Mentalizing: Feeling Thoughts And Thinking Feelings, by Duncan Cartwright
"In this way, mentalizing is always an imaginative, intuitive, playful activity, necessary for perceiving, tracking, and interpreting human behaviour. "
The term ‘mentalizing’ is a slippery term: apparently simple, but abstruse at the same time. Similarly, while the act of mentalizing may appear easy, we are always necessarily struggling to grasp its ‘essence’ in the therapy room as it constantly fluctuates. I will return to this later.
Simply put, in the therapeutic context, mentalizing involves the therapist’s ability to accurately track and make sense of the patient’s emotions and mental states. In doing so, the therapist works to show the patient that actions are dependent on the way we interpret thoughts and feelings about ourselves and others. Mentalizing differs from ‘mindfulness’ in that mindfulness focuses on the compassionate non-judgemental witnessing of a current event or action. Mentalizing is quite different in that is involves a focus solely on mental states that needn’t be in the present. Empathy and mentalizing also share some common features. However, empathy involves connecting with others’ mental states and emotions, while mentalizing involves jointly attending to the psychic reality of both self and other.
Mentalizing is a feature of all psychotherapies, it is also a general protective factor against many forms of psychopathology. Whether we are focusing on how irrational beliefs influence behaviour, identifying and making sense of emotional states, or focusing on the transference relationship, all require a basic ability to focus on the mental states that lie behind behaviours.
This may sound remarkably simple. In fact, for this reason, mentalizing is often misunderstood to be just another term for the production of thoughts, or a general term for cognitive functioning. Although it involves cognitive processes, it specifically involves our ability to identify and respond to mental states. It is a perceptual process intimately associated with emotion, a form of emotional knowing. The fact that we can never truly, or directly, know what is on someone else’s mind introduces a degree of complexity to mentalizing that makes us all imperfect mentalizers. Put another way, because our minds are opaque, accurately tracking the mental states of others requires constant guesswork where we are often getting things wrong.
In conversation with my son about doing his homework, I am quick to assume that he avoids hard graft and I take on the role of reminding him to get it done. When I take time to focus on his thinking about it and my reaction, I start to notice something different. I first notice feeling hassled myself, I start to blame him for being lazy. Then I become aware of his agitation and ask him what’s going on. I start to wonder to myself if he is angry with me, if he is ill, worried about something, or just upset because he feels unable to do the work. He fobs me off, at first, when I ask him if there is somethinggoing on. But later he starts to talkabout how he felt humiliated by a teacher at school the previous day. Together, we work out that this had something to do with his resistance to doing his homework. The more he talks about the experience, the more he realises how angry he was with the teacher.
There is a lot going on in this interaction that helps illustrate the processes involved in mentalizing. When I am hassled and preoccupied myself, emotionally dysregulated, I cannot focus on mental states as they unfold (mine, or my son’s). Instead, I make assumptions and project my own unprocessed emotion onto him. In short, I am not mentalizing, although I am thinking. I am treating my son like an object instead of an experiencing subject. However, when I stop and notice my own intentions and thoughts, when I start to mentalize, a different narrative, based on unprocessed emotion and unformulated thoughts, starts to form and that helps shed light on his behaviour. But we have to start by guessing and following our hunches as the process unfolds. In this way, mentalizing is always an imaginative, intuitive, playful activity, necessary for perceiving, tracking, and interpreting human behaviour. Here, behaviour starts to be understood as always linked to intentional mental states (desires, beliefs, feeling, goals and purposes etc.) and the thoughts and feelings behind actions.
Although we are sometimes consciously aware of monitoring mental states in ourselves or others, most of our mentalizing ability is unconscious and intuitive. How we regulate a conversation, take turns, be responsive and reflect the perceived intentions of the other, largely takes place outside of awareness. Deficits in this ability are best illustrated in cases of autism where the ability to perceive and respond to mental states is severely compromised (often termed ‘mindblindness’). As a result, words are understood very literally and social interactions become awkward and robotic. We might think about this internal situation as occurring when the mind starts misrepresenting or misinterpreting its own experience.
This, of course, is not limited to autism. We are all familiar with how heated arguments shut down our ability to reflect on experience. The loss of reflective function, in turn, makes it difficult to regulate emotions. When we are able to focus on the other’s perspective, their intentions, as separate from our own, we notice that this leads to a down-regulation of destructive emotions. This is usually called ‘perspective-taking’ and is an important clue to identifying when mentalizing is occurring.
When we lose the capacity to mentalize, something else happens. More primitive ways of thinking start to re-emerge. Firstly, we start to equate mental reality with outerreality. When arguments escalate, for example, one’s bad feelings (inner reality) may be automatically equated with the other person being ‘bad’ (out reality). This is also why flashbacks (a mental image) can feel so real to trauma sufferers. What we think is felt to be reality itself, instead of a representation of it.
Secondly, when mentalizing fails, we may also withdraw into a ‘pretend’ existence where thoughts are not linked to external reality. When this occurs we experience a disconnect between emotions and external reality and between our own thoughts and feelings. We give excessive detail but exclude feelings and motivations. There is also a preoccupation with rules, labels, excessive certainty about the thoughts of others and constant allocation of blame. When you’re sitting with someone operating in the pretend mode, it is difficult to stay connected to what they are saying and boredom quickly sets in because the conversation feels inconsequential and not clearly linked to the person’s reality.
The capacity to track and process mental states is partly learned and partly influenced by our genetic makeup. We learn to identify emotional states and thought processes first by internalizing how our attachment figures interpreted and responded to us as preverbal infants. When a mother is able to notice distress and respond to it in her infant, she effectively draws the infant’s attention to the fact that she is having an experience that can be thought about and attended to. In doing so, the infant starts to feel soothed and held in the mother’s mind. This results in the internalization of a hopeful, soothing internal object that can be relied upon and re-experienced in times of distress. Put simply, attachment figures have a crucial role to play in ‘thinking for the infant’, in ‘marking’ their experience and generating basic connections between somatic/affective states and mental representations. Tronick’s (1975) still-face experiment demonstrates how this can easily go wrong. After getting mothers to interact with their one-year olds normally, he asked them to maintain a ‘still-face’ and remain non-responsive to their baby’s gestures and attempts at communication. In this state the baby very quickly becames emotionally dysregulated and starts behaving destructively (hitting things and himself). This demonstrates how dependent the infant is on the mother’s ability to notice and regulate the infant’s emotions, giving him a sense that he is sharing experience and being ‘seen’. Without this the child is left swamped by feelings that have no meaning, forcing him to resort to destructive behaviours as an attempt to self-regulate emotion. Aside from having to deal with unprocessed affect, there is also an intersubjective component to this that involves the absence of an experience of feeling mentalized, leading to a sense of feeling invisible or absent to others.
The mother’s mentalizing capacity is crucial in building the infant’s mental representations about his own experience and the experience of others. Being able to ‘re-present’ something mentally effectively teaches us that our mental world exists separate from physical reality (and similarly, separate from the thoughts of others). This grants us our capacity to distance ourselves from difficult feeling states so as to put them in perspective. We have a sense of being able to ‘ look in on ourselves’ and notice that ‘feelings are only feelings’ that can be thought about and their meaning understood.
Mentalization-based therapy has been effective with Borderline patients because this is the essence of what they struggle with. In a nutshell, the borderline struggle is about living with feeling that cannotbe easily identified, communicated or regulated. Rather than being able to identify and track feeling states so as to understand behaviour and act accordingly, borderline patients mostly describe an unprocessed mass of ‘pressure’ that they cannot escape, a feeling of always being trapped in the present with little sense of time passing. This explains why borderline patients, on the one hand, are so easily overwhelmed by everyday experiences, minor slights or interpersonal difficulties, and on the other hand, don’t know they’re feeling overwhelmed until emotions have reached explosive levels.
Perhaps the most intriguing aspect of mentalization theory is how it informs our therapeutic stance and our approach to forming a solid therapeutic alliance. Given that mentalizing fails when unresolved affect escalates (and ‘acting out’ begins), the therapeutic task essentially involves inducing or focusing on emotion while, at the same time, trying to enhance the patient’s ability to mentalize (create multiple perspective and representations about the situation). Because minds are opaque, the therapist adopts a ‘not-knowing’ stance, always communicating and modelling the idea that therapist and patient have to investigate mental states before jumping to conclusions. This is often difficult to do because we naturally recoil from thinking about difficult emotions. A patient might say after an argument, for instance, “ It just happened, I don’t know why, I was mad at him’ (a non-mentalized account). While recalling the account the patient may seem content to settle for this account (often convincing the therapist to accept it too) as he begins to feel uncomfortable emotions rise in him in the retelling. But it is at these times that the therapist needs to jump in to enquire and insist on hearing about the mental states behind the act. The revised mentalized account might sound something like: “I felt I was smaller than him and he was saying I was useless. This triggered an embarrassed feeling in me that I used get as a boy. I fought with him because I felt him as arrogant. Now I can see he was just trying to get his point of view across.” There are constant references to internal states here that help build up a plausible ‘picture’ of the situation, in turn building a more coherent sense of self.
Our best clue to when mentalizing starts to fail is our countertransference. As a rule of thumb, when the patient is mentalizing they are effective in building representation in the therapsit’s mind and the narrative is easily followed and understood. It is at points when the therapist struggles to follow that he or she needs to be astute in communicating a difficulty in understanding the patient, inviting further thought and enquiry. Certainty about emotions and mental states stands in the way of the mentalizing. Rather, the therapist communicates doubt and curiosity, inviting a collaborative focus on his/her mind to build plausible and detailed accounts of psychic life.
The intense focus on minds builds a strong sense of alliance a complex reciprocal sense of “ I see you seeing me seeing you’—a process that embodies how we need each other to think. Importantly, this also has the effect of building a sense of agency in our interaction with the world. As a patient of mine once put it: “In the heat of emotion I can now think about what’s on my mind, what leads me there. Before, my feelings had me, I didn’t have feelings”.
About the author
Duncan Cartwright is head of the Centre for Applied Psychology, University of Kwa-Zulu Natal, South Africa. He is in part-time private practice. He is the author of Psychoanalysis, Violence and Rage-Type Murder (Routledge 2002) and Containing States of Mind (Routledge 2010)
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