically necessitates the help of other people. While all kinds of psychotherapy try to promote better mentalization, it is not, in itself, the end of therapy. The end of therapy is to feel better, and, in addition, to cultivate the capacity to be able to handle whatever happens in life. Mentalization is a spur to digest experience and to rid of ourselves of unnecessary mental by-products, so we understand ourselves as moving in the direction of fulfilling our ideal sense of agency.
There are two emerging trends that mentalization theory has begun to grapple with and will continue to do so in the future. The first concerns the relation between mentalization and the body. Embodied mentalization has come into prominence as a specific aspect of mentalization, a kind of corrective to conceiving mentalization as defined by mind/body dualism. Fotopoulou & Tsakiris offer an insightful perspective on embodied mentalization, defining it: “as the inferential brain process by which primary sensorimotor and multisensory signals are progressively integrated and schematized to form multiple, predictive models of our embodied states in given environments” (p. 8).[x] Their neuroscientific perspective places a special emphasis on the mind’s capacity to be activated apart from online sensory experience (without discounting sensory experience that does come from the external world). What is crucial for embodied mentalization to thrive is interoceptive sensitivity, which fosters a sense of ownership of one’s experience. Interoception denotes the perception of the physiological state(s) of the body, which involves things like “temperature, itch, pain, cardiac signals, respiration, hunger, thirst, pleasure from sensual touch, and other bodily feelings relating to homeostasis” (p. 14). In this account, interoception transcends the status of perception of the body from within; it has the key role of monitoring homeostasis.
While Fotopoulou & Tsakiris point to phenomenology as a source of embodied mentalization, where there is a pre-reflective sense of self that comes from the body, they ultimately argue that embodied mentalization is intersubjectively constituted, that is, that it comes into being through interaction with other bodies. They wish to affirm how this manifests developmentally (between caregivers and infants), and socially (defined by the physical proximity and interaction among bodies). Fotopoulou & Tsakiris’ contribution follows other neuroscientific accounts, like Damasio, in challenging dualism by stressing how the brain is constantly monitoring the body and adjusting itself accordingly. Fotopoulou & Tsarkiris build on a developmental account, avoiding reductionistic neuroscientific accounts that bypass subjective and intersubjective experience. Mentalization is given an early and large purpose in promoting humans to be able to function as individuals and in society.
The second emerging trend concerns the relation between mentalization and culture. Insofar as mentalization is construed as a product of evolution, and as facilitating social communication, it seems plausible to assume that the construct is universal. However, mentalization theory has started to address how culture presides over various kinds of “we experiences,” the basis of mentalization in groups and communities.[xi]
Let’s pose a basic question that is not easy to answer: do different cultures mentalize differently? Only one study, as far as I am aware, has attempted to address this, Aival, et al.’s Keeping Culture in Mind: A Systematic Review and Initial Conceptualization of Mentalizing from a Cross-Cultural Perspective.[xii] In order to explore how mentalization might be influenced by culture, the authors look at several related concepts across 112 studies from 1995-2019: theory of mind, empathy, perspective-taking, alexithymia and mindfulness (all of which share some features with mentalization). They imagine that mentalizing about the self might be more developed in individualistic cultures, and mentalizing about others might be more developed in collective cultures. However, they examine this critically, acknowledging studies that challenge such a simple juxtaposition. For example, in perspective taking, many studies find an egocentric bias in Westerners and an other-oriented bias in East Asians. Wu et al. used a sophisticated time-series analysis, using eye tracking, to show that Chinese subjects initially show an egocentric response, but then suppress this as interference.[xiii] In other words, it is less that Chinese subjects fail to do something than that they do the same thing and more than American subjects.
My research team has had to come to terms with an ethnocentric bias in connection with our work on mentalized affectivity: assuming that the category of “expressing emotions” would be construed positively by subjects (we did make a distinction between expressing emotions outwardly or inwardly). In Asian cultures, this is not necessarily the case, as there is an expectation that others who are close to you will know what you are feeling, and so having to tell them shades into a negative valence. In exploring related research, we found a study by Ma et al., which argues that Asians evaluate positive emotions differently from people in the West, as positive emotions are to be regarded as unstable.[xiv] In other words, it is prudent to guard against indulging them as a way not to exhibit hubris and also to avoid disappointment from their evaporation. The implications are impressive, if studies of emotions must question the assumption that ideal human agency is defined by the dominance of positive emotion and the diminishing of negative emotions.
No grand conclusions can be made about mentalization and culture. It will be crucial for mentalization theory and research to take more account of this in the coming years. The fact that mentalization continues to evolve, in my mind, is an indication of its vitality as a paradigm. Mentalization theory has always sought to be rooted in research, which distinguishes it from other psychoanalytic perspectives. It has always been driven, too, by a practical, clinical agenda. Psychoanalysis has become more isolated from the realm of mental health over time. Mentalization provides a path for ideas that derive from psychoanalysis, like the enduring influence of early life experience through the caregiver relationship, fresh meaning and clinical relevance.
Mentalization forges a bridge between the mental health world of the past and the future in affirming the salutogenetic function of psychotherapy, that is, the ideal of cultivating the capacity to negotiate and thrive in—as much as that is possible—the social environment.
[i] Bateman, A., & Fonagy, P. (1999). Effectiveness of partial hospitalization in the treatment of borderline personality disorder: A randomized controlled trial. American Journal of Psychiatry,156(10), 1563–1569.
[ii] Bateman, A., & Fonagy, P. (2001). Treatment of borderline personality disorder with psychoanalytically oriented partial hospitalization: An 18-month follow-up. American Journal ofPsychiatry, 158(1), 36–42.
[iii] Bateman, A., & Fonagy, P. (2008). 8-year follow-up of patients treated for borderline personality disorder: Mentalization-based treatment versus treatment as usual. American Journalof Psychiatry, 165(5), 631–638.
[iv] Fonagy, P., Bateman, A. W., & Luyten, P. (2012). Introduction and Overview. In A. W. Bateman & P. Fonagy (Eds.), Handbook of Mentalizing in Mental Health Practice (pp. 3–42). Arlington, VA: American Psychiatric Publishing.; also see Allen, J. G., Fonagy, P., & Bateman, A. (2008). Mentalizing in Clinical Practice. Washington, DC: American Psychiatric Association Press.
[v] Jurist, E. (2018). Minding Emotions: Cultivating Mentalization in Psychotherapy (New York: Guilford).
[vi] Fonagy, P., Luyten, P., Allison, E., & Campbell, C. (2017). What We Have Changed Our Minds about: Part 1. Borderline Personality Disorder as a Limitation of Resilience. Borderline Personality Disorder and Emotion Dysregulation, 4, 11. https://doi.org/10.1186/s40479-017-0061-9 (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5389119/)
[vii] Mentalization has been seen as providing a competitive advantage over others as well as a way to enhance and extend cooperation.
[viii] There is no doubt that “epistemic vigilance” applied as a clinical term is awkward and potentially misleading, as the construct should denote hesitation and reflection, but not suspiciousness or paranoia. Perhaps, epistemic circumspection would be a preferable term.
[ix] Boyer, P (2018). Minds Make Societies: How Cognition Explains the World Humans Create. New Haven, CT: Yale.
[x] Fotopoulou, A. & Tsakiris, M. (2017). Mentalizing Homeostasis: The Social Origins of Interoceptive Inference. Neuropsychoanalysis, 19(1): 3-28.
[xi] Fonagy, P., Campbell, C., Constantinou, M., Higgitt, A., Allison, E., & Luyten, P. (2021). Culture and Psychopathology: An Attempt at Reconsidering the Role of Social Learning. Development and Psychopathology, 1-16. doi:10.1017/S0954579421000092
[xii] Aival‐Naveh, E., Rothschild‐Yakar, L., & Kurman, J. (2019). Keeping Culture in Mind: A Systematic Review and Initial Conceptualization of Mentalizing from a Cross‐cultural Perspective. Clinical Psychology: Science and Practice, 26, e12300.
[xiii] Wu, S., Barr, D., Gann, T., & Keysar, B. (2013). How Culture Influences Perspective Taking: Differences in Correction, not Integration. Frontiers in Human Neuroscience, 7, 822.
[xiv] Ma, X., Tamir, M., & Miyamoto, Y. (2018). A Socio‐cultural Instrumental Approach to Emotion Regulation: Culture and the Regulation of Positive Emotions. Emotion, 18(1), 138– 152.