What is Mentalizing and Why Do It?

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What is Mentalizing and Why Do It?

• Jon G. Allen, Ph.D.
• The Menninger Clinic
• Baylor College of Medicine
• jallen_at_menninger.edu

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Collaboration

• The Menninger Clinic
• Baylor College of Medicine
• Human Neuroimaging Laboratory at Baylor
• Anna Freud Centre
• University College London
• Yale Child Study Center
• Colleagues
• Peter Fonagy Mary Target Anthony Bateman
• Efrain Bleiberg, Pasco Fearon, George Gergely,
  Toby Haslam-Hopwood, Jeremy Holmes, Elliot
  Jurist, Linda Mayes, Richard Munich, Lois Sadler,
  John Sargent, Carla Sharp, Arietta Slade, Helen
  Stein, Stuart Twemlow, Laurel Williams

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For further information

• Allen JG, Bleiberg, E, Haslam-Hopwood, GTG
  (2003). Mentalizing as a compass for treatment.
  Menninger Clinic, Houston, TX.
• Allen JG, Fonagy P, Bateman AW (2008). What is
  mentalizing and why do it? (Appendix to chapter
  on psychoeducation in Mentalizing in Clinical
  Practice).

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Overview

• Defining mentalizing
• Attachment and the development of mentalizing
• Mentalizing impairments in psychiatric disorders
• Promoting mentalizing in treatment

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Part I

• Defining mentalizing

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Defining mentalizing

• Quickies
• holding mind in mind
• attending to mental states in self and others
• mindfulness of mind
• Mentalizing is a form of imaginative mental
  activity, namely, perceiving and interpreting
  human behavior as conjoined with intentional
  mental states (e.g., needs, desires, feelings,
  beliefs, goals, purposes, and reasons)
• Mentalizing versus mentalization
• the advantages of a verb, mentalizing as mental
  action

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Origins of Mentalize

• First recorded use of the word, 1807
• First appeared in Oxford English Dictionary, 1906
• give a mental quality to picture in the mind
• cultivate mentally
• Used in French psychoanalytic literature in late
  1960s
• Employed in understanding autism in 1989 (Morton)
• Employed in understanding developmental
  psychopathology in 1989 (Fonagy)

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A capsule history Three waves of mentalizing

• autism conceptualized as a stable failure of
  mentalizing based on neurobiological deficits
  (mindblindness)
• borderline personality disorder conceptualized as
  context-dependent failures of mentalizing
  (distrust, anxiety, frustration in attachment
  relationships), for which mentalization-based
  treatment was developed
• mentalizing a core common factor in a wide range
  of therapies (psychodynamic psychotherapy,
  interpersonal psychotherapy, cognitive therapy)
  educating patients and families accordingly

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Broad scope of mentalizing
feelings
thoughts
self
others
empathy
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Mentalizing implicitly versus explicitly
IMPLICIT
EXPLICIT
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Mentalizing as an umbrella term

• Full range of mental states
• Implicit and implicit processes
• Self and others
• Varying time frame
• present
• past
• future
• Varying scope
• narrow (e.g., feeling at the moment)
• broad (e.g., autobiographical narrative)

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Complaint

• Mentalization has an intellectualizing and
  potentially dehumanizing ring to it and must be
  humanized
• We must keep in mind that the mental states
  perceived and the process of perception are
  suffused with emotion mentalizing is a form of
  emotional knowing
• Jeremy Holmes
• thinking about feelings
• feeling about thinkings
• Holding heart and mind in heart and mind

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Mentalizing emotion

• Mentalizing while remaining in the emotional
  state
• 1. identifying feelings
• labeling basic emotions
• awareness of conflicting emotions
• attributing meaning to emotions (narrative)
• 2. modulating emotion
• downward and upward
• 3. expressing emotion
• outwardly and inwardly

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Holding mind in mind
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Holding mind in mind in emotional states
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Brain areas associated with mentalizing

• Perceiving social and emotional cues
• fusiform gyrus (identifying individuals, e.g.,
  by face)
• superior temporal sulcus (perceiving agency and
  intention)
• temporal pole (interpreting social scenarios)
• amygdala (detecting emotion, especially threat)
• Resonating emotionally
• mirror neurons (activated by performing and
  observing actions and by feeling and observing
  emotions)
• Mentalizing emotion and interpersonal
  interactions
• medial prefrontal cortex
• anterior cingulate cortex

mentalizing region
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From mentalizing to defensive fight-or-flight
prefrontal capacities
executive complex flexible
low arousal
high arousal
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Part II

• Attachment and the development of mentalizing

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Mentalizing links to other domains of knowledge
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Mentalizing links to other domains of knowledge
MENTALIZING
ethics
philosophy of mind
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Core functions of attachment

• safe haven provides a feeling of security
  (regulation of emotional distress)
• secure base fosters exploration of the outer
  world and the inner world, including exploring
  the mind (mentalizing)

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Intergenerational transmission Overview
parental security of attachment ? parental
mentalizing capacity
mind-minded interactions with infant
infant secure attachment (comfort seeking)
enhanced mentalizing capacity in childhood
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Non-mentalizing begets non-mentalizing
non-mentalizing interactions
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Part III

• Mentalizing impairments and psychiatric disorders

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Vicious circles
Substance abuse Depression Anxiety Trauma Personal
ity disorders
psychiatric symptoms
impaired mentalizing
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Resilience from vicious to benign circles
psychiatric symptoms
improved mentalizing
impaired mentalizing
improved functioning
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Vicious circles in deliberate self-harm
SELF
OTHER
abandonment
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Pushing the pause button mentalizing
mentalizing
constructive coping
bearable emotional state
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Part IV

• Promoting mentalizing in treatment

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Developmental science informs mentalizing
Therapists learning from parents

• Conditions that promote mentalizing
• secure attachment mentalizing
• Formulations of skillful mentalizing
• Main metacognitive monitoring
• Fonagy reflective functioning
• Slade mentalizing of the child
• Meins mind-minded commentary in interaction

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The gist of psychotherapy

• John Bowlby the role of the psychotherapist is
  to provide the patient with a secure base from
  which he can explore the various unhappy and
  painful aspects of his life, past and present,
  many of which he finds it difficult or perhaps
  impossible to think about and reconsider without
  a trusted companion to provide support,
  encouragement, sympathy, and, on occasion,
  guidance. A Secure Base
• Jon Allen The mind can be a scary place.
• Patient Yes, and you wouldnt want to go in
  there alone!

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• Much, if not all, of the effectiveness of
  different forms of psychotherapy may be due to
  those features that all have in common rather
  than those that distinguish them from each other.
• Jerome Frank (1961) Persuasion and healing

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The Mentalizing Stance (attitude)

• inquisitive, curious, playful, open-minded
• not knowing (cleverness is a cardinal sin)
• not creating the capacity but rather promoting
  attentiveness to the activity of mentalizing
• consistent with the relation between secure
  attachment and mentalizing, advocating a spirit
  of good will and compassion while acknowledging
  that we also must mentalize in a distrusting mode

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Mentalizing Programs for borderline personality
disorder

• Day Hospital Program (Bateman Fonagy)
• 5 days/week 18-36 months
• individual, group, expressive therapies 9
  hours/week
• Intensive Outpatient Program
• once weekly individual group therapy
• 18 months duration
• Effectiveness (Day Hospital vs. Treatment as
  Usual)
• 8-year follow-up (5 years post-termination of
  MBT)
• 23 versus 74 of patients made suicide attempts
• fewer ER visits and hospital days less
  medication use
• 13 versus 87 met criteria for BPD at end of
  follow-up
• Significant differences in impulsivity and
  interpersonal functioning (including marked
  improvement in intense-unstable relationships and
  frantic efforts to avoid abandonment)
• three times longer periods of good vocational
  functioning

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Parallel contributions to mentalizing Meeting of
minds
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Why mentalize?

• Mentalizing enables us to determine whom we can
  trust (and when we can relax mentalizing)
• Mentalizing enables us to establish and maintain
  secure attachment relationships through mutual
  empathy (takes two)
• Mentalizing entails self-awareness, which is
  essential for self-compassion (empathizing with
  oneself) and for regulating emotions (e.g.,
  pushing the pause button)