Bringing Mentalizing to Mind

How succinctly and accurately can you describe the term “mentalizing”?

A relative newcomer to the psychotherapeutic lexicon, mentalizing is by no means a new idea, being intrinsically part of most therapeutic modalities. Perhaps that’s why the term is not struggling to make its way into the vocabularies of therapists of a wide range of theoretical persuasions. But what exactly is mentalizing and why should you care? And does it offer anything new to therapists? New Therapist interviewers Julie Manegold and Helen Jones asked Jon Allen, one of the most lucid proponents of the virtues of mentalizing, to give us the low-down on where mentalizing comes from, is going to and why we might like to go along for the ride.

New Therapist: As you have indicated, mentalizing is not a new concept. You also have indicated that, while it is embedded in attachment research, it is a fundamental factor in all varieties of psychotherapy. It also appears to be a technique employed naturally by most therapists in the course of their work. However, despite its longevity as a concept and its far-reaching generalizability, the concept of mentalizing seems in recent years to have been refined to refer to something very specific. Could you give us a definition of mentalizing that can help us understand it?

Jon Allen: Mentalizing is the natural human capacity to understand behavior in relation to intentional mental states—in essence, being aware of thinking and feeling in self and others and interpreting behavior accordingly. My favorite shorthand for mentalizing is Peter Fonagy’s phrase, holding mind in mind. Mentalizing is an umbrella term, a multifaceted process. Hence we distinguish among several facets of mentalizing: regarding mental states in self versus others; in explicit versus implicit forms (i.e. reflective narrative versus automatic and intuitive responsiveness); in relation to external versus internal phenomena (i.e., responses to observable behavioral cues versus making inferences about unobservable mental states); in relation to cognitive versus affective processes (i.e., thoughts and beliefs versus emotions and feelings); and regarding present versus past or future (i.e., in relation to current mental states versus retrospective reflection about past mental states or anticipating future mental states in self or others). Although there is no exact synonym, mentalizing overlaps with many other concepts: psychological mindedness, theory of mind, observing ego, social cognition, metacognition, mindreading, emotional intelligence, empathy, and insight.

The overlap of mentalizing with mindfulness is especially noteworthy: as I think about it, mindful attention to mental states is the foundation for skillful mentalizing (i.e., in its explicit form, mentalizing is a more reflective and interpretive process than mindfulness). Mindfulness and mentalizing are similar in two fundamental respects: first, both entail at least intuitive awareness of the distinction between mental states and the reality they represent; second, ideally, both entail an open-minded, nonjudgmental attitude of inquisitiveness and curiosity toward mental states.

NT: Can you elaborate further on mentalizing as a common factor amongst the various therapeutic techniques?

JA: It is hard to imagine conducting psychotherapy without mentalizing—attending to mental states in the patient and the therapist, as well as thinking about mental states involved in the patient’s key relationships. Insofar as all brands of therapy require mentalizing on the part of patient and therapist, we have made the strong claim that mentalizing is the most fundamental common factor among psychotherapies. Given our belief that mentalizing is crucial for all psychotherapies, we acknowledge that our focus on mentalizing is the least novel approach imaginable.

We have introduced some potential confusion by claiming that mentalizing is a common factor as well as a specialized treatment approach. That is, on the one hand, Anthony Bateman and Peter Fonagy have developed Mentalization-Based Treatment (MBT) as a specific treatment for a borderline personality disorder (BPD). Moreover, MBT is an evidence-based treatment for BPD, with the longest (i.e., eight-year) follow-up study of the treatment of BPD conducted to date. Hence promoting mentalizing as a common factor is somewhat akin to advocating “Empathy Therapy” or “Therapeutic Alliance Therapy,” in effect, turning a common factor into a brand of therapy. I address this confusion as follows: Many therapists, me included, are generalists who treat patients with a wide range of psychiatric disorders. I think of the mentalizing approach as a style of therapy with broad applicability that employs general principles from MBT in the treatment of diverse patients. Employing this generic version of MBT with a foundation in attachment theory and research, I have declared myself a practitioner of “plain old therapy” in my recent books. I like the acronym.

NT: Your own work, as well as other studies, indicates an integral interplay between attachment, mentalizing, and affect regulation. Can you help us understand the relationships among the three?

JA: As I already stated, we’ve acknowledged that our focus on mentalizing is the least novel approach to psychotherapy imaginable, and I’ve declared myself a practitioner of plain old therapy. But I am being somewhat ironic here. While I am aspiring to articulate the crucial elements in the venerable practice of psychotherapy, I am making use of contemporary theory and research. The relation between attachment and mentalizing, along with the crucial role of attachment and mentalizing in developmental psychopathology, gives the mentalizing approach specific substance. In short, attachment relationships, from infancy onward, are formed on the basis of mentalizing. The primary function of attachment is emotion regulation; proximity to an attachment figure provides a feeling of security and safety in the context of threat and emotional distress. Yet, for attachment to function in this optimal way, the relationship must entail mentalizing on the part of the comforting attachment figure (i.e., psychological attunement, mindful attention, understanding of the basis of threat or distress, and appropriate responsiveness). By twelve months of age, infants have made this connection intuitively; they seek comfort from caregivers who mentalize, and they develop alternate adaptive strategies to manage their emotions and relationships with caregivers who do not mentalize consistently.

NT: So is it correct to assume then that the quality of an individual’s affect regulation may be determined by certain aspects of attachment and mentalizing and that, similarly, affect regulation is impaired when something goes wrong with attachment and mentalizing?

JA: This is a correct assumption, and your question gets to the crux of the relation between attachment and mentalizing that I just forecasted. Research shows that good parental mentalizing plays a key role in the development of secure attachment and that impaired parental mentalizing contributes to insecurity in attachment. Moreover, research has demonstrated an intergenerational transmission process: prospective parents who demonstrate mentalizing in relation to their own childhood attachment relationships in Mary Main’s Adult Attachment Interview are more inclined to mentalize in their interactions with their infants; in turn, their infants are more securely attached at one year of age (as evident in Mary Ainsworth’s laboratory assessment, the Strange Situation). To cap it off, these securely attached infants, with their history of having been mentalized, become more effective mentalizers than their insecure counterparts in later childhood (e.g., better able to succeed at theory-of-mind tasks and to interact empathically with their peers). We might thus predict that, as adults, these securely attached individuals would be able to mentalize in relation to their childhood attachments and would become effectively mentalizing parents, carrying on the process of intergenerational transmission in an optimal fashion.

NT: What can we assume has gone wrong when someone cannot mentalize effectively and thus cannot regulate their affect?

JA: We must keep in mind that mentalizing capacity and security of attachment are matters of degree and, moreover, they are somewhat relationship-specific. Of greatest clinical concern are relatively severe and pervasive mentalizing impairments associated with trauma in attachment relationships—the context for which MBT was developed. As I construe it, the crux of attachment trauma is the combination of being in an unbearably painful emotional state and feeling psychologically alone in that state, that is, without the aid of a trusted person who is attuned to that painful emotional state. Various forms of abuse and neglect in attachment relationships exemplify that traumatic combination (i.e., abusing and neglecting a child are incompatible with mentalizing). Yet, short of outright maltreatment, more subtle failures of emotional attunement in early attachment relationships—in the context of the child’s emotional distress—have been found to relate to clinically significant attachment insecurity (i.e., disorganized attachment). As Peter Fonagy and Mary Target aptly put it, such attachment trauma confers a “dual liability,” that is, it evokes emotional distress and also undermines the development of the capacity to regulate that distress.

The child’s impaired mentalizing limits the child’s ability to stay out of harm’s way to the (perhaps very limited) extent possible; prevents the child from comprehending his or her emotional distress; and—most important—compromises the child’s capacity to make use of attachment relationships to alleviate distress.

NT: So what does this tell us then about the role of attachment in psychotherapy?

JA: As John Bowlby made plain, psychotherapists take on the characteristics of attachment figures in providing a safe haven and a secure base for exploration—which includes exploration of mental states in self and others (i.e., mentalizing). In a trauma education group, I once made the point that the mind can be a scary place. A patient exclaimed, “Yes, and you wouldn’t want to go in there alone!” She was in sync with Bowlby and thus articulated the pithiest characterization of trauma therapy I have heard.

Patients’ proclivities to form secure attachments or various forms of insecure attachment (e.g., avoidant or ambivalent) are clearly evident in their psychotherapy relationships. Not surprisingly, patients who are securely attached are more likely to develop effective therapeutic alliances and thus to benefit more from treatment than their insecure counterparts. Of course, patients struggling with insecure attachments—especially in conjunction with attachment trauma—are most likely to need psychotherapy. There is some evidence—albeit not enough—that psychotherapy has the potential to increase attachment security. Most impressive, parent-child therapies designed to enhance parents’ psychological attunement (and mentalizing) can increase attachment security. The research on the intergenerational transmission of attachment illustrates what George Gergely construes as a “pedagogical” process that is utterly commonsensical: parents who are good mentalizers relate to their children in a mentalizing way and thereby foster mentalizing in their children. A simple developmental principle: mentalizing begets mentalizing (and conversely, nonmentalizing begets nonmentalizing). Moreover, mentalizing begets attachment security (and nonmentalizing begets insecurity). Accordingly, in psychotherapy, as in other attachment relationships, therapists’ mentalizing begets patients’ mentalizing and attachment security.

NT: You have indicated that if we are doing our job as therapists we are already mentalizing. Can you explain what it is that we are, or should, already be doing?

JA: I have listened to many therapists who have never heard of “mentalizing” talk about the way they work, and I have the impression that they are engaging in a first-rate mentalizing process with their patients. Our evolution as a species has been predicated on mentalizing; accordingly, I have concluded that our therapeutic competence comes down to our skill in being human. Patients whom we have treated at The Menninger Clinic in the hospital worry about finding a “mentalizing therapist” when they are discharged. I reassure them that their therapist does not need to know about “mentalizing” as long as they feel their therapist is attuned and understanding. We advocate a mentalizing stance, that is, an open-minded attitude of curious inquisitiveness and reflectiveness about mental states in self and others. Therapists need not know the literature on mentalizing to practice in this manner, but knowledge about the development of mentalizing and the developmental conditions that foster it helps. Maintaining a mentalizing stance (which includes mindful attentiveness) sounds easy until you try to do it. What undermines patients’ mentalizing undermines therapists’ mentalizing, namely, strong affects, defenses, and insecurity. One thing I like about the mentalizing approach is that it puts therapists in the same boat with their patients; both are challenged to maintain mentalizing in the context of strong emotion. Knowledge, training, and practice help.

NT: In your opinion, and experience, can someone with a poor capacity to regulate their affect be taught how to mentalize, and thereby improve their affect modulation?

JA: The catch-22: we most need to mentalize when we are least capable of doing it, that is, in key attachment relationships when emotion runs high. Another catch-22: patients who most need therapy (e.g., traumatized patients with extensive and severe psychiatric disorders) are least capable of using it easily, owing to their distrust and impaired mentalizing. Yet we must keep in mind that, short of profound autism, all of us are capable of mentalizing. Our patients experience transient—if frequent and profound—disruptions of mentalizing. I like the advice, “Strike while the iron is cool.” We can help our patients achieve a state of equilibrium in which mentalizing is possible, and we can gradually help them to push the envelope, mentalizing when the going gets tough: in Peter Fonagy’s terms, feeling and thinking while feeling (alternatively, in Marsha Linehan’s terms, using “wise mind”). I also like Mario Mikulincer’s idea that we all have “islands of security” in relationships, and psychotherapy builds on those islands.

A final point: the best way to improve affect modulation is through secure attachments. Our treatments place a premium on self-regulation of affect (e.g., cognitive-behavioral approaches) but our best means of regulating affect are relational. From this perspective, individual psychotherapy is an indirect route to affect regulation (albeit a good practice ground). Working directly in key attachment relationships in couples and family therapy to improve mentalizing and security makes a great deal of sense. Group therapy also is a mainstay of MBT as it challenges and promotes mentalizing by providing multiple perspectives. In sum, we bank on the fact that all our patients have some mentalizing capacity and all are capable of improving that capacity with proper help: mentalizing begets mentalizing.

NT: Mentalizing appears to draw on different areas, including neuroscience. Can you help us understand how neuroscience of mentalizing can contribute to our therapeutic interventions?

JA: Broadly, neuroscience is helping us fully appreciate the magnitude of mentalizing impairments associated with traumatic attachment relationships and thereby promoting realistic expectations for treatment, which are essential to maintaining hope. More specifically, neuroimaging research is on the path to identifying particular brain regions associated with different facets of mentalizing, which will help us understand mentalizing impairments in greater detail. Linking different forms of psychopathology to specific mentalizing impairments will help direct treatment, and neuroscience promises to contribute to this endeavor. But I have protested what I’ve dubbed “biomania,” namely, excessive enthusiasm for exclusively neurobiological understanding. In my view, the work on mentalizing and attachment bolsters the century-old tradition of psychotherapy in its most humanistic form, to reiterate, the value of plain old therapy and plain old human relationships in healing.

NT: The concept of mentalizing has contributed enormously to our understanding of why therapy works. Can you predict a way forward for this exciting concept? What can we look forward to in future?

JA: As just stated in relation to neuroscience, I think we can look forward to more precision in our understanding of mentalizing impairments and their relation to different forms of psychopathology. Peter Fonagy and his colleagues are working on identifying facets of mentalizing that are particularly impaired in conjunction with borderline personality disorder, the focus of MBT. This work is being extended gradually into a broad range of psychiatric disorders. As usual, theory is more abundant than data. We need more research demonstrating that therapeutic interventions improve mentalizing and that improved mentalizing contributes to improved functioning, including the development of increasingly secure attachments. After a half-century of psychotherapy research, to borrow the titles of Anthony Roth and Peter Fonagy’s books, we still need better answers to the question, What works for whom? Owing to its role in prevention, research on parent-infant and parent-child interventions that promote attunement and attachment security is especially encouraging; therapists, as well as parents, will have much to learn from it. From the common-factors point of view, we might say that learning and teaching psychotherapy revolves around developing skill in promoting mentalizing; the experts like Anthony Bateman and Peter Fonagy have a knack for it. Research linking interventions to improved mentalizing—and tailoring the interventions to individual differences among patients—might help the rest of us do this more skillfully. Meanwhile, the general principles from MBT are a good place to start.

About the author

Jon G. Allen, Ph.D., is a senior staff psychologist and Helen Malsin Palley Chair in Mental Health Research, The Menninger Clinic; Professor of Psychiatry, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas. He conducts psychotherapy, psychoeducational groups, diagnostic evaluations, and research on treatment outcomes, specializing in trauma-related disorders. He is past editor of the Bulletin of the Menninger Clinic and serves on the editorial boards of Psychiatry, the Journal of Trauma and Dissociation, and Psychological Trauma. His recent books are Restoring Mentalizing in Attachment Relationships: Treating Trauma with Plain Old Therapy (American Psychiatric Publishing) and Mentalizing in the Development and Treatment of Attachment Trauma (Karnac).