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(p. 77) Mentalization in transition 

(p. 77) Mentalization in transition
Chapter:
(p. 77) Mentalization in transition
Author(s):

Robbie Duschinsky

and Sarah Foster

DOI:
10.1093/med-psych/9780198871187.003.0005
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date: 06 December 2021

Introduction

By the end of the 1990s, Fonagy and colleagues had worked for 10 years in developing the concept of mentalization, alongside a developmental model of its emergence from early child–caregiver relationships. They had highlighted the importance of mentalization for psychotherapy, and especially for work with patients with borderline personality disorder (BPD). Furthermore, the reflective functioning scale for the Adult Attachment Interview had been validated as a measure of mentalization in the context of attachment relationships and demonstrated impressive prediction to infant–caregiver relationships as assessed in the Strange Situation procedure. Yet, over the 2000s, Fonagy and colleagues became more and more dissatisfied with their initial model, identifying that the concept of ‘mentalization’ was too absorptive and that they had placed too much weight on early childhood experiences and the role of disorganized attachment. Attempts to correct these problems led to a revised and more mature account of forms of mentalizing.1 In this chapter, we will trace these developments of the 2000s, paying particular attention to Fonagy and Luyten’s 2009 account of four dimensions of mentalizing. The chapter will close by attempting to discern the underpinning logic of the concept of mentalization across its diverse uses and definitions. Synthesising the various uses of the term, mentalization will be ultimately defined as a capacity to:

  1. 1. conceive of

  2. 2. and make available for reconsideration

  3. 3. the thoughts

  4. 4. and feelings

  5. 5. implicated in motivations and intentions

  6. 6. in order to account for and explain

  7. 7. the observable social behaviour

  8. 8. and present and past perceptual experience

  9. 9. of oneself

  10. 10. and others.

Self-criticism

As we saw in the previous chapter, in the 1990s, Fonagy and colleagues had tended to write about reflective functioning and mentalization as if they were relatively basic and discrete. (p. 78) However, in the late 1990s and especially from the early 2000s, the terms ‘reflective functioning’ and ‘mentalizing’ were increasingly recognized as descriptive accounts of composite psychological processes. Particular attention was given to effortful attentional control and affect regulation as developmental requisites2 and component elements of mentalization, as well as—additionally—effects of mentalization. For instance, attentional control would help an individual retain access to inferential information about the other’s mind even in the context of distractions or stress. In turn, awareness of the other’s mind could help inform attentional processes, helping to organize and scaffold them.3

Fonagy characterized attentional control, affect regulation, and mentalizing as interacting elements of a meta-process he termed the ‘interpersonal interpretive function’.4 This was the beginning of the network approach to mental health that would be developed in the work of Fonagy and colleagues in later years (see Chapter 7). In the late 1990s and early 2000s, however, Fonagy and colleagues initially adopted a more linear model, grounded in attachment theory. They proposed the importance of attachment patterns for attentional control and affect regulation, which in turn serve as the scaffolding for mentalization in general.5

Despite this importance given to attachment, a transition in Fonagy and colleagues’ perspective was growing acknowledgement that adverse early caregiving experiences was not the only factor in play. Already in 1997, Fonagy and Target acknowledged that ‘the child’s biological vulnerabilities such as hyperactivity, attention problems, low impulse control, are all likely to obstruct the opportunity the child has for evolving a mentalized reflective model’.6 One early project addressing potential biological vulnerabilities was Pasco Fearon’s 1998 doctoral study under Fonagy’s supervision. Sixty-two same-sex twins were seen in the Strange Situation procedure with a primary caregiver. Fearon found that there was no more concordance in the twins’ patterns of attachment to a primary caregiver than would be expected by chance.7 These findings were then replicated in collaboration with van IJzendoorn (p. 79) and colleagues at Leiden.8 However, a later study by Fearon with 551 twin pairs, and using an adaptation of the Adult Attachment Interview for adolescents, found very substantial associations between monozygotic twins’ scores for coherence and their overall security of attachment (r = .42), but substantially lower associations for dizygotic twins (r = .20).9 Fearon and colleagues concluded that genetic factors may have little influence on infant attachment, but that genetic expression may have greater influence by adolescence.

Fonagy and colleagues were also interested in the potential for heritable contributions to other aspects of psychological functioning relevant to mentalization, such as predisposition to mental illness. For instance, a study by Belsky, Caspi, and colleagues, in which Fonagy was involved, found that 47% of early adolescents showed clinical levels of BPD symptomatology if they had experienced maltreatment and also had a parent with mental health problem, whereas only around 7% of adolescents showed these symptoms when one or the other factor was present. Although, naturally, parental mental illness could also contribute to child caregiving and the general atmosphere of the home, the researchers interpreted these findings as indicating the potentiating role of genetic vulnerability when combined with maltreatment.10 Whereas Fonagy had earlier emphasized a solely environmental pathway to BPD, the collaboration with Belsky and Caspi indicated concern with the potential for genetic susceptibilities that could interact with environmental risk factors.

As well as growing interest in genetic factors, the 2000s also saw a strengthening emphasis in the writings of Fonagy and colleagues on the diversity of social experiences that could influence mentalizing capacities. Fonagy and Target described the importance of non-parental influence and care—for instance, the role of grandparents, older siblings, teachers, and friends: ‘Children can perceive and conceive of their mental states to the extent that the behaviour of those around them has implied that they have them. This can happen through an almost unlimited set of methods.’11 One important study in support of this position from the early 2000s was the trial of a school-based intervention, which will be discussed further in Chapter 9.12 The weight given to additional discrete figures beyond the primary caregiver was in line with developments in attachment theory.13 Nonetheless, this innovation put additional pressure on the integrity of the conceptualization of reflective functioning and mentalizing as unitary processes.

(p. 80) In their 2003 book, Psychoanalytic Theories, Fonagy and Target reviewed each psychoanalytic model, and appraised its strengths and weaknesses. Admirably, their own work was not spared such appraisal. One major criticism they levelled at themselves was that ‘some people seem to be able to mentalise well but show poor functioning’. That is to say, some people’s difficulties in mentalizing primarily occur in relation to attachment relationships and not in relation to other relationships. Ultimately, they acknowledged, it was not clear that mentalization and reflective function should be regarded as ‘a single mechanism’.14 Similarly, an individual may be good at identifying mental states, such as the difference between sadness and tiredness, but not thinking about or contextualizing these states—or vice versa. The individual may be good at thinking about others, but not themselves—or vice versa. An individual may be good at sustaining mentalization but find it difficult to regain when lost—or vice versa. These are all highly clinically relevant distinctions. Over the 2000s, there was growing awareness among Fonagy and colleagues that a whole menagerie of various clinically-relevant differences could be observed within, and to an extent hidden by, the concept of mentalization if one opened up the roof and looked inside.

Impetus to address these problems came with public criticisms by Choi-Kain and Gunderson in their 2008 review of mentalization as a concept and psychological construct. Choi-Kain and Gunderson expressed concern that Fonagy and colleagues too often had veered towards treating mentalization as a single thing, which they felt was encapsulated in the way that reflective function had been operationalized:

There are limitations in interpreting the meaning of a given reflective functioning score. The capacity that is assessed by the Reflective Functioning Scale is multidimensional, with factors such as plausibility, consistency, complexity, and originality. However, the grading is done using a unidimensional score that cannot be submitted to factor analysis. In two different transcripts coded for reflective functioning with a score of 3, one transcript may reflect a consistently superficial, clichéd, and general understanding of mental states, while the other transcript reflects a highly variable capacity to understand mental states with some moments of antireflectiveness and other moments of marked reflectiveness.15

This concern was fully accepted by Target, Fonagy, and Luyten in papers over the subsequent months.16 They proposed that mentalization represented a hierarchically organized set of capacities. This meant that different components tended to occur together, giving (p. 81) the aggregate impression of mentalization and reflective function as unitary properties of a person. This aggregation, as it appeared in the context of the Adult Attachment Interview, was what was measured by the reflective functioning scale. But, in fact, substantial differences would be anticipated in the challenges individuals face in mentalizing, depending on their history and the characteristics of the present situation.

Fonagy, Gergely, and Target acknowledged that mentalization requires ‘a complex set of cognitive capacities’. These include the abilities: ‘1) to represent causal mental states of others with counterfactual contents (false beliefs), 2) to represent causal mental states of others with fictional contents (pretence, imagination, fantasy), 3) to simultaneously represent and differentiate between the mental models of the self and of the other about reality, 4) to infer and attribute the mental states of others from visible behavioural cues, and 5) to detect our own perceptible (behavioural, physiological, emotional, arousal, etc.) cues in order to infer, interpret, and attribute mental states to our self.’17 It by no means could be assumed that these cognitive capacities would have the same developmental trajectory, neurological supports, or social scaffolding for their elaboration. The conditions that would help one capacity flourish might even at times inhibit one or all of the other four. The distinctions between the five cognitive sub-capacities of mentalization suggest important individual differences in the capacity to mentalize the self compared with the capacity to mentalize others, and to distinguish these. However, they also imply that individuals may differ in the cognitive supports that permit the imaginative capacity to envision and represent counterfactual mental states, and the ability to detect observable cues for inferring and interpreting mental states.

A second major self-criticism raised by Fonagy and Target in Psychoanalytic Theories was the concern that, as a consequence of its origins in psychoanalysis, there ‘is over-emphasis on the earliest years as formative’ in their work to date.18 At this point, in 2003, Fonagy and colleagues still generally claimed that disorganized attachment, conceptualized as a kind of relational trauma, specifically would form the most important pathway to difficulties with mentalizing. When this trauma was severe and/or remained unresolved, the result could be anticipated to be BPD.19 However, this account did not sit well with the growing recognition of the variety of factors that could influence attentional control, affect regulation, and mentalization in general. In the mid-2000s, Fonagy and colleagues—Bateman especially—were struck by growing evidence from longitudinal research suggesting that the majority of patients with BPD do not have a history of sexual or physical abuse, though these experiences are certainly more common in this population.20 Childhood and adolescence were clearly (p. 82) important periods for the development of mental health symptoms.21 However, the exact developmental processes in question required further examination. Whereas Fonagy and colleagues had previously emphasized the integral role of attachment in the development of BPD, this claim was increasingly tempered. A prominent criticism of the emphasis on attachment was offered by Gergely at a conference in 2005. Gergely argued that mentalization capabilities develop alongside, not out of, qualitative differences in attachment.22 He also proposed a developmental role for epistemic trust (see Chapter 7).

Four poles of mentalizing

Responding to problems with the construct of ‘mentalization’ and the question of developmental trajectory, Fonagy worked with Patrick Luyten in the late 2000s to address these concerns. Drawing on a review by Lieberman of the neuroscientific basis of forms of social cognition, in a paper published in 2009, Fonagy and Luyten described four ‘polarities’ of mentalization: internal and external; affective and cognitive; self and other; implicit and explicit.23 They proposed these polarities as the most significant areas of potential individual differences in mentalizing. Following Lieberman, they also speculated that they would be subserved by different neurological structures. Since they were introduced, the four polarities have been absolutely central to guidance on matters of clinical technique offered by Fonagy and colleagues over the subsequent 10 years. They have regarded it as extremely helpful for clinicians to consider whether patients can engage flexibly in different forms of processing: internal and external; affective and cognitive; self and other; implicit and explicit. When a patient seems to be stuck on one ‘side’ of the polarity, Fonagy and colleagues have advised that clinicians should consider attempting a ‘contrary move’ to support mentalization on the other ‘side’.24 This has been generally well received, and regarded as a helpfully specific and coherent piece of guidance. Yet, as well as pragmatic guidance for clinical technique, the four polarities were also presented as an account of the fundamental aspects of mentalization as a construct, and have subsequently been discussed in these terms.

A first distinction drawn by Fonagy and Luyten was between attention to the internal thoughts and feelings of a person, and attention to their behaviour. This distinction appeared to be an attempt to respond to their clinical impression that many patients with BPD can be vigilant and effective in observing external behavioural cues and have specific capabilities to notice the emotional states of others. Experimental researchers had also begun to document that patients with BPD do no worse, and sometimes actually better, than controls in facial emotion recognition and in theory of mind tasks.25 However, the distinction between (p. 83) external and internal mentalization was quite a confused one. Previously, attention directed towards external behavioural cues rather than their internal mental states was not considered part of mentalizing: in fact, it had been considered specifically as a form of non-mentalizing (see Chapter 5). In Fonagy and Luyten’s proposal, this non-mentalizing was termed ‘external mentalizing’. It was contrasted with the identification and interpretation of mental states, which was now officially termed ‘internal mentalizing’, but generally just ‘mentalizing’. There was evident room for muddle here, with ‘mentalizing’ being used to mean non-mentalizing.

Part of the problem was the expansive semantic domain covered by the term ‘mentalization’. Where mentalising meant the capacity to notice and respond to mental states in others, then vigilance in observing external behavioural cues could be an asset. However, where mentalisation was taken to mean the more general capacity to describe and interpret thoughts, feelings and intentions in oneself and others, then a focus on external behaviour at the expense of consideration of the motivations and inner life of the other or the self was non-mentalizing. Later, Fonagy and Bateman would claim that ‘mentalising is optimal when the dimensions—for example, emotion and cognition, or representation of self and other—are in balance and nonmentalizing modes are inactive.’26 It is telling that the example of internalizing and externalizing mentalizing is not chosen to illustrate the ideal state of balance, because ‘external mentalizing’ veers towards a form of non-mentalizing. Detection and interpretation of observable behavioural cues is clearly a helpful contributor to mentalization, but only when it is in the service of envisioning and representing mental states. And this is not ‘balance’ between two poles.

In Fonagy and Luyten’s 2009 paper, another distinction was drawn between the ‘poles’ of cognitive and affective mentalizing. This was, in fact, more a formalization of an existing distinction than a new addition to the theory. Since his earliest writings, Fonagy had tended to use the phrase ‘thoughts and feelings’ as a synonym for mental states, and this usage became more frequent in his writings with Target.27 In their 2009 paper, Fonagy and Luyten drew a distinction between the capacity to identify and interpret thoughts, and the capacity to identify and interpret feelings. The former was termed ‘cognitive mentalizing’ and the latter was termed ‘affective mentalizing’. This echoed developments in Baron-Cohen’s work, which distinguished between systematizing and empathizing forms of social cognition.28 Cognitive mentalizing and affective mentalizing appear in Fonagy and Luyten’s 2009 paper to reflect the target of the activity—thoughts or feelings. It was not in the first instance a distinction regarding how the thought or feeling was recognized, which was generally assumed to be aligned and therefore left undistinguished. In principle, mental states could be understood through various means, among them formal-deductive reasoning and embodied affective resonance. The former might often be used to interpret thoughts. However, (p. 84) it can certainly be applied to feelings. In the latter case, then technically, according to Fonagy and Luyten’s 2009 paper, formal-deductive reasoning would then be affective mentalizing. Likewise, embodied affective resonance is often used to interpret feelings, but might also be used to understand thoughts. In the latter case, technically embodied affective resonance would then be cognitive mentalizing. In sum, the characterization of cognitive and affective mentalizing by Fonagy and Luyten failed to draw a distinction between the cognitive/affective means of understanding and the target of mentalization. This has caused serious problems for subsequent work in discussions of phenomena like empathy, with a lack of clarity in the respective roles of cognition and affect, and the relative interdependence and independence of mentalizing and empathy.29 Sharper attentiveness in the work of Jurist between affect as the means of understanding and as the target of mentalization has yet to filter effectively into wider discussions in the mentalization literature of the cognitive/affective ‘poles’.30

A third distinction drawn by Fonagy and Luyten was between mentalizing the self and mentalizing others. However, this was, by their own admission, not actually an opposition of the same kind as the others. When Fonagy and colleagues first announced the reflective functioning scale in 1991, they had acknowledged that—in contrast to Main’s metacognitive monitoring scale—their reflective functioning scale collapsed differences between people who were good at reflecting on their own mental states, and those who were good at reflecting on the mental states of others.31 Yet, at the time, and through to the late 1990s, Fonagy and colleagues argued that mentalization of self and others was ultimately integrated into a unitary process in the course of development, which meant that it was reasonable to measure them all together with a unitary scale.32 In their 2009 paper, Fonagy and Luyten still held that the capacity to mentalize the self and others would generally come together. The reason for this was that they held that the capacity to understand the self is secondary, essentially an extension of the capacity to understand others in the context of attachment relationships. They held that it would be impossible to have a good understanding of the self and a poor understanding of others.33 This claim appears to have been backtracked in (p. 85) subsequent work, or even reversed into the proposition that “to mentalise others requires the capacity to mentalise the self.”34 The developmental precedence and the causal precedence of mentalizing others and mentalizing the self has been an ongoing and unsolved problem in the work of Fonagy and colleagues. Nonetheless, there is clearly a distinction here. In the Fonagy and Luyten 2009 paper, as well as in subsequent work, the authors have urged attention to the possibility that individuals may have better understanding of others than of themselves, or poor understanding of both—for instance, through confusion of the mental states of self and other.

Perhaps the most important of the four distinctions drawn by Fonagy and Luyten was between automatic and controlled mentalizing, a distinction drawn from existing discussions in social cognition. There had been growing attention in the 2000s in cognitive neuroscience to the distinction between automatic and controlled mental processes.35 Drawing on this literature, in 2004, Frith had argued that people at the high-functioning end of the autistic spectrum may lack automatic mentalizing, but have acquired skills in explicit mentalizing on the basis of experience and reasoning.36 The distinction between automatic and controlled mentalizing appealed to Fonagy and Luyten’s mutual commitment to psychoanalysis, and the importance of non-conscious processes, including clinicians’ own implicit understandings.37 The characterization of automatic mentalizing offered by Fonagy and Luyten has dissatisfied many commentators as insufficiently fleshed out.38 However, in general terms, it would appear that they regarded automatic mentalizing as a quick, affect-led, unintended (p. 86) process of identifying and making use of knowledge of mental states, running in the background of lived experience without awareness or effort, and responsive to the challenges of the particular moment. Controlled mentalizing seems to have been regarded as the deliberate, cognition-led and effortful attempt to identify and reason about mental states, a relatively slow and serial process, somewhat more removed from the hurly-burly of the demands of the moment.

The way that the distinction between automatic and controlled processing was introduced by Fonagy and Luyten gives the impression that automatic processing is the same as implicit, non-mentalizing processing. However, elsewhere in the article, it is implied that it is possible to have i) automatic mentalizing and ii) automatic non-mentalizing; just as it is possible to have iii) controlled mentalizing and iv) controlled non-mentalizing. Havsteen-Franklin has recently drawn out these distinctions, and termed this the ‘mentalizing quadrant’.39 It is very confusing for Fonagy and Luyten to refer to both automatic mentalizing and automatic non-mentalizing as ‘automatic mentalizing’. It forces them into strange claims, such as that the fight/flight/freeze response is a form of mentalizing.40 Or again, consider that Fonagy and colleagues have described the reflective functioning scale for the Adult Attachment Interview as measuring automatic mentalizing.41 This would simply be contradictory if by this they meant implicit, non-mentalizing processing.42 In brief, Fonagy and Luyten’s primary characterization of automatic and controlled mentalization presumed alignment with non-mentalizing and mentalizing, when even statements in their own article suggest a more complicated situation.43 It also presumed alignment of automatic with fast, and controlled with slow, mentalizing. This provides no place for the implicit, slow processes of ‘feeling things out’ that precisely, as Fonagy has acknowledged elsewhere, comprise a large bulk of work in psychotherapy.44 It also leaves unclear the respective role of culture in (p. 87) implicit mentalizing—perhaps as conventional response, perhaps as habit—and controlled mentalizing—perhaps as semiotic scaffolding for reflection. This makes automatic and controlled mentalization appear to be solely kinds of individual response, cutting them out from their constitutive contexts. As we shall see in Chapter 9, Fonagy and colleagues have spotlighted such processes as central to their current thinking about mentalization; however, they are yet to reconsider automatic and controlled mentalizing on this basis.

Fonagy has spoken of his dismay at the lack of uptake of the 2009 model of four dimensions by other researchers and clinicians, and he has speculated that the model may be too complicated.45 We hold that, rather than too complicated, the lack of uptake results from the fact that the account is confusing on several grounds. For instance, the term ‘mentalizing’ in the account of automatic and controlled processes sometimes was used, precisely, to mean ‘non-mentalizing’. Likewise, ‘external mentalizing’ sometimes meant, precisely, ‘non-mentalizing’. The opposition between affective and cognitive mentalizing was also not especially sharp, because it was not clear whether what is ‘affective’ or ‘cognitive’ refers to the target of understanding or the mechanism for understanding. The opposition between automatic and controlled mentalizing also gives no clear place to the slow process of ‘feeling things out’, which is not well characterized either as automatic or controlled processing.

Leaving the four poles of mentalizing aside, the Fonagy and Luyten paper also offered an important revision of the developmental model. They argued that attachment relationships calibrate: i) the threshold at which an individual will feel tugged towards automatic processing under conditions of high arousal, ii) the extent to which automatic processing is able to identify and interpret mental states; iii) the ability of the individual to resist the tug of automatic processing and retain the capacity for explicit reasoning; and iv) the extent to which familiar others are sought in the context of high arousal.46 Fonagy and Luyten anticipated that secure attachment would raise the threshold for activation of the attachment system, increase capacities for automatic mentalizing, stabilize the retention of explicit reasoning, and draw effectively on social support for the maintenance of emotion regulation. Just like the secure infant in the Strange Situation can shift readily between exploration and care-seeking, depending on the context, Fonagy and Luyten presumed that secure attachment would facilitate the easy shift of gears between automatic and controlled mentalizing depending on what was called for.47

Avoidant attachment would raise the threshold for activation of the attachment system, reduce capacities for automatic mentalizing about the self, stabilize the retention of explicit reasoning, and make less use of familiar others in achieving emotion regulation. However, this explicit reasoning could still have gaps or lapses in mentalizing where it would otherwise (p. 88) need to be informed by affect and automatic mentalizing.48 By contrast, ambivalent/resistant attachment and disorganized attachment would be anticipated to i) lower the threshold for activation of the attachment system, ii) reduce capacities for automatic mentalizing about others and prompt self/other confusions, iii) destabilize the retention of explicit reasoning, and iv) contribute to difficulties in making use of familiar others for emotion regulation.49 This configuration is of particular importance for Fonagy and Luyten, because they regarded these interacting elements specifically as the basis for the development of BPD. There may be few deficits in mentalizing for patients with BPD when they are calm. But it was anticipated—and indeed later research would find—that in response to arousal, and specifically the activation of the attachment system, the anticipated difficulties in mentalizing would become evident.50 Early disruptions in attachment would make mental states difficult to identify and attribute to self or other, while simultaneously prompting vigilance regarding mental states, which would be interpreted as potentially threatening. The lowered threshold for activation of the attachment system would keep controlled mentalization offline, hindering the integration of affective and cognitive forms of mentalizing. In turn, this would sustain difficulties in mentalizing the self and others, and ensuing difficulties in making use of social relationships for modulating troubling affects (see Figure 4.1).51

Figure 4.1 Model of the causes and feature of BPD.

Figure 4.1 Model of the causes and feature of BPD.

Source: Reproduced from Peter Fonagy and Patrick Luyten, ‘A Developmental, Mentalization-Based Approach to the Understanding and Treatment of Borderline Personality Disorder’, Development and Psychopathology 21(4): 1355–1381, Figure 2, DOI: https://doi.org/10.1017/S0954579409990198 Copyright © Cambridge University Press 2009.

In short, Fonagy and Luyten’s model suggested that difficulties with mentalising, affect regulation, social relationships and executive function can exacerbate one another. When arousal is low and there is little perception of threat few, if any, deficits in mentalisation are likely to be evident. However, when the individual faces difficult feelings or situations, Fonagy and Luyten proposed that the result will be a lowered threshold for entering a state of automatic non-mentalized responding, and a raised threshold for engaging in the controlled mentalized processing that might help integrate affective arousal with cognitive understanding and perspective. Automatic, non-mentalized responses are likely to be headlong, lacking in measure and composure, and predisposed to contribute to relationship difficulties, especially in attachment relationships.52 In this state, there is little patience for prompts (p. 89) to stop and reconsider before acting. Repeated or sustained deployment of these responses will also hinder the capacity of the individual to identify and understand their own mental states and experience fulfilment from their relationships, contributing to identity diffusion and feelings of inner emptiness.

In 2012, Luyten, Fonagy, and colleagues built on this account to propose a multidimensional approach to the assessment of mentalizing.53 They advised that psychological assessment should appraise the extent to which the mentalizing profile differs across specific attachment relationships. Some relationships may prompt lowered or raised thresholds for states of automatic, non-mentalized processing, and may hinder or support the maintenance of the capacity for controlled, mentalized processing. They emphasized the importance of the extent to which an individual can accept help and support in sustaining mentalizing under conditions of perceived threat or arousal. They also presented the concept of a ‘mentalizing profile’ as a characterization of how an individual functions on each of the four axes: whether the individual attends only to external behavioural cues, or also considers internal feelings, thoughts, and motivations; whether the individual can describe and interpret more readily thoughts or feelings; whether the individual has greater ability to consider mental states in (p. 90) others or also to understand mental states in themselves; and how readily the individual enters into states of automatic, non-mentalized processing, as well as whether they can readily access states of controlled, mentalized processing. However, without any measure available of the four poles of mentalizing, the concept of the mentalizing profile has remained a recommendation for clinical practice based much more in theory than in dedicated empirical research. This has made claims about the mentalizing profiles of different client groups, or the treatments that should be tailored to different mentalizing profiles, essentially unfalsifiable. Given the problems with the four poles framework, it is not certain that creation of such a measure is even technically possible without significant further revision to the framework. Nonetheless, the proposal to attend to mentalizing profiles represents an advance in advocating a reduction of the reification of mentalizing in clinical practice.

In line with this concern for greater specificity in conceptualizing mentalization, Berthelot, Fonagy, and colleagues attempted a replication of the Fonagy, Steele, Moran, Steele, and Higgitt study of intergenerational transmission, with a sample of 57 mothers screened for high probability of inadequate care in their own childhoods.54 Adult Attachment Interviews and Strange Situation procedures were conducted, as in the original study. However, as well as using the reflective functioning scale on the Adult Attachment Interviews conducted with the mothers, the researchers also elaborated a sub-scale focused specifically on the capacity of the speaker to mentalize about traumatic episodes at any point in their attachment history. As in the original study, in 72% of cases, there was a match between the Adult Attachment Interview classification of the caregiver and Strange Situation classifications of the infant–caregiver dyad on security/insecurity. In the case of speakers unresolved for loss or trauma, 70% had relationships classified as disorganized in the Strange Situation procedure. In a regression, unresolved trauma accounted for 22% of variance in infant attachment disorganization. The general reflective function scale made no additional contribution to predicted variance. Yet, when reflective function about attachment-related trauma was entered into the regression, the model accounted for 41% of variance. The researchers concluded that it was not lack of mentalization in general that was influential for predisposing disorganized infant–caregiver attachment relationships, but the caregiver’s capacity to mentalize about specific attachment-related traumas.55

Another qualification to the Fonagy and Luyten model came through Fonagy’s collaboration with Karin Ensink and colleagues. Fonagy and Luyten had implied an undifferentiated contribution of non-mentalizing to mental health symptoms. Yet the pathway to impulsive and aggressive behaviour might not be the same as to inner emptiness and depression. This is hinted at by Figure 2 in Fonagy and Luyten’s paper, where internalizing and externalizing symptoms were placed in different boxes. But the distinction was not drawn in the text.56 Ensink and colleagues conducted a study with 74 mother–child dyads where the child had experienced sexual abuse, and 96 matched controls.57 The children in the study were aged (p. 91) 7–12 and completed the adaptation of the Adult Attachment Interview for this age group, which was coded for age-appropriate reflective function. Child dissociative, externalizing, and inappropriate sexual behaviours were assessed by parent report; depression was measured by child self-report. Path analysis modelling revealed that the association between sexual abuse and impulsivity and aggression accounted for around 60% of variance, and was entirely mediated by child reflective function and dissociation. Most of the mediation was accounted for by dissociation. However, there was also some sequential mediation through the effects of sexual abuse on reflective function, which in turn contributed to dissociation. Similar findings were found for inappropriate sexual behaviours. By contrast, 34% of the effects of abuse on child depression could be accounted for by child reflective functioning, and here dissociation had no mediating role. Ensink and colleagues concluded from their findings that the Fonagy and Luyten model needed to be rectified to specify the role of dissociation rather than merely absorbing it into non-mentalizing, given the finding of serial mediation between reflective function and dissociation in predicting impulsivity and aggression. Fonagy has admitted that dissociation has tended to be a rather ‘shadowy concept’, and requires renewed discrimination and attention from non-mentalizing.58 This has been facilitated in recent years by the availability of a self-report measure of mentalizing (see Chapter 5).59

A response to the limitations of the Fonagy and Luyten 2009 account was presented by Fonagy, Luyten, Allison, and Campbell in 2017 in a landmark paper entitled ‘What We have Changed our Minds about’.60 The major amendment made there to the model of the genesis of BPD was to qualify the importance of early attachment. Instead of insisting on the importance of early disorganized attachment (see Chapter 3), Fonagy and colleagues argued for a cycle that could begin at any point between problems in relationships, difficulties in sustaining attention to and understanding mental states, and heightened negative affect. Problems in attachment relationships across childhood and adolescence might contribute to all three processes, but without attachment being regarded as a foundational cause, as in the Luyten and Fonagy 2009 model. It was now proposed that the roots of borderline as a ‘personality’ disorder lay not in the long-term influence of attachment or in the stability of personality, but in the stability of the interaction between problems in relationships, difficulties in sustaining attention to and understanding mental states, and heightened negative affect. This account will be discussed further in Chapter 7.61 Another shift from 2009 to 2017 has been to stress the importance of social interaction in stabilizing or destabilizing mentalizing capacities. In particular, Fonagy’s collaboration with Liz Allison, Chloe Campbell, and Patrick Luyten had led to a perspective that does not treat mentalization as a good in itself, (p. 92) but as a catalyst to allow an individual to sift and learn from social experience, effectively and with good discrimination. This will be discussed further in Chapter 9.

Defining mentalizing

In a recent commentary, Fonagy and colleagues recalled that ‘initially we provided a model proposing improvements in the capacity to mentalize as a central mechanism shared by a wide range of treatment approaches. Further reflection and empirical and clinical evidence have led us to doubt the sufficiency of this assumption. We have all seen many patients whose capacity to mentalize benefited from psychanalytic psychotherapy without corresponding improvement in their social-emotional functioning. It seems, then, that we should be more specific.’62 Even allies of Fonagy and colleagues have come to characterize the concept of ‘mentalization’ as functionally ‘bloodless’ now.63 Such a characterization takes matters too far. The concept remains very much alive and purposive. However, to support future attempts at greater specificity, as well as effective articulation and review of ideas in the rest of the book, to close this chapter we will present a survey of definitions of mentalization over 30 years: from Fonagy’s first use of the term in 1989 to the present. Our discussion of the different definitions is certainly not an end in itself; instead, our intention is to be constructive in attempting to map the scope of the concept, on the way to a new synthesis and definition. This will then support an analysis of the central elements of the construct, to facilitate the discussion of the subsequent chapters. Twenty-eight distinct definitions of mentalization can be identified in the writings of Fonagy and his collaborators. These can be seen in Table 4.1.

Table 4.1 Definitions of mentalization

Year

Source

Definition of mentalization

1989

Fonagy, P. (1989). ‘On Tolerating Mental States: Theory of Mind in Borderline Patients’. Bulletin of the Anna Freud Centre, 12: 91–115, p. 97.

‘For the sake of brevity rather then reification I would like to label the capacity to conceive of mental states in oneself, as the capacity to mentalize.’

1995

Fonagy, P. and Target, M. (1995). ‘Understanding the Violent Patient: The Use of the Body and the Role of fhe Father’. The International Journal of Psychoanalysis, 76: 487–501, p. 487.

‘Mentalisation, as the capacity to think about mental states’

1995

Fonagy, P. and Target (1995). ‘Playing with Reality: The Development of Psychic Reality and its Malfunction in Borderline Personalities’. The International Journal of Psychoanalysis, 76: 39–44.

‘With the capacity to mentalize, to see ideas as merely ideas and not facts, to play with different points of view, there comes the capacity to test ideas against reality and therefore to moderate their impact’ (p. 229).

1996

Fonagy, P. (1996). ‘The Significance of the Development of Metacognitive Control over Mental Representations in Parenting and Infant Development’. Journal of Clinical Psychoanalysis, 5(1): 67–86, p. 74.

‘The psychological processes underpinning the view of oneself and others as motivated by mental states’

1997

Fonagy, P. (1997). ‘Where Cure was Inconceivable. The Aims of Modern Psycho-Analysis with Borderline Patients’. Texte, 3(17): 11–25, p. 15.

‘These representations were unmetabolized, in Bion’s terms, non-mentalising within our theoretical framework.’

1997

Fonagy, P. ([1997] 2002). ‘Multiple voices versus meta-cognition: An attachment theory perspective’, in V. Sinason (ed.), Attachment, Trauma and Multiplicity: Working with Dissociative Identity Disorder London: Brunner-Routledge, pp. 71–85, p. 79.

‘The symptom of dissociation itself, the predominance of multiple voices in treatment may be usefully seen as the converse of mentalization.’

1998

Fonagy, P. (1998). ‘Prevention, the Appropriate Target of Infant Psychotherapy’. Infant Mental Health Journal, 19(2): 124–150, p. 136.

‘Mentalizing, conceiving of interpersonal experience in terms of mental states or minds’ (p. 136).

1999

Fonagy, P. (1999). ‘Points of Contact and Divergence between Psychoanalytic and Attachment Theories: Is Psychoanalytic Theory Truly Different?’ Psychoanalytic Inquiry, 19(4): 448–480, p. 461.

‘The notion of reflective function or mentalization is already present in Freud’s (1911) notion of Bindung, or linking. Bindung refers to the qualitative change from the physical (immediate) to the psychological (associative) quality of linking’

1999

Fonagy, P. (1999). ‘Male Perpetrators of Violence against Women: An Attachment Theory Perspective’. Journal of Applied Psychoanalytic Studies, 1(1): 7–27, p. 13.

‘Mentalization, the capacity to understand and interpret human behavior in terms of the putative mental states underpinning it, arises through the experience of having been so understood in the context of an attachment relationship.’

2000

Fonagy, P. and Target, M. (2000). ‘Playing with Reality: III. The Persistence of Dual Psychic Reality in Borderline Patients’. The International Journal of Psychoanalysis, 81: 853–873, p. 854.

‘The capacity to mentalize: to assume the existence of thoughts and feelings in oneself and in others, and to recognize these as connected to outer reality’

2002

Fonagy, P., Gergely, G., Jurist, E.L. and Target, M. (2002). Affect Regulation, Mentalisation and the Development of the Self, London: Karnac Books, p. 3.

‘Mentalisation … is the process by which we realise that having a mind mediates our experience of the world’

2003

Allen, J. G. (2003). ‘Mentalizing’. Bulletin of the Menninger Clinic, 67(2): 91–112, p. 94.

‘Mentalizing entails interpreting the behavior of oneself and others in terms of intentional mental states, such as desires, feelings, beliefs, and the like’

2004

Bateman, A. W. and Fonagy, P. (2004). Psychotherapy for Borderline Personality Disorders: Mentalization Based Treatment, Oxford: Oxford University Press, p. 70.

‘The capacity to think about mental states as separate from, yet potentially causing actions.’

2006

Fonagy, P. and Target, M. (2006). ‘The Mentalization-Focused Approach to Self Pathology’. Journal of Personality Disorders, 20: 544–576, p. 545.

‘Mentalization involves both a self-reflective and an interpersonal component. It is underpinned by a large number of specific cognitive skills, including an understanding of emotional states, attention and effortful control, and the capacity to make judgements about subjective states as well as thinking explicitly about states of mind—what we might call mentalization proper. In combination, these functions enable the child to distinguish inner from outer reality and internal mental and emotional processes from interpersonal events.’

2007

Fonagy, P., Gergely, G., and Target, M. (2007). ‘The Parent–Infant Dyad and the Construction of the Subjective Self’. Journal of Child Psychology and Psychiatry, 48(3–4): 288–328, p. 288.

‘We define mentalization following a tradition in philosophy of mind established by Brentano (1973/1874), Dennett (1978) and others as a form of mostly preconscious imaginative mental activity, namely, perceiving and interpreting human behaviour in terms of intentional mental states (e.g., needs, desires, feelings, beliefs, goals, and reasons).’

2008

Bateman, A. and Fonagy, P. (2008). ‘Comorbid Antisocial and Borderline Personality Disorders: Mentalization‐Based Treatment’. Journal of Clinical Psychology, 64(2): 181–194, p. 182.

‘Mentalizing simply implies a focus on mental states in oneself or in others, particularly in explanations of behaviour’

2008

Sharp, C. and Fonagy, P. (2008). ‘The Parent’s Capacity to Treat the Child as a Psychological Agent: Constructs, Measures and Implications for Developmental Psychopathology’. Social Development, 17(3): 737–754, p. 740.

‘What exactly does mentalizing mean within this context? Slade (2005), writing from a psychoanalytic perspective, summarizes the concept as referring to both a cognitive process, akin to psychological insight or perspective-taking, and an emotional process, that is, the capacity to hold, regulate, and fully experience one’s own and others’ emotions in a non-defensive way without becoming overwhelmed or shutting down.’

2008

Bouchard, M. A., Target, M., Lecours, S., Fonagy, P., Tremblay, L. M., Schachter, A., and Stein, H. (2008). ‘Mentalization in Adult Attachment Narratives: Reflective Functioning, Mental States, and Affect Elaboration Compared’. Psychoanalytic Psychology, 25(1): 47–66, p. 48.

‘Mentalization is a term used by both developmental psychologists and psychoanalysts to refer to a core process of human social functioning and self- regulation, involved in the establishment of robust links between personally meaningful early experiences and their representation … However, mentalization has been diversely construed and measured.’

2009

Slade, A. (2009). ‘Mentalizing the Unmentalizable: Parenting

Children on the Spectrum’. Journal of Infant, Child, and Adolescent Psychotherapy, 8(1): 7–21, p. 8.

‘The term mentalization (or reflective functioning) refers to the capacity to envision mental states in the self or other, to use an understanding of mental states—intentions, feelings, thoughts, desires, and beliefs—to make sense of, and even more important, to anticipate another’s (or her own) actions.’

2010

Fonagy, P. (2010). ‘Attachment Trauma and Psychoanalysis: Where Psychoanalysis meets Neuroscience’, in M. Leuzinger-Bohleber, J. Canestri, and M. Target (eds), Early Development and its Disturbances: Clinical, Conceptual and Empirical Research on ADHD and other Psychopathologies and its Epistemological Reflections, London: Karnac Books, pp. 53–75, p. 55.

‘Mentalization is a concept originally introduced by French psychoanalysts (Luquet 1981, 1987; Marty and De M’Uzan 1963) working with psychosomatic patients. They noted a lack of symbolization of mental states in such individuals, a lack of freedom in free association, and a characteristic way of thinking too close to sensations and primary unconscious fantasies.’

2012

Asen, E. and Fonagy, P. (2012). ‘Mentalization‐Based Therapeutic Interventions for Families’. Journal of Family Therapy, 34(4): 347–370, p. 347.

‘Mentalizing is a process and it generally occurs without effort or specific consciousness. It can be summarized as seeing ourselves from the outside and seeing others from the inside.’

2012

Fonagy, P., Bateman, A. W. and Luyten, P. (2012). ‘Introduction and Overview’, in Handbook of Mentalizing in Mental Health Practice. Washington, DC: American Psychiatric Publishing, pp. 3–42, p. 3.

‘Mentalising is a term that has been introduced simultaneously into neuroscience and clinical thinking to denote the remarkable and pervasive human tendency to look beyond the visible shell of the body in understanding behaviour and seeking descriptions and explanations in terms of states of mind.’

2015

Target, M. (2015). ‘A Developmental Model of Sexual Excitement, Desire and Alienation’. Sexualities: Contemporary Psychoanalytic Perspectives, Alessandra Lemma and Paul E. Lynch (eds), London: Karnac Books, pp. 43–62, p. 46.

‘Mentalization is the conscious or preconscious recognition that behaviour is understandable given underlying mental states and intentions, that it therefore has motivation and meaning.’

2016

Bateman, A. W. and Fonagy, P. (2016). Mentalization-Based Treatment for Personality Disorders: A Practical Guide (2nd edn), Oxford: Oxford University Press, p. 291.

‘Mentalising needs to be defined along the lines of being a mental process by which we attribute intentions to each other; it is how we understand each other and ourselves as being driven by underlying motives.’

2017

Bo, S., Sharp, C., Fonagy, P., and Kongerslev, M. (2017). ‘Hypermentalizing, Attachment, and Epistemic Trust in Adolescent BPD: Clinical Illustrations’. Personality Disorders, 8(2): 172–182, p. 173.

‘Mentalizing is related to the concepts of Theory of Mind, social cognition, metacognition, and emotional sensitivity, but considered a broader concept referring to the process of understanding and linking behavior and mental states’

2017

Bevington, D., Fuggle, P., Cracknell, L. and Fonagy, P. (2017). Adaptive Mentalisation-Based Integrative Treatment: A Guide for Teams to Develop Systems of Care, Oxford: Oxford University Press, p. 24.

‘Mentalising will be considered as a mental process that is fundamentally about the constant, concerned effort required to hold an adaptive balance between competing components of psychological functioning.’

2017

Perroud, N., Badoud, D., Weibel, S., Nicastro, R., Hasler, R., Küng, A.L., Luyten, P., Fonagy, P., Dayer, A., Aubry, J.-M., Prada, P. and Debbané, M. (2017). ‘Mentalization in Adults with Attention Deficit Hyperactivity Disorder: Comparison with Controls and Patients with Borderline Personality Disorder’. Psychiatry Research, 256: 334–341, p. 334.

‘The capacity to appreciate the mental states that underlie behaviour’

2019

Duschinsky, R. Collver, J., and Carel, H. (2019). ‘Trust Comes From a Sense of Feeling One’s Self Understood by Another

Mind: An Interview With Peter Fonagy’. Psychoanalytic Psychology, 36(3): 224–227.

‘To have mentalizing you need to be balanced on four dimensions of mentalizing: between cognition and affect, self and other, inside and outside, and reflective and intuitive. We concluded that if you are balanced on these four dimensions then you’re mentalizing.’

2019

Bateman, A. and Fonagy, P. (2019). ‘Introduction’. In Anthony Bateman and Peter Fonagy (eds), Handbook of Mentalising in Mental Health Practice (pp. 3–20). New York: American Psychiatric Association, p. 3.

‘Mentalising describes a particular facet of the human imagination: an individual’s awareness of mental states in himself or herself and in other people, particularly in explaining their actions.’

Remarks on the definitions of mentalizing:

i. Conceiving and reconsidering: The initial definition, in 1989, of the capacity to ‘conceive’ of mental states, was too narrow. The capacity to conceive of mental states would not be helpful to an individual if these conceptions could not then be employed. A second attempt can be seen in the definition, in 1995, of mentalization as the capacity to think about mental states, which also presumably contains the capacity to conceive of the states thought about. From 1999, this is further revised to the capacity to ‘understand and interpret’ the mental states. This is then relatively stable over time. The 2012 definition unpacks interpreting mental states as entailing two processes: ‘describing’ and ‘explaining’. This is different from behaviour, which is to be ‘understood’ in terms of mental states. Understanding, then, appears to be the successful outcome of describing and explaining behaviour in terms of mental states, though this is not pinned down. The definitions do not imply that affectively attuning to mental states is construed as mentalizing, except insofar as it is encompassed by conceiving of or reconsidering mental states.

ii. No future: From the late 1990s, definitions stress that thinking, understanding, or interpreting are all integrative forms of mental processing. From the mid-2000s, we see a specification of integration of experiences and representation as a requisite component of mentalization. The nature of representation here is not specified, but would seem entailed by thinking, understanding, and interpreting. Across the definitions, it seems to be implied that the perceptual experiences that mentalization targets may occur in the present or be drawn (p. 93) (p. 94) (p. 95) (p. 96) (p. 97) from the past. Contrary to the operationalization of reflective function (see Chapter 3), there is no explicit indication that future experiences are considered relevant for mentalizing. The reason for this is unclear but may be because concrete particulars are less available for future than present or past perceptual experience, resulting in a tangible object for mentalizing.

iii. Not simply a focus: At times, mentalization is defined as a ‘focus’ on mental states, for instance in 2008. Here mentalization is not a capacity, but the extent of sustained attention. Certainly, possession of the capacity increases the extent it will be used. But focus of mental states seems a potential correlate of mentalization, rather than a necessary element. Relevant here, perhaps, is that measures of mind-mindedness are unrelated to measures of mentalization.64 It is telling that the definition of mentalization in terms of a focus on mental states drops away as the concept of ‘hypermentalization’—overactive and ineffective mentalization—is introduced and distinguished from ‘mentalization’ proper.

iv. Self and others: The 2012 definitions appear to distinguish the kind of mentalizing required for understanding and interpreting the mental states of oneself and visible others. The mental states of oneself require objectification and interpretation (‘seeing ourselves from the outside’); the mental states of others require inference and interpretation (‘seeing others from the inside’). However, placed together with the other definitions, such as the 2009 definition by Slade, it would appear that mentalization also still encompasses the ability to think about the self’s own social behaviour as well as the internal experience of others. These are all called ‘mentalizing’, even if they may have different underpinning processes.

v. Intentions : The content of ‘mental states’ is variously defined. In 1995, mentalization is equated with the capacity to take multiple points of view, suggesting that thinking about mental states is the same as the ability to take multiple perspectives. However, in 1996, the content of mental states is specified as motivations/intentions. In 2000, this content is specified as ‘thoughts and feelings’, which are presumed to be the basis for motivation. This is aligned with Target’s definition where intentions are distinguished from mental states, but recognition of both is required. In 2007, mental states are described as including ‘needs, desires, feelings, beliefs, goals, and reasons’, which encompasses various forms of thought, feeling, and motivation. The 2009 definition gives intentions as a species of mental state, alongside feelings and thoughts, and some others. By contrast, the 2016 definition reverts to the 1996 sense of mental states as motivations/intentions, highlighting the instability of the theorized content of mental states.

Yet what is meant by intentions? Fonagy and colleagues seem to use the term in two senses. First, ‘the intentionality of mental states such as beliefs and desires refers to their “aboutness” (Brentano 1874; Dennett and Haugeland 1987)—thus a belief is “about” an actual or possible state of affairs.’65 Following Brentano, then, for mental states to be intentional means only that they are directed towards some object, that ‘in perception something is perceived, in imagination, something is imagined, in a statement something stated, in love something loved, in (p. 98) hate hated, in desire, desired, etc.’66 Brentano’s meaning appears to have been much closer to our notion of attention than intention.67 However, Dennett (mis)read into Brentano’s appeal to ‘intention’ the implication that we interpret minds through ascription of motivations in order to account for and explain behaviour and experience, with motivations conceptualized as like individual will.68 Fonagy and colleagues do not appear to recognize that ‘intention’ is being used in different ways by Brentano and Dennett. As a result, it remained unclear for Fonagy and colleagues what exactly is the object of mentalizing: i) intentional mental states, ii) mental states and intentions, or iii) mental states or intentions. The difference is potentially vast, depending on what is meant by intentional, and consequential both for theory and clinical work to encourage mentalizing. Not least it runs the risk of confusing the way a person takes a stance on, and responds to, the prompts of the state of affairs that comprises their environment (Brentano) with the expression of an individual’s will (Dennett). We will return to this problem later (Chapter 9). For now it can be identified, across the definitions of mentalizing, that the general idea appears to have been that mentalization entails the acknowledgement of mental states, where mental states are implicated in motivations and intentions.

As the table of definitions of mentalizing signals, there are many meanings of mentalization. It is unlikely that any one definition can, or perhaps should, completely encompass them all. However, in considering its different definitions, a workable characterization of the core elements of mentalization can be picked out:

A capacity to:

  1. 1. conceive of

  2. 2. and make available for reconsideration

  3. 3. the thoughts

  4. 4. and feelings

  5. 5. implicated in motivations and intentions

  6. 6. in order to account for and explain

  7. 7. the observable social behaviour

  8. 8. and present and past perceptual experience

  9. 9. of oneself

  10. 10. and others.

When all 10 of these elements are present, full mentalizing can be regarded as present. Bringing together all elements in this configuration is rare. More commonly, specific mentalizing can be identified where certain elements are not needed in a particular situation. For a form of specific mentalizing to take place, examination of the definitions suggests that certain elements are essential. When mentalizing is solely automatic, conceiving (1) is more important than reconsidering, though the availability for reconsideration (2) remains. When mentalizing is controlled, reconsideration is dominant, though access to conceiving is still needed. In principle, either (3) (thoughts) or (4) (feelings), is absolutely required, because these are the denotation of ‘mental states’, though naturally the distinction between thoughts (p. 99) and feeling is an abstraction, and other mental states are possible. For instance, values may be encompassed by the concept of mental states, and considered fed by both thoughts and feelings—though the definitions offer little guidance in considering such a case.

It is possible to conceive of motivations or intentions without attributing them to mental states, but this would not be mentalizing (see Chapter 5). Also essential are (2) and (6), the ability to reconsider mental states and to use them to account for or explain. Just to conceive of mental states is not enough, as shown by the rectification of Fonagy’s original 1989 definition in 1995 by Fonagy and Target to ‘the capacity to think about mental states’. To an extent, both (7) (observable behaviour) and (8) (present and past experience) are needed as the objects of the activities of accounting for and explaining. When one or the other is missing, the interpretation starts to spin loose and feed on itself, rather than remaining informed by the thoughts and feelings implicated in behaviour. It could be imagined that other objects of mentalization would be possible besides observable behaviour, present experience, and past experience. As we have seen, for example, Dunn proposed the social standards of groups as a possible object of mentalization. However, this possibility appears to have been excluded by Fonagy and Target. As such, examining the definitions, mentalization needs to be of either (9) (the self) or (10) (another person), or both.

So, for instance, only thoughts (3) or feelings (4) may be relevant to a particular occasion for mentalizing. This corresponds to Fonagy and Luyten’s distinction between affective and cognitive mentalizing. Or, to take another example, only the mental states of oneself (9) or another (10) may be relevant to a particular situation. This corresponds to Fonagy and Luyten’s distinction between mentalizing self and other. Mentalizing may also be used to conceive of thoughts and/or feelings without an attempt to then develop an account for motivations and intentions. When a therapist offers ‘brief, accurate and simple statements of the analyst’s perception of the patient’s current mental state’, this may—or may not—also entail an account of the patient’s motivations or intentions.69

Examination of the 10 elements of mentalization also revises and clarifies Fonagy and Luyten’s distinction between internal and external mentalizing. Fonagy and Luyten characterized attention to (8) as ‘internal mentalizing’ and attention to (7) as ‘external mentalizing’. But (7) alone is not mentalizing. The analysis above identifies either or both of (3) and (4) as required. Yet an important distinction can be drawn between attempts to mentalize the observable behaviour of others—and attempts to mentalize the observable behaviour of oneself. In fact, this would be a fruitful distinction because the 2012 Asen and Fonagy definition implies that these occur through distinct processes. But the implication is left unexplored, perhaps in part because it cross-cuts Fonagy and Luyten’s internal/external polarity and the self/other polarity.

In their 2016 book. Bateman and Fonagy assert that ‘good mentalizing takes but one form.’70 They give two characteristics of all good mentalizing:

  • ‘Tentativeness—on the whole, a lack of absolute certainty about what is right and what is wrong, and a preference for complexity and relativism.

  • (p. 100) Moderation—a balanced attitude to most statements about mental states in both oneself and others that comes from accepting the possibility that one is not in a privileged position in regard to either one’s own mental state or that of another person.’71

They then give eight characteristics of good mentalizing of others, which differ from eight characteristics of good mentalization of oneself, suggesting that they do not take the same form.72

Good mentalization of others is described as:

  • acknowledging the opacity of other minds;

  • not being paranoid;

  • expressing a desire to reflect on how others think;

  • awareness of different perspectives;

  • interest in others;

  • openness to discovery;

  • a forgiving stance;

  • oriented by a sense that, on the whole, the reactions of others are predictable given knowledge of what they think and feel.

Good mentalization of oneself is described as:

  • acknowledging that the self can change;

  • adopting a developmental perspective;

  • recognizing that feelings can be confusing;

  • recognizing that there may be feelings outside of conscious awareness

  • awareness that we can have incompatible ideas and feelings;

  • inquisitive about ourselves;

  • interested in the way our mind works differently to others;

  • recognizing the impact of affects.

Clearly the qualities in each set may vary independently of one another. One person’s mentalizing of themselves may have strengths in acknowledging change over time but struggle to recognize the impact of affects. Another person’s mentalizing of themselves may have strengths in inquisitiveness about their own mind and how it differs from others. But the individual may regard feelings as simply present or absent, rather than acknowledging the role of hybrids and half-formed emotions. The more important point, though, is that good mentalization of others and good mentalization of the self look very different (p. 101) in Bateman and Fonagy’s estimation. Good mentalization of others requires no developmental perspective or particular interest in feelings or their conflict. Instead, the focus is on awareness of different perspectives, relatively opaque to one another. By contrast, good mentalization of the self is not, perhaps surprisingly, characterized by a sense that we are predictable on the basis of knowledge of what we think and feel. Self-forgiveness is also not characteristic. Instead, the focus is on taking a developmental perspective and awareness of the preconscious mind. Luyten, Malcorps, Fonagy, and Ensink have subsequently added ‘belief in changeability’ as characteristic of good mentalizing of oneself, whereas this is not mentioned for mentalizing of others.73

Overall, the qualities that characterize good mentalizing of others seem to privilege considering their different thoughts and perspectives; the qualities that characterize good mentalizing of oneself seem to privilege scrutiny of feelings and awareness of change in perspectives over time. It seems difficult to sustain Bateman and Fonagy’s claim that good mentalizing ‘takes but one form’, when their own descriptions are considered closely. It is an encouraging development that the adaptation of the reflective functioning scale for children by Karin Ensink, in her doctoral work supervised by Target and Fonagy, distinguishes between mentalizing the self (RF-S) and mentalizing others (RF-O), and research using this scale has begun to document their distinct correlates and developmental trajectories.74 It can be hoped that this measurement innovation will be extended to other measures of mentalization, including for reflective function as measured in adults.75 Indeed, Debbané and Bateman and Morken and colleagues76 have all argued that disentangling RF-S and RF-O as distinct causal processes will be important for supporting future advances in MBT.77

Notes:

1 The characterization of the 2009 paper as the commencement of a ‘mature model of mentalizing’ is supported by Fonagy’s description of the work in the UCL REF 2014 impact case study as the place where ‘the model is fully developed’: University College London (2014). REF 2014: Psychology, Psychiatry and Neuroscience impact case study. Accessed at: https://results.ref.ac.uk/(S(jj2mvvb3fbee3zpqb1artx2d))/DownloadFile/ImpactCaseStudy/pdf?caseStudyId=44202.

2 Fonagy, P. and Target, M. (2002). ‘Early Intervention and the Development of Self-Regulation’. Psychoanalytic Inquiry, 22(3): 307–335: ‘There is good reason to believe that the capacity for effortful attentional control may be necessary for the development of the mentalizing function. First, there is a chronological overlap between these developments and they share a common developmental timetable. Second, brain imaging studies suggest that the structures for mentalizing and those for effortful control are at least close if not overlapping in location. Third, individuals with Theory of Mind (ToM) deficits (e.g. individuals with autism) also have difficulty with executive function tasks that require inhibitory control. Finally, success at the mentalizing tasks requires a certain capacity for attentional control’ (p. 322).

3 See also Jones, B. and Allison, E. (2010). ‘An Integrated Theory for Attention-Deficit Hyperactivity Disorder [ADHD]’. Psychoanalytic Psychotherapy, 24(3): 279–295.

4 Fonagy, P. (2002). ‘The Internal Working Model or the Interpersonal Interpretive Function’. Journal of Infant, Child, and Adolescent Psychotherapy, 2(4): 27–38.

5 Fonagy, P. and Target, M. (2006). ‘The Mentalization-Focused Approach To Self Pathology’. Journal of Personality Disorders, 20: 544–576: ‘An enfeebled attentional control system is a likely consequence of attachment disorganisation, perhaps linked with enfeebled affect representation, and serves to undermine the development of mentalisation as well as its appropriate functioning in later development. The prepotent response is to attribute one’s own mental state to the other. Attentional control is essential if the child is to arrive at a differentiation of their own and others’ thoughts, feelings, beliefs and desires. The disruption of attentional control is likely to account for many instances where we encounter temporary and selective disruptions of mentalising’ (p. 556). See also Fonagy, P. and Target, M. (2002). ‘Early Intervention and the Development of Self-Regulation’. Psychoanalytic Inquiry, 22(3): 307–335: ‘All the key mechanisms underpinning the enduring effects of early relationship experiences interface with individuals’ capacity to control (a) their reaction to stress, (b) their capacity to maintain focused attention, and (c) their capacity to interpret mental states in themselves and others’ (p. 307).

6 Fonagy, P. and Target, M. (1997). ‘Attachment and Reflective Function: Their Role in Self-Organization’. Development and Psychopathology, 9(4): 679–700, p. 696.

7 Fearon, P. (1998). Determinants of Mother-Infant Attachment Classification In Twins. Unpublished doctoral dissertation, London: University College London.

8 Bokhorst, C. L., Bakermans‐Kranenburg, M. J., Pasco Fearon, R. M., van IJzendoorn, M. H., Fonagy, P., and Schuengel, C. (2003). ‘The Importance of Shared Environment in Mother–Infant Attachment Security: A Behavioral Genetic Study’. Child Development, 74(6): 1769–1782.

9 Fearon, P., Shmueli‐Goetz, Y., Viding, E., Fonagy, P., and Plomin, R. (2014). ‘Genetic and Environmental Influences on Adolescent Attachment’. Journal of Child Psychology and Psychiatry, 55(9): 1033–1041.

10 Belsky, D. W., Caspi, A., Arseneault, L., Bleidorn, W., Fonagy, P., Goodman, M., … and Moffitt, T. E. (2012). ‘Etiological Features of Borderline Personality Related Characteristics in a Birth Cohort of 12-Year-Old Children’. Development and Psychopathology, 24(1): 251–265: ‘This analysis presents the number of extreme borderline group and comparison children in four groups of children defined by family history (positive/negative) and physical maltreatment (positive/negative). Children with both risk factors were 13.41 (95% CI = 8.61, 22.04) times more likely to be in the extreme borderline group than were children with neither risk factor. In contrast, children with only positive family history were only 2.53 (95% CI = 1.64, 3.92) times more likely, and children with only maltreatment were only 2.15 (95% CI = 0.69, 6.71) times more likely to be in the extreme borderline group relative to children with neither risk factor’ (pp. 258–259).

11 Fonagy, P., and Target, M. (2006). ‘The Mentalization-Focused Approach to Self Pathology’. Journal of Personality Disorders, 20: 544–576, p. 562.

12 Twemlow, S. W., Fonagy, P., and Sacco, F. C. (2005). ‘A Developmental Approach to Mentalizing Communities: II. The Peaceful Schools Experiment’. Bulletin of the Menninger Clinic, 69(4): 282–304.

13 van IJzendoorn, M. H. (2005). ‘Attachment in Social Networks: Toward an Evolutionary Social Network Model’. Human Development, 48(1–2): 85–88.

14 Fonagy, P. and Target, M. (2003). Psychoanalytic Theories: Perspectives from Developmental Psychopathology, London: Whurr Publications, p. 281. A finding that may have influenced this conclusion was that avoidant/dismissing adolescents were found to be ‘capable of mentalising in a nonpersonal context, such as the stories used to elicit mentalising, but show more difficulty in generating an organised, elaborated and coherent response to personal questions concerning attachment figures.’ Humfress, H., O’Connor, T. G., Slaughter, J., Target, M., and Fonagy, P. (2002). ‘General and Relationship-Specific Models of Social Cognition: Explaining the Overlap and Discrepancies’. Journal of Child Psychology and Psychiatry, 43(7): 873–883, p. 880.

15 Choi-Kain, L. W., and Gunderson, J. G. (2008). ‘Mentalization: Ontogeny, Assessment, and Application in the Treatment of Borderline Personality Disorder’. American Journal of Psychiatry, 165(9): 1127–1135, p. 1133.

16 Target, M. (2008). ‘Commentary’, in F. N. Busch (ed.), Mentalization: Theoretical Considerations, Research Findings, and Clinical Implications (Psychoanalytic Inquiry Book Series: Volume 29), New York: Analytic Press, pp. 261–279: ‘Mentalisation is not a unitary capacity that a person either does or does not have. It is really a hierarchy of capacities’ (p. 270); Fonagy, P. and Luyten, P. (2009). ‘A Developmental, Mentalization-Based Approach to the Understanding and Treatment of Borderline Personality Disorder’. Development and Psychopathology, 21(4): 1355–1381: ‘Research with this scale makes the further assumption that mentalization elicited in relation to past relationships will be related to current and even future relationships (Fonagy, Steele, Moran, Steele, & Higgitt, 1991). However, research has called into question the assumption that working models are traitlike. The substantial within-person variation in internal working models of others (e.g., father vs. mother) (e.g., Fraley, 2007; Pierce & Lydon, 2001) supports a view of internal working models as hierarchically organized networks’ (p. 1374). For a recent re-affirmation that the mentalisation construct remains obscure, see Sharp, C., Shohet, C., Givon, D., Penner, F., Marais, L., and Fonagy, P. (2020). ‘Learning to Mentalize: A Mediational Approach for Caregivers and Therapists’. Clinical Psychology: Science and Practice, 27(3): e12334.

17 Fonagy, P., Gergely, G., and Target, M. (2007). ‘The Parent–Infant Dyad and the Construction of the Subjective Self’. Journal of Child Psychology and Psychiatry, 48(3–4): 288–328, p. 290.

18 Fonagy, P. and Target, M. (2003). Psychoanalytic Theories: Perspectives from Developmental Psychopathology, London: Whurr Publications, p. 282. The self-criticism was reiterated in Fonagy, P. and Target, M. (2006). ‘The mentalization-focused approach to self pathology’. Journal of Personality Disorders, 20: 544–576: ‘we have placed too much emphasis on parents (particularly mothers)’ (p. 562).

19 Fonagy, P., Target, M., Gergely, G., Allen, J. G., and Bateman, A. W. (2003). ‘The Developmental Roots of Borderline Personality Disorder in Early Attachment Relationships: A Theory and Some Evidence’. Psychoanalytic Inquiry, 23(3): 412–459.

20 Bateman, A. W. and Fonagy, P. (2004). Psychotherapy for Borderline Personality Disorders: Mentalization Based Treatment, Oxford: Oxford University Press, pp. 27–37.

21 Kessler, R. C., Berglund, P., Demler, O., Jin, R., Merikangas, K. R., and Walters, E. E. (2005). ‘Lifetime Prevalence and Age-Of-Onset Distributions of DSM-IV disorders in the National Comorbidity Survey Replication’. Archives of General Psychiatry, 62(6): 593–602.

22 The conference paper was later published as Gergely, G. and Unoka, Z. (2008), ‘Attachment, Affect-Regulation and Mentalization: The Developmental Origins of the Representational Affective Self’, in C. Sharp, P. Fonagy, and I. Goodyer (eds), Social Cognition and Developmental Psychopathology Social Cognition and Developmental Psychopathology, Oxford: Oxford University Press, pp. 303–340.

23 Fonagy, P. and Luyten, P. (2009). ‘A Developmental, Mentalization-Based Approach to the Understanding and Treatment of Borderline Personality Disorder’. Development and Psychopathology, 21(4): 1355–1381. See also Lieberman, M. D. (2007). ‘Social Cognitive Neuroscience: A Review of Core Processes’. Annual Review of Psychology, 58: 259–289.

24 Bateman, A. W. and Fonagy, P. (2016). Mentalization-Based Treatment for Personality Disorders: A Practical Guide (2nd edn), Oxford: Oxford University Press, p. 197.

25 Domes, G., Czieschnek, D., Weidler, F., Berger, C., Fast, K., and Herpertz, S. C. (2008). ‘Recognition of Facial Affect in Borderline Personality Disorder’. Journal of Personality Disorders, 22: 135–147; Arntz, A., Bernstein, D., Oorschot, M., and Schobre, P. (2009). ‘Theory of Mind in Borderline and Cluster-C Personality Disorder’. Journal of Nervous and Mental Disease, 197: 801–807.

26 Bateman, A. W. and Fonagy, P. (2016). Mentalization-Based Treatment for Personality Disorders: A Practical Guide (2nd edn), Oxford: Oxford University Press, p. viii.

27 E.g. Fonagy, P. (1989). ‘On Tolerating Mental States: Theory of Mind in Borderline Patients’. Bulletin of the Anna Freud Centre, 12: 91–115, p. 100; Target, M. and Fonagy, P. (1996). ‘Playing with Reality II: The Development of Psychic Reality from a Theoretical Perspective’. The International Journal of Psychoanalysis, 77: 459–479, p. 473; Fonagy, P. and Target, M. (2000). ‘Playing with Reality: III. The Persistence of Dual Psychic Reality in Borderline Patients’. The International Journal of Psychoanalysis, 81: 853–873, p. 854.

28 Baron-Cohen, S., Golan, O., Chakrabarti, B., and Belmonte, M. K. (2008). ‘Social Cognition and Autism Spectrum Conditions’, in C. Sharp, P. Fonagy, and I. Goodyer (eds), Social Cognition and Developmental Psychopathology, Oxford: Oxford University Press, pp. 29–56.

29 Cf. Borelli, J. L., Stern, J. A., Marvin, M. J., Smiley, P. A., Pettit, C., and Samudio, M. (2020). ‘Reflective Functioning and Empathy among Mothers of School-Aged Children: Charting the Space Between’. Emotion, Early View. As such, the relationship and potential overlap between mentalization-based therapy (MBT) and therapeutic modalities such as compassion-focused therapy remain to be worked out. This is a question currently pursued by Steve Pilling and collaborators: ‘Compassion and mentalization: complementary, overlapping or opposed?’. Accessed at: https://www.ucl.ac.uk/psychoanalysis/events/2021/may/compassion-and-mentalization-complementary-overlapping-or-opposed.

30 Jurist, E. L. (2005). ‘Mentalized Affectivity’. Psychoanalytic Psychology, 22(3): 426–444.

31 Fonagy, P., Steele, M., Steele, H., Moran, G. S., and Higgitt, A. C. (1991). ‘The Capacity for Understanding Mental States: The Reflective Self in Parent and Child and its Significance for Security of Attachment’. Infant Mental Health Journal, 12(3): 201–218: ‘The primary difference lies in the emphasis in Main’s scale upon reflection by the subject on his or her own cognitive capacity (Flavell, 1976). In contrast, our scale emphasizes the use of psychological constructs to understand the behavior of self and other. The advantage of Main’s scale is that it does not confound the subject’s tendency to self-reflection with his or her accuracy in so doing. Our scale, by collapsing accuracy and habitual mode of thinking runs the risk of ascribing a high degree of reflective self function to individuals who are able to tell a plausible but inaccurate psychological story’ (p. 215).

32 Fonagy, P. and Target, M. (1997). ‘Attachment and Reflective Function: Their Role in Self-Organization’. Development and Psychopathology, 9(4): 679–700: ‘The “fractionation” or splitting of all abilities as a function of tasks and domains is well demonstrated and we might expect reflective function to be subject to the same kind of developmental decalage (unevenness) which characterizes the rest of cognitive development … Reflective function does not begin as a general capacity but is a particular skill tied to the task and domain where it is learned … Normal development is from fractionation towards integration, which involves the coordination of previously separate skills’ (pp. 695–696).

33 For evaluation of Fonagy and Luyten’s position on self–other interaction in the formation of subjectivity, see Liljenfors, R. and Lundh, L. G. (2015). ‘Mentalization and Intersubjectivity towards a Theoretical Integration’. Psychoanalytic Psychology, 32(1): 36–60.

34 Bateman, A., Fonagy, P., and Campbell, C. (2019). ‘Antisocial Personality Disorder in Community and Prison Settings’, in Anthony Bateman and Peter Fonagy (eds), Handbook of Mentalising in Mental Health Practice (2nd edn), Washington, DC: American Psychiatric Association, pp. 335–349, p. 347. One way of interpreting this claim would be that Bateman and colleagues are here describing one part of a spiral. This is implied by Fonagy, P. and Allison, E. (2018). ‘The Origin of Human Life: A Psychoanalytic Developmental Perspective’, European Psychoanalytical Federation, 31st Annual Conference, Warsaw, 24 March: ‘Our model suggests that our understanding of ourselves emerges from an internalization of the understanding that others have of us (the primary caregiver). In order to understand them, however, we rely on self-understanding. If our self-understanding is good enough this creates the potential to establish a virtuous cycle. The better I understand myself, the better I will be able to understand my caregiver understanding me; this will enable me to elaborate my understanding of myself, in turn improving my capacity to grasp what she is teaching me about myself, and so on.’

35 Satpute, A. B. and Lieberman, M. D. (2006). ‘Integrating Automatic and Controlled Processes into Neurocognitive Models of Social Cognition’. Brain Research, 1079: 86–97.

36 Frith, U. (2004). ‘Emanuel Miller Lecture: Confusions and Controversies about Asperger Syndrome’. Journal of Child Psychology and Psychiatry, 45(4): 672–686.

37 E.g. Fonagy, P. (2003). ‘Epilogue’. Bulletin of the Menninger Clinic, 67: 271–280: ‘As clinicians, our helpfulness to our patients may have more to do with the quality of implicit mentalization we offer through a general attitude rather than explicit elaboration of specific mental contents as has been frequently suggested in the past’ (p. 271). The line of influence is not clear, but this would seem well aligned with Bion’s recommendation that psychoanalysts should attempt to avoid constructing determinate thoughts and articulated feelings in sessions in order to keep themselves open for implicit understandings. Ogden, T. H. (2015). ‘Intuiting the Truth of What’s Happening: On Bion’s “Notes on Memory and Desire”’. Psychoanalytic Quarterly, 84(2): 285–306. See also Bion, W. R. (1970). Attention and Interpretation, London: Karnac Books: ‘There is the possibility of suppressing one or all of these functions of memory, desire, understanding, and sense either together or in turn. Practice in suppression of these faculties may lead to an ability to suppress one or other according to need, so that suspension of one might enhance the effect of domination by the other’ (p. 44).

38 E.g. Køster, A. (2017). ‘Mentalization, Embodiment, and Narrative: Critical Comments on the Social Ontology of Mentalization Theory’. Theory & Psychology, 27(4): 458–476: ‘implicit mentalization suffers the somewhat unfortunate fate within MT of being attributed a gross significance in the literature while never receiving a systematic theoretical articulation’ (p. 464). Perhaps of particular importance for conceptualizing the distinction between the two, it remains unexamined whether the object of controlled mentalizing is always first an object of automatic mentalizing, as Hegel would suggest. This is hinted at in Shai, D. and Fonagy, P. (2014). ‘Beyond Words: Parental Embodied Mentalizing and the Parent Infant Dance’, in M. Mikulincer and P. R. Shaver (eds), Mechanisms of Social Connections: From Brain to Group, Washington, DC: American Psychological Association, pp. 185–203. However, questions of embodied mentalizing, even if acknowledged, have not been well integrated in subsequent work by Fonagy and colleagues.

39 Havsteen-Franklin, D. (2019). ‘Creative Arts Therapies’, in Anthony Bateman and Peter Fonagy (eds), Handbook of Mentalising in Mental Health Practice, pp. 181–195, Washington, DC: American Psychiatric Association, Figure 11.1. This point is also suggested in Bateman, A. W. and Fonagy, P. (2016). Mentalization-Based Treatment For Personality Disorders: A Practical Guide (2nd edn), Oxford: Oxford University Press, pp. 7–9. See also Davidsen, A. S. and Fosgerau, C. F. (2015). ‘Grasping the Process of Implicit Mentalization’. Theory & Psychology, 25(4): 434–454.

40 Luyten, P., Malcorps, S., Fonagy, P. and Ensink, K. (2019). ‘Mentalising and Trauma’, in Anthony Bateman and Peter Fonagy (eds), Handbook of Mentalising in Mental Health Practice, Washington, DC: American Psychiatric Association, pp. 79–102, p. 84.

41 E.g. Bateman, A. W. and Fonagy, P. (2016). Mentalization-Based Treatment For Personality Disorders: A Practical Guide (2nd edn), Oxford: Oxford University Press, p. 111.

42 Allen has likewise characterized implicit mentalizing in terms that suggest that it is mentalising, and distinct from implicit non-mentalizing: ‘We are mentalizing implicitly when we empathize intuitively and nonverbally, “mirroring” others’ emotional states. We mentalize implicitly when we respond with a look of interest to what our patient just said, perhaps leaning forward a bit and raising our brow.’ Allen, J. G. (2003). ‘Mentalizing’. Bulletin of the Menninger Clinic, 67(2): 91–112, p. 95.

43 Recently, Fonagy and colleagues have tended to refer less to automatic and controlled mentalizing, and instead to ‘fast’ and ‘slow’ mentalising. This follows Kahneman, D. (2011). Thinking, Fast and Slow, London: Macmillan. Fonagy, P., Allison, E., and Campbell, C. (2019). ‘Mentalising, Resilience and Epistemic Trust’, in Anthony Bateman and Peter Fonagy (eds), Handbook of Mentalising in Mental Health Practice (2nd edn), Washington, DC: American Psychiatric Association, pp. 63–77, p. 68.

44 Fonagy, P. (2003). ‘Epilogue’. Bulletin of the Menninger Clinic, 67(3): 271–280. See also Jurist, E. L. (2005). ‘Mentalized Affectivity’. Psychoanalytic Psychology, 22(3): 426–444. Recently it has been acknowledged that ‘MBT is constrained by its representational conceptualization’. Sharp, C., Shohet, C., Givon, D., Penner, F., Marais, L., and Fonagy, P. (2020). ‘Learning to Mentalize: A Mediational Approach for Caregivers and Therapists’. Clinical Psychology: Science and Practice, 27(3): e12334. The focus of MBT on representational processes has various roots, among them the development of ideas of mentalizing from work using the Adult Attachment Interview (see Chapter 3). However, an additional factor is the lack of space in the theory for considering implicit, slow processes of ‘feeling things out’, which occur without explicit representational content and sometimes without a discrete intention.

45 Duschinsky, R., Collver, J., and Carel, H. (2019). ‘“Trust Comes from a Sense of Feeling One’s Self Understood by Another Mind”: An Interview with Peter Fonagy’. Psychoanalytic Psychology, 36(3): 224–227.

46 Fonagy, P. and Luyten, P. (2009). ‘A Developmental, Mentalization-Based Approach to the Understanding and Treatment of Borderline Personality Disorder’. Development and Psychopathology, 21(4): 1355–1381: ‘Neuroimaging studies support the notion that attachment history affects the setting of the “switch,” which turns the mentalizing system from planned, controlled and organized cognition to automatic processing with narrowed, poorly sustained attention, and increased vigilance for attachment disruptions such as rejection and abandonment’ (p. 1368).

47 The point is made again, and somewhat more clearly, in Bateman, A. W. and Fonagy, P. (2016). Mentalization-Based Treatment for Personality Disorders: A Practical Guide (2nd edn), Oxford: Oxford University Press: ‘Particularly in a secure attachment environment, when things are running smoothly on an interpersonal level, more deliberate or controlled mentalising is not called for; in fact, the use of such a mentalising style might hinder such interactions, making them feel unduly weighty or uncomfortably overwrought (hypermentalised)’ (p. 8); ‘Well functioning mentalising involves the ability to switch flexibly and responsively from automatic to controlled mentalising’ (p. 9).

48 See also Bateman, A. W. and Fonagy, P. (2016). Mentalization-Based Treatment for Personality Disorders: A Practical Guide (2nd edn), Oxford: Oxford University Press: ‘Explicit reflection cannot feel real unless it is contextualised by intuitive awareness of the mental states being reflected on’ (p. 10).

49 The distinction between ambivalent/resistant and disorganized attachment is not sharply drawn in the work of Fonagy and colleagues. This aligns with the work of Roisman and colleagues, whose psychometric studies have suggested that the two categories should be treated as contributories to a single dimension of dysregulated attachment. See e.g. Raby, K. L., Labella, M. H., Martin, J., Carlson, E. A. and Roisman, G. I. (2017). ‘Childhood Abuse and Neglect and Insecure Attachment States of Mind in Adulthood: Prospective, Longitudinal Evidence from a High-Risk Sample’. Development and Psychopathology, 29(2): 347–363. Other attachment researchers have contested this position e.g. van IJzendoorn, M. H. and Bakermans‐Kranenburg, M. J. (2014). ‘Confined Quest for Continuity: The Categorical versus Continuous Nature of Attachment’. Monographs of the Society for Research in Child Development, 79(3): 157–167. It is interesting, in this regard, that though borderline individuals are over-represented in the preoccupied classification of the Adult Attachment Interview on a three-way analysis, when the unresolved classification is included, there is no over-representation in the preoccupied classification—only in the unresolved classification. This finding could in principle be used to support either position. Bakermans-Kranenburg, M. J. and van IJzendoorn, M. H. (2009). ‘The First 10,000 Adult Attachment Interviews: Distributions of Adult Attachment Representations in Clinical and Non-Clinical Groups’. Attachment & Human Development, 11(3): 223–263, p. 230.

50 E.g. Dixon-Gordon, K. L., Chapman, A. L., Lovasz, N., and Walters, K. (2011). ‘Too Upset to Think: The Interplay of Borderline Personality Features, Negative Emotions, and Social Problem Solving in the Laboratory’. Personality Disorders: Theory, Research, and Treatment, 2: 243–260; Sharp, C. (2014). ‘The Social-Cognitive Basis of BPD: A Theory of Hypermentalizing’, in C. Sharp and J. L. Tackett (eds), Handbook of Borderline Personality Disorder in Children and Adolescents, Volume 5, New York: Springer, pp. 211–225.

51 Fonagy, P. and Luyten, P. (2009). ‘A Developmental, Mentalization-Based Approach to the Understanding and Treatment of Borderline Personality Disorder’. Development and Psychopathology, 21(4): 1355–1381.

52 See also Allison, E. and Campbell, C. (2019). Transforming Child Mental Health: Principles of Sustainable Development, London: Anna Freud Centre: ‘there is no context more likely to induce a loss of mentalizing than attachment relationships of all kinds, including family interactions. It is here that relationships tend to be at their most fraught, their most loving and their most intense emotionally, and so the stage is set on a daily basis for interactions that potentially stimulate a loss of mentalizing in one or more members of the family.’

53 Luyten, P., Fonagy, P., Lowyck, B., and Vermote, R. (2012). ‘The Assessment of Mentalization’, in A. W. Bateman and P. Fonagy (eds), Handbook of Mentalizing in Mental Health Practice, Washington, DC: American Psychiatric Association, pp. 43–66.

54 Berthelot, N., Ensink, K., Bernazzani, O., Normandin, L., Luyten, P., and Fonagy, P. (2015). ‘Intergenerational Transmission of Attachment in Abused and Neglected Mothers: The Role of Trauma‐Specific Reflective Functioning’. Infant Mental Health Journal, 36(2): 200–212.

55 See also Borelli, J. L., Cohen, C., Pettit, C., Normandin, L., Target, M., Fonagy, P., and Ensink, K. (2019). ‘Maternal and Child Sexual Abuse History: An Intergenerational Exploration of Children’s Adjustment and Maternal Trauma-Reflective Functioning’. Frontiers in Psychology, 10.

56 The researchers have recently conducted factor analytic work on self-report items of depression, identifying a distinct factor in which depression is accompanied by aggression. Rost, F., Luyten, P., and Fonagy, P. (2018). ‘The Anaclitic–Introjective Depression Assessment: Development and Preliminary Validity of an Observer‐Rated Measure’. Clinical Psychology & Psychotherapy, 25(2): 195–209.

57 Ensink, K., Bégin, M., Normandin, N., Godbout, N., and Fonagy, P. (2017). ‘Mentalization and Dissociation in the Context of Trauma: Implications for Child Psychopathology’. Journal of Trauma & Dissociation, 18(1): 11–30.

58 Fonagy, P. (2018). ‘Preface’ to Werner Bohleber, Destructiveness, Intersubjectivity and Trauma: The Identity Crisis of Modern Psychoanalysis, London: Routledge, pp. xi–xiv, p. xii. See also Schimmenti, A. (2015). ‘Behind the Closed Doors of Mentalizing. A Commentary on “Another Step Closer to Measuring the Ghosts in the Nursery: Preliminary Validation of the Trauma Reflective Functioning Scale”’. Frontiers in Psychology, 6: 380; Ensink, K., Fonagy, P., Berthelot, N., Normandin, L., and Bernazzani, O. (2015). ‘Response: Behind the Closed Doors of Mentalizing. A Commentary on “Another Step Closer to Measuring the Ghosts in the Nursery: Preliminary Validation of the Trauma Reflective Functioning Scale”’. Frontiers in Psychology, 6: 697.

59 E.g. Huang, Y. L., Fonagy, P., Feigenbaum, J., Montague, P. R., Nolte, T., and Mood Disorder Research Consortium (2020). ‘Multidirectional Pathways between Attachment, Mentalizing, and Posttraumatic Stress Symptomatology in the Context of Childhood Trauma’. Psychopathology, 53: 48–58.

60 Fonagy, P., Luyten, P., Allison, E., and Campbell, C. (2017). ‘What We have Changed our Minds about. Part 2. Borderline Personality Disorder, Epistemic Trust and the Developmental Significance of Social Communication’. Borderline Personality Disorder and Emotion Dysregulation, 4: 9.

61 See also Luyten, P., Campbell, C., and Fonagy, P. (2020). ‘Borderline Personality Disorder, Complex Trauma, and Problems with Self and Identity: A Social-Communicative Approach’. Journal of Personality, 88(1): 88–105.

62 Fonagy, P., Allison, E. and Campbell, C. (2019). ‘Commentary on “ ‘Trust Comes from a Sense of Feeling One’s Self Understood by Another Mind’: An Interview with Peter Fonagy”’. Psychoanalytic Psychology, 36(3): 228.

63 See e.g. Auerbach, J. Allen, J. G., Fonagy, P., and Bateman, A. W. (2007) ‘Mentalizing in Clinical Practice (Book Review)’. Accessed at: https://www.apadivisions.org/division-39/publications/reviews/mentalizing-2.

64 E.g. Barreto, A. L., Fearon, R. P., Osório, A., Meins, E., and Martins, C. (2016). ‘Are Adult Mentalizing Abilities Associated with Mind-Mindedness?’ International Journal of Behavioral Development, 40(4): 296–301.

65 Fonagy, P., Gergely, G., Jurist, E. L., and Target, M. (2002). Affect Regulation, Mentalisation and the Development of the Self, London: Karnac Books, p. 147, discussing Brentano, F. ([1874] 2015) Psychology from an Empirical Standpoint, London: Routledge: ‘every mental phenomenon is characterized by what the Scholastics of the Middle Ages called the intentional (or mental) inexistence of an object, and what we might call, though not wholly unambiguously, reference to a content, direction towards an object’ (p. 92).

66 Husserl, E. ([1901] 1970). Logical Investigations, Volume 2, London: Routledge, p. 95, glossing his teacher Brentano’s discussion of ‘aboutness’.

67 Cf. Watzl, S. (2011). ‘Attention as Structuring of the Stream of Consciousness’, in C. Mole, D. Smithies, and W. Wu (eds). Attention: Philosophical and Psychological Essays, New York: Oxford University Press, pp. 145–173.

68 Dennett, D. C. (1991), The Intentional Stance, Cambridge, MA: The MIT Press.

69 Fonagy, P. and Target, M. (1995). ‘Understanding the Violent Patient: The Use of the Body and the Role of the Father.’ The International Journal of Psychoanalysis, 76: 487–501, 498. In Bion’s terms, the analyst may offer awareness and comment on a patient’s mental state without moving from receptive attention into explanatory forms of thought (i.e. ‘downwards’ on the grid). Bion, W. R. (1963). Elements of Psycho-Analysis, London: Karnac Books.

70 Bateman, A. W. and Fonagy, P. (2016). Mentalization-Based Treatment for Personality Disorders: A Practical Guide (2nd edn), Oxford: Oxford University Press, p. 116.

71 Ibid. 118.

72 Bateman and Fonagy also identified three qualities of the self-representation that facilitate mentalizing:

  1. ‘a. Advanced pedagogic and listening skills.

  2. b. Autobiographical continuity—the capacity to remember oneself as a child and evidence the experience of a continuity of ideas.

  3. c. Rich internal life—the person rarely experiences their mind as empty or content-less.’ Bateman, A. W. and Fonagy, P. (2016). Mentalization-Based Treatment for Personality Disorders: A Practical Guide (2nd edn), Oxford: Oxford University Press, p. 117.

However, these three appear rather a hodgepodge. The first seems less a quality of the self-representation than a skill, and of more relevance for mentalizing others (depending on what is meant by pedagogic) than mentalizing the self. It is not clear exactly how autobiographical continuity facilitates mentalizing others, though access to episodic memory will certainly facilitate mentalizing the self. The construct of ‘rich inner life’ seems, from other statements by the authors, to be an effect of mentalizing, rather than a quality of it.

73 An updated list of the qualities of good mentalizing of oneself is provided by Luyten, P., Malcorps, S., Fonagy, P., and Ensink, K. (2019). ‘Assessment of Mentalising’, in Anthony Bateman and Peter Fonagy (eds), Handbook of Mentalising in Mental Health Practice (2nd edn), Washington, DC: American Psychiatric Association, pp. 37–62:

  • ‘Developmental perspective

  • Realistic scepticism

  • Internal conflict awareness

  • Self-inquisitive stance

  • Awareness of importance of affect

  • Acknowledgment of unconscious and preconscious functioning

  • Belief in changeability’ (p. 46).

Comparison of the two lists indicates that interest in how our mind works differently from others has dropped out of good mentalizing, as has recognition that feelings can be confusing. They have instead been replaced by belief in changeability.

74 Ensink, K. (2004). Assessing Theory of Mind, Affective Understanding and Reflective Functioning in Primary School‐Aged Children. Unpublished doctoral dissertation, London: University College London; Ensink, K., Normandin, L., Target, M., Fonagy, P., Sabourin, S., and Berthelot, N. (2015). ‘Mentalization in Children and Mothers in the Context of Trauma: An Initial Study of the Validity of the Child Reflective Functioning Scale’. British Journal of Developmental Psychology, 33(2), 203–217; Bizzi, F., Ensink, K., Borelli, J. L., Mora, S. C., and Cavanna, D. (2019). ‘Attachment and Reflective Functioning in Children with Somatic Symptom Disorders and Disruptive Behavior Disorders’. European Child & Adolescent Psychiatry, 28(5): 705–717. A parallel distinction has been made in scaling the Parent Development Interview for mentalization by Suchman, N. E., DeCoste, C., Leigh, D., and Borelli, J. (2010). ‘Reflective Functioning in Mothers with Drug Use Disorders: Implications for Dyadic Interactions with Infants and Toddlers’. Attachment & Human Development, 12: 567–585.

75 For one attempt, see Dimitrijević, A., Hanak, N., Altaras Dimitrijević, A., and Jolić Marjanović, Z. (2018). ‘The Mentalization Scale (MentS): A Self-Report Measure for the Assessment of Mentalizing Capacity’. Journal of Personality Assessment, 100(3): 268–280.

76 Debbané, M. and Bateman, A. (2019). ‘Psychosis’, in Anthony Bateman and Peter Fonagy (eds), Handbook of Mentalising in Mental Health Practice (2nd edn), Washington, DC: American Psychiatric Association, pp. 417–429, p. 426.

77 Morken, K. T., Binder, P. E., Arefjord, N., and Karterud, S. (2019). ‘Juggling Thoughts and Feelings: How Do Female Patients with Borderline Symptomology and Substance Use Disorder Experience Change in Mentalization-Based Treatment?’ Psychotherapy Research, 29(2): 251–266.