What Is… Mentalization

In this series, I dig a little deeper into the meaning of psychology-related terms. This week’s term is mentalization.

Mentalizing is something you do, but probably haven’t heard of. My browser’s spell-checker tells me it’s not a word. Okay, so what is it? Well, that’s not the easiest thing to explain.

Defining mentalism

The American Psychological Association defines mentalization as “the ability to understand one’s own and others’ mental states, thereby comprehending one’s own and others’ intentions and affects.”

If that sounds like a lot of words that don’t really mean anything, here’s another definition from the developers of mentalization-based therapy:

“Mentalization, or better mentalizing, is the process by which we make sense of each other and ourselves, implicitly and explicitly, in terms of subjective states and mental processes.”

Bateman & Fonagy, 2010

That may not be much clearer, so let’s try to simplify. We all have beliefs, emotions, motivations, intentions, and needs, and these influence our behaviour. Mentalizing is the ability to capture those in our imagination.

What’s involved

There are both interpersonal and self-reflective components. The former involves trying to imagine what’s going on inside someone else’s head as we attempt to understand their behaviour; the latter involves being able to conceptualize how others view us and recognize that as separate from our subjective sense of self.

Mentalization can occur implicitly or explicitly. We implicitly mentalize on an automatic level, like when we’re having a conversation and hold a sense of the other person’s mind in our mind. Explicit mentalization is conscious and deliberate. We may do both at the same time, intuitively picking up clues while at the same consciously trying to make sense of what might be going on in someone’s head.

It’s not about assuming we know what someone else is thinking; it’s not the cognitive distortion of mind-reading. We can’t see into anyone else’s head directly. Mentalizing is more about having the capacity to create an imaginary representation in our minds of what might be going on in someone else’s mind. That representation will never be completely accurate, but we can still imagine it.

The false belief test

Young children, on the other hand, aren’t able to do this. This is demonstrated using the false belief test. If Mary puts candy in a drawer and leaves the room, then someone else moves the candy from the drawer to a cupboard, where will Mary look for the candy when she returns to the room?

Children younger than about 4 think she’ll look for it in the cupboard it was moved to, because they can’t conceptualize that she still thinks it’s in the drawer. They aren’t yet able to mentalize, so they can’t conceptualize what Mary is likely to be thinking.

Overlap with other concepts

There is some overlap with mindfulness, but mentalization is more relationally-oriented and doesn’t draw in the concept of acceptance as mindfulness tends to. There’s also overlap with empathy, but empathy doesn’t have the self orientation that mentalization includes, and mentalization doesn’t involve the sharing of mental states and empathic concern that are involved in empathy.

Mentalization theory

In the early 1990s, psychologist and psychoanalyst Peter Fonagy developed mentalization theory, which incorporated psychoanalytic concepts, attachment theory, developmental psychopathology, and the philosophical theory of mind. He conceptualized borderline personality disorder (BPD) as a disorder of mentalization arising from developmental attachment issues.

Fonagy believed that children learn to mentalize as part of their development, and this can occur unimpeded in the context of secure attachment with parents. Mirroring plays a role, with the parent being responsive to the child’s emotions and mirroring them in a re-presented way (e.g. responding to crying with an expression of concern rather than crying. Oxytocin appears to play an important role in this mirroring. Family conversation may also play a role in learning how to understand and predict others’ behaviour.

In BPD, Fonagy believed that insecure attachment with insufficient mirroring produced a deficit in the ability to mentalize. Trauma could also impact mentalization, inhibiting it as a defense mechanism to avoid conceptualizing the malicious intent of the perpetrator.

Prementalistic/nonmentalistic modes

Fonagy described three prementalistic/nonmentalistic modes that people with BPD may enter at times of distress when they’re unable to mentalize. These are ways of thinking that can be observed in children who are not yet capable of mentalizing. These three modes are:

• psychic equivalence mode: seeing no other possible perspectives on reality than one’s own; that reality can become unbearably real, triggering flashbacks and paranoia
• pretend mode: thoughts and feelings exist but aren’t anchored in reality
• teleological stance: mental states only exist if they’re shown in concrete ways and actions; this can lead to cutting, or relying on physical intimacy to feel closeness and achieve emotional regulation

Other conditions that affect mentalization

Schizophrenia also appears to involve deficits in mentalization, which may contribute to social deficits in the disorder and may also affect positive symptoms. In particular, inferring the mental states of others seems to be impaired. Some researchers have also suggested that the self aspect of mentalizing may also be affected, with a decreased ability to identify and interpret emotion-related sensory information. From a mentalization theory perspective, these deficits are attributed to childhood abuse and other attachment issues. Other theoretical perspectives offer different explanations for the same observed cognitive deficits.

A number of studies have identified impaired mentalization in people on the autism spectrum, although there seems to be variability in results regarding the specifics. Implicit mentalizing appears to be the most consistent impairment; conflicting results have been found in terms of explicit mentalizing deficits.

Some studies (e.g. Cole et al., 2019) have linked this to changes in functional connectivity in certain areas of the brain. However, a relatively large recent European study (Moessnang et al., 2020) did not see significant changes on MRI scans of people with autism vs. neurotypicals performing mentalization tasks.

Therapies targeting mentalization

Mentalization-based therapy (MBT), a type of psychodynamic therapy, was developed by Peter Fonagy and Anthony Bateman as a treatment for borderline personality disorder. The focus is on helping people to reinstate mentalizing when they’ve gone into prementalistic modes, as well as helping them to maintain mentalizing when it is at risk of being lost.

In MBT, the therapist’s stance includes a sense of not-knowing, legitimizing and accepting different perspectives, asking for detailed descriptions of experience rather than explanations of experience, and accepting that some things just don’t make sense. Like other psychodynamic therapies, transference plays a role, but instead of trying to interpret the transference, the therapist focuses on helping the client to mentalize the transference by encouraging them to think about what’s happening in the relationship with the therapist at the present moment. The therapist works to re-present patients’ feelings and thoughts to them in a coherent manner so that patients are able to identify themselves as thinking and feeling within an intense attachment relationship.

References

• APA Dictionary of Psychology: Mentalization
• Bateman, A., & Fonagy, P. (2010). Mentalization based treatment for borderline personality disorder. World Psychiatry, 9(1), 11.
• Choi-Kain, L. W., & Gunderson, J. G. (2008). Mentalization: Ontogeny, assessment, and application in the treatment of borderline personality disorder. American Journal of Psychiatry, 165(9), 1127-1135.
• Fonagy, P., & Allison, E. (2011). What Is Mentalization? The Concept and Its Foundations in Developmental Research and Social-Cognitive Neuroscience. (submitted book chapter)
• Schuwerk, T., Jarvers, I., Vuori, M., & Sodian, B. (2016). Implicit mentalizing persists beyond early childhood and is profoundly impaired in children with autism spectrum condition. Frontiers in Psychology, 7, 1696.
• Weijers, J. G., Ten Kate, C., Debbané, M., Bateman, A. W., De Jong, S., Selten, J. P., & Eurelings-Bontekoe, E. H. M. (2020). Mentalization and psychosis: A rationale for the use of mentalization theory to understand and treat non-affective psychotic disorder. Journal of Contemporary Psychotherapy, 1-10.