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Mentalizing as Common Ground for Psychotherapy: Educating Patients and Clinicians. Jon G. Allen, Ph.D. The Menninger Clinic Baylor College of Medicine Collaboration. Colleagues

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mentalizing as common ground for psychotherapy educating patients and clinicians

Mentalizing as Common Ground for Psychotherapy:Educating Patients and Clinicians

Jon G. Allen, Ph.D.

The Menninger Clinic

Baylor College of Medicine



  • Peter Fonagy, Mary Target & Anthony Bateman; Efrain Bleiberg, Pasco Fearon, Toby Haslam-Hopwood, Elliot Jurist, George Gergely, Jeremy Holmes, Linda Mayes, Richard Munich, Lois Sadler, John Sargent, Carla Sharp, Arietta Slade, Helen Stein, Stuart Twemlow, Laurel Williams


  • University College London, Anna Freud Centre, Yale Child Study Center, The Menninger Clinic, Human Neuroimaging Laboratory at Baylor College of Medicine

Fonagy, Gergely, Jurist & Target (2002). Affect regulation, mentalizing, and the development of the self. New York: Other Press.

Bateman & Fonagy (2004). Psychotherapy for borderline personality disorder: Mentalization-Based Treatment. New York: Oxford University Press.

Bateman & Fonagy (2006). Mentalization-Based Treatment for borderline personality disorder: A practical guide. New York: Oxford University Press.

Allen & Fonagy, Eds. (2006). Handbook of Mentalization-Based Treatment. Chichester, UK: John Wiley & Sons.

Allen, Fonagy, & Bateman (2008). Mentalizing in clinical practice. Washington, DC: American Psychiatric Publishing.

definitions of mentalizing
Definitions of “mentalizing”

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)


attending to mental states in self and others

holding mind in mind

holding heart and mind in heart and mind

mindfulness of mind

understanding misunderstandings

part i

Part I

Mentalizing as a common factor in psychotherapeutic treatment

a capsule history of mentalizing
A capsule history of “mentalizing”

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) and extended to treatment of BPD (Bateman & Fonagy)

Advocated as a common factor in psychotherapeutic treatment (Allen, Fonagy & Bateman)


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

What is the therapeutic alliance if not an attachment bond?

—Jeremy Holmes (2001): The search for the secure base


Mentalizing is the most fundamental common factor among psychotherapeutic treatments…perforce, clinicians mentalize in conducting psychotherapies and also engage their patients in doing so. —Allen, Fonagy, & Bateman, Mentalizing in Clinical Practice

In advocating mentalization-based treatment we claim no innovation. On the contrary, mentalization-based treatment is the least novel therapeutic approach imaginable.

—Allen & Fonagy, Handbook of Mentalization-Based Treatment

mentalizing, even if not always explicit in our language, is implicit in many forms of psychotherapy…Allen and colleagues, of course, have already said this, when they suggest: “You’re already doing it.” And indeed we are, if we’re doing our job.

—Oldham (2008), Epilogue to Mentalizing in Clinical Practice

two broad questions
Two broad questions

What is distinctive about mentalizing?

as a treatment approach?

as a concept?

What’s all the fuss about?

plakun s y model generic and specific facets
Plakun’s Y model: Generic and specific facets






empathic listening

common factors

plakun s y model generic and specific facets11
Plakun’s Y model: Generic and specific facets




treatments for bpd
Treatments for BPD

Dialectical Behavior Therapy

Mentalization-Based Therapy

Transference-Focused Psychotherapy


relatively single-minded focus on mentalizing process: consistency; a style of psychotherapy

Implication: extensive overlap between MBT and other treatment approaches to BPD

mentalizing generic and specific facets
Mentalizing: Generic and specific facets

Third-Generation Cognitive-Behavioral Therapies

Mentalizing Focus in Psychotherapy

metacognitive approaches

Acceptance and Commitment Therapy (ACT)

mindfulness practice


the menninger clinic historical context
The Menninger Clinic: Historical Context

Long-term psychoanalytically oriented hospital treatment throughout most of its history in Topeka, Kansas

Gradual reductions in hospital stays coupled with increasing array of partial-hospital and outpatient services

Increasing theoretical eclecticism (e.g., CBT, DBT, psychoeducational approaches)

Downsizing to specialty inpatient treatment programs with 4-8 week lengths of stay

Relocation to Houston, Texas to partner with Baylor College of Medicine

Jump-starting treatment for treatment-resistant patients

developing the common factor approach to mentalizing at the menninger clinic
Developing the “common factor” approach to mentalizing at The Menninger Clinic

Wide range of disorders beyond BPD: depression, anxiety, trauma, substance abuse, other PDs

Professionals in Crisis program emphasizes mentalizing; initiated psychoeducational intervention

Clinicians’ resistance to “mentalizing”

sounds foreign

already know it all

Increasing desire for conceptual coherence in a psychotherapeutic culture (integrative function)

Belatedly educating clinicians after educating patients

Mentalization-Based Adolescent Treatment Program developed in consultation with Peter Fonagy, Mary Target, & Anthony Bateman


“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

A grammatical preference for the verb (or gerund)

emphasizes agency, activity, and process;

mentalizing is mental action; something we do

Aspiring to render “mentalizing” an everyday word rather than a technical concept

new words
New words

The word in language is half someone else’s. It becomes ‘one’s own’ only when the speaker populates it with his own intention….many words stubbornly resist, others remain alien, sound foreign in the mouth of the one who appropriated them and who now speaks them…Language is populated—overpopulated—with the intentions of others. Expropriating it, forcing it to submit to one’s own intentions and accents, is a difficult and complicated process.

—Wertsch: Mind as action

mentalizing emotion mentalized affectivity
Mentalizing emotion (“mentalized affectivity”)


transforming non-mental into mental

mentally elaborating primitively mental experience

Emotion includes much that is potentially non-mentalized

non-conscious cognitive appraisals

physiological arousal

action tendencies and motoric activation

expressive motor behavior

Emotion (affect) is mentalized when felt

Mental elaboration includes understanding and attributing meaning to feelings, which includes continuous conscious cognitive appraisals and reappraisals

mentalizing in the midst of emotion
Mentalizing in the midst of 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

two impairments of mentalizing besides misuse too little or too much imaginativeness
Two impairments of mentalizing (besides misuse):too little or too much imaginativeness

distorted mentalizing



concreteness, indifference, aversion

grounded imagination

imagination gone wild (paranoia)



overlapping concepts hairsplitting
Overlapping concepts (hairsplitting)

mindblindness: antithesis of mentalizing; employed originally to characterize autism

mindreading: applies to others and focuses on cognition

theory of mind: conceptual framework for mentalizing, focuses on cognitive development

metacognition: focuses primarily on cognition in the self

decentering: observe one’s thoughts/feelings as events in mind

reflective functioning:measurement of mentalizing in attachment context

mindfulness: focuses on present and not limited to mental states

empathy: focuses on others and emphasizes emotional states

emotional intelligence: pertains to mentalizing emotion in self and others

psychological mindedness: broadly defined, the disposition to mentalize

insight: mental content that is the product of the mentalizing process

mentalizing as an umbrella term
Mentalizing as an umbrella term

Full range of mental states

Self and others

Implicit (intuitive) and explicit (deliberate) processes

Varying time frame




Varying scope

narrow (e.g., feeling at the moment)

broad (e.g., autobiographical narrative)

criticisms of mentalizing
Criticisms of “mentalizing”

Choi-Kain & Gunderson (Am J Psychiatry, in press)

The concept is broad and multidimensional

The core measure, the Reflective Functioning Scale, yields only a single score, is time-consuming and costly, and has limited research

Research should focus on more limited-domain concepts for which (primarily self-report) measures have been developed (e.g., theory of mind, mindfulness, psychological mindedness, empathy, affect consciousness)

Semerari, Dimaggio et al., Metacognitive Assessment Scale

Separates self and others

Differentiates four facets

Identifying mental states

Differentiating subjective from objective (mental states as representational)

Relating mental states to each other and behavior

Integrating metacognitive knowledge into abstract narratives

Limitations of emphasizing process over content

mentalizing links to other domains of knowledge
Mentalizing: links to other domains of knowledge









philosophy of mind

mentalizing links to other domains of knowledge25
Mentalizing: links to other domains of knowledge









philosophy of mind

part ii

Part II

Attachment trauma and impaired mentalizing:

A focus for psychotherapy

trauma spectrum

impersonal trauma

interpersonal trauma

attachment trauma

nonhuman agent

attachment figure

human agent

Trauma spectrum
attachment trauma two senses
Attachment trauma: Two senses
  • Trauma that occurs in an attachment relationship, in childhood or adulthood
  • Trauma that adversely affects the capacity for secure attachment—the bane of the therapeutic relationship
dual liability associated with attachment trauma in childhood fonagy target
Dual liability associated with attachment trauma in childhood (Fonagy & Target)
  • provokes extreme, repeated stress
  • undermines the development of the capacity to regulate distress
    • insecure (disorganized) attachment
    • impaired mentalizing capacity
    • impaired self-regulation
intergenerational transmission of mentalizing
Intergenerational transmission of mentalizing

A mother’s capacity to hold in her own mind a representation of her child as having feelings, desires, and intentions allows the child to discover his own internal experience via his mother’s representation of it; this representation takes place in different ways at different stages of the child’s development and of the mother-child interaction. It is the mother’s observations of the moment to moment changes in the child’s mental state, and her representation of these first in gesture and action, and later in words and play, that is at the heart of sensitive caregiving, and is crucial to the child’s ultimately developing mentalizing capacities of his own [Slade, 2005]

intergenerational transmission of mentalizing31
Intergenerational transmission of mentalizing

mentalizing [is] the mechanism by which (1) the mother-child relationship exerts its influence on the attachment security of the child and (2) the mother-child relationship influences the child’s socio-cognitive development…secure attachment is fostered through accurate and appropriate parental mentalizing of the child, which in turn positively stimulates the development of the mentalizing capacity of the child. As a result, the mentalizing child is able to form a secure attachment to the parent…The parent’s capacity to engage in accurate and appropriate mentalizing may be disrupted by a variety of child characteristics, most notably temperament. The process by which secure attachment is fostered via accurate and appropriate parental mentalizing is therefore likely to be bidirectional. (Sharp & Fonagy, 2008, Social Development)

high parental reflective functioning mentalizing
High parental reflective functioning (mentalizing)

Sometimes she gets frustrated and angry (child mental state) in ways I’m not sure I understand (opacity of child’s mental state). She points to one thing and I hand it to her but it turns out that's not really what she wanted (opacity). It feels very confusing to me (mother's mental state) when I’m not sure how she’s feeing (opacity of child's mental state) especially when she’s upset. Sometimes she’ll want to do something and I won’t let her because it’s dangerous and so she'll get angry (mother recognizes diversity of mother and child mental states). (Slade, 2005)

model of intergenerational transmission and developmental psychopathology
Model of intergenerational transmission and developmental psychopathology

child attachment security

parental attachment security

parental mentalizing in relation to childhood attachment

child mentalizing

emotion regulation

psychosocial functioning

parental mentalizing of child

adapted from Sharp & Fonagy (2008) Social Development

intergenerational transmission of trauma
Intergenerational transmission of trauma

Disturbed and abusive parents obliterate their children’s experience with their own rage, hatred, fear, and malevolence. The child (and his mental states) is not seen for who he is, but in light of the parents’ projections and distortions. The infant then takes on the parent’s hatred and aggression, a primitive form of identification with the aggressor

[Slade 2005]

trauma broadly construed
“Trauma” broadly construed



invalidating environment


absence of experience of being mentalized

feeling abandoned neglected, unloved, invisible


unbearable emotional states




mentalizing failure in traumatizing behavior
Mentalizing failure in traumatizing behavior





absence of experience of being mentalized

feeling abandoned neglected, unloved, invisible


unbearable emotional states



non mentalizing modes of experience
Non-mentalizing modes of experience

psychic equivalence: world=mind; mental representations are not distinguished from the external reality that they represent, such that mental states are experienced as real, as in dreams, flashbacks, and paranoid delusions. [clinical example: “dead”]

pretend:mental states are separated from reality but maintain a sense of unreality inasmuch as they are not linked to or anchored in reality

teleological: an action-oriented mode in which mental states such as needs and emotions are expressed in action; only actions and their tangible effects—not words—count.

mentalized:actions are understood in conjunction with mental states (as contrasted to the teleological mode), and mental states have neither an exaggerated sense of reality nor unreality but rather are appreciated as representing multiple perspectives on reality (as contrasted with the psychic equivalence and pretend modes).

ptsd and psychic equivalence
PTSD and psychic equivalence

psychic equivalence


mind represents world


REEXPERIENCING flashbacks & nightmares

REMEMBERING as painful experience

the pretend mode bullshitting
The pretend mode: bullshitting

This is the crux of the distinction between [the bullshitter] and the liar. Both he and the liar represent themselves falsely as endeavouring to communicate the truth. The success of each depends upon deceiving us about that. But the fact about himself that the liar hides is that he is attempting to lead us away from a correct apprehension of reality; we are not to know that he wants us to believe something he supposes to be false. The fact about himself that the bullshitter hides, on the other hand, is that the truth-values of his statements are of no central interest to him; what we are not to understand is that his intention is neither to report the truth nor to conceal it. This does not mean that his speech is anarchically impulsive, but that the motive guiding and controlling it is unconcerned with how the things about which he speaks truly are.

Frankfurt:On Bullshit

an ironic mentalizing perspective on self knowledge
An ironic mentalizing perspective on self-knowledge

There is nothing in theory, and certainly nothing in experience, to support the extraordinary judgment that it is the truth about himself that is easiest for a person to know. Facts about ourselves are not peculiarly solid and resistant to skeptical dissolution. Our natures are, indeed, elusively insubstantial--notoriously less stable and less inherent than the natures of other things. And insofar as this is the case, sincerity itself is bullshit.

Frankfurt:On Bullshit

applications to bpd
Applications to BPD

Persons with BPD often mentalize adequately but are highly vulnerable to losing mentalizing, especially when attachment needs are activated in the context of insecure attachments (e.g., distrust; threat of loss or betrayal)

frantic responses to perceived abandonment can be construed as posttraumatic reexperiencing of painful emotional states in the context of non-mentalizing attachment relationships

the core “trauma” in BPD might be the failure to develop robust mentalizing capacities stemming from relative deficiency of mentalizing in early attachment relationships (with or without abuse)

this trauma is associated with impaired affect regulation and impaired social cognition, especially in attachment contexts (i.e., when attachment needs are evoked), including in psychotherapy relationships, which have the potential to undermine mentalizing if too stimulating

mentalization based therapy for bpd bateman fonagy american journal of psychiatry 2008
Mentalization-Based Therapy for BPDBateman & Fonagy, American Journal of Psychiatry, 2008

Effectiveness of MBT 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

minding the baby sadler slade mayes
Minding the Baby: Sadler, Slade, & Mayes

High-risk, first-time inner city parents and infants

Extends from pregnancy to child’s second birthday

Nurse home visitation

Infant-parent psychotherapy

promote mother’s mentalizing re: the self (e.g., verbalizing feelings about pregnancy)

promote mother’s mentalizing re: the infant (e.g., speaking for the infant)

mentalization based adolescent treatment program efrain bleiberg laurel williams carla sharp
Mentalization-Based Adolescent Treatment Program:Efrain Bleiberg, Laurel Williams, Carla Sharp

Develop assessment and treatment for emerging personality disorder



Mentalizing capacity

Executive and cognitive functioning

Trauma history

Emotion regulation and risky behaviors

Family functioning (parenting style, attachment, mentalizing)

part iii

Part III

Promoting an alliance through psychoeducation

psychoeducational approach
Psychoeducational Approach


promote a therapeutic alliance

draw patients’ attention to a natural process


understanding mentalizing and its development

psychiatric disorders and mentalizing impairments

how treatment modalities promote mentalizing

mentalizing exercises (projective, metaphors, role-playing, etc.)

Incorporating “mentalizing” into other psychoeducational groups

Coping with trauma

Coping with depression

Articles for patients and family members

Allen, Bleiberg, & Haslam-Hopwood (2003). Mentalizing as a compass for treatment.

Allen, Fonagy, Bateman (2008). What is mentalizing and why do it? (Appendix in Mentalizing in clinical practice)

broad scope of mentalizing
Broad scope of mentalizing






part iv

Part IV

Cultivating mentalizing in psychotherapy:

Mentalizing begets mentalizing


what good therapists do with their patients is analogous to what successful parents do with their children

—Jeremy Holmes (2001): The search for the secure base

Mentalizing as the engine of attachment: Therapist’s contribution (in caregiving role)

Fostering an attachment relationship; emotional proximity

Attentiveness to distress (empathy, attunement, responsiveness)

“Marked” emotional responsiveness: representing the patient’s emotion to the patient rather than becoming fully immersed in it

Emotional self-awareness and self-regulation

Providing support, encouragement and help while appraising and respecting the patient’s competence and autonomy

Questioning and challenging the patient’s perspective while providing alternative perspectives

Understanding how attachment patterns are reenacted from childhood to adulthood and in the transference with the caveat that process (mentalizing capacity) is emphasized over content (specific insights)

Note parallels to a secure base in supervision

Core mentalizing competencies for therapists (and patients)

Affective competence (Diana Fosha)

How affect is handled relationally

The capacity to feel and deal while relating

Neither overwhelmed nor hostile to emotion in patient or self

Requires affect tolerance and affect regulation

Allows therapist to provide an affect-facilitating environment

Note: entails “mentalized affectivity” or mentalizing emotion

Narrative competence (Jeremy Holmes)

Psychological equivalent of immunological competence

Collaborative and coherent discourse (e.g., as in secure/autonomous AAI narratives)

Balancing prose and poetry, stories and images

Evident in story telling, story listening, story-understanding; story making and story breaking


Narrative competence

Secure attachment is marked by coherent stories that convince and hang together, where detail and overall plot are congruent, and where the teller is not so detached that affect is absent, is not dissociated from the content of her story, nor is so overwhelmed that her feelings flow formlessly into every crevice of the dialogue. Insecure attachment, by contrast, is characterized either by stories that are over-elaborated and enmeshed, or by dismissive, poorly fleshed-out accounts…[there are] three prototypical pathologies of narrative capacity: clinging to rigid stories, being overwhelmed by unstoried experience, or being unable to find a narrative strong enough to contain traumatic pain.

—Jeremy Holmes (2001): The search for the secure base

our humanity the art of mentalizing
Our Humanity: The art of mentalizing

Appeal to special abilities of analysts must not violate the following principle: It must be possible to show that the claimed capacities are refinements of ordinary human capacities, and it must be made plausible why under specified circumstances such refinement can actually occur. This can be called the continuum principle, because it postulates that the abilities claimed for analysts must be on a continuum with ordinary human abilities.

—Carlo Strenger Between hermeneutics and science: An essay on the epistemology of psychoanalysis

Mentalizing as the engine of attachment: patient contribution to attachment relationships

Selection of attachment figures and appraisal of trustworthiness

Self-awareness regarding needs and feelings

Expression of emotional distress (affective competence) and context (narrative competence); associated emotion-regulation skills

Appraisal of the attachment figure’s receptiveness, attunement, responsiveness (i.e., the caregiver’s mentalizing)

Appraisal of the effectiveness of strategies to influence the caregiver’s responsiveness

Ability to manage conflicts, understand misunderstandings, and repair ruptures

Correcting and updating mental representations of self and others (internal working models)

Reciprocating caregiving

Mentalizing in maintaining an internalized secure base

Jeremy Holmes: “the secure base can be seen not just as an eternal figure, but also as a representation of security within the individual psyche”

Activating mental representations and memories of secure attachment experiences

Relating to oneself in an empathic manner, for example, protective, encouraging, reassuring, accepting, compassionate, approving (mentalizing stance)

Engaging in comforting and self-soothing activities

parallel contributions to mentalizing meeting of minds in therapy
Parallel contributions to mentalizing: Meeting of minds in therapy

attachment & arousal

developmental history



attachment & arousal

current functioning



current functioning

attachment & arousal



developmental history

attachment & arousal

a patient s perspective on bowlby
A patient’s perspective on Bowlby

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 wouldn’t want to go in there alone!”


The ability to think and talk about past pain is a protective factor leading to secure attachment, no matter how traumatic a childhood may have been. This inspiring finding is in itself an endorsement of psychotherapy, on of whose main functions, it can be argued, is to enhance reflective function [mentalizing].

—Jeremy Holmes (2001): The search for the secure base

challenges simone weil
Challenges: Simone Weil

At the bottom of the heart of every human being, from earliest infancy until the tomb, there is something that goes on indomitably expecting, in the teeth of all experience of crimes committed, suffered, and witnessed, that good and not evil will be done to him. It is this above all that is sacred in every human being.

Affliction is by nature inarticulate. The afflicted silently beseech to be given the words to express themselves. There are times when they are given none; but there are also times when they are given words, but ill-chosen ones, because those who choose them know nothing of the affliction they would interpret.

Thought revolts from contemplating affliction, to the same degree that living flesh recoils from death. A stag advancing voluntarily step by step to offer itself to the teeth of a pack of hounds is about as probable as an act of attention directed towards a real affliction, which is close at hand, on the part of a mind which is free to avoid it.

the mentalizing stance mentalizing mindfully
The Mentalizing Stance (mentalizing mindfully)

Psychological aspects

inquisitive, curious, playful, open-minded

“not knowing” (cleverness as cardinal sin)

not creating the capacity but rather promoting attentiveness to the activity of mentalizing

Ethical aspects (as in parenting, for example)

good will and compassion

acceptance and forgiveness

respect for autonomy


therapeutic paradox
Therapeutic paradox

activating attachment needs undermines mentalizing for patients with insecure attachment

psychotherapy activates attachment needs

patient must learn to mentalize in the context of intense emotional states in attachment relationships

note contrast with mindfulness practice

general tips on mentalizing in psychotherapy
General tips on mentalizing in psychotherapy

You are doing it already

Cultivate alternative perspectives

Balance focus on self and others

Maintain an optimal level of emotional arousal

Challenge patient’s assumptions about your mental states

Focus on mental states in the here-and-now, in current relationships and in the transference

Avoid attributing mental states to patients of which they are unaware; liable to be taken in as alien or rejected outright [extremely common in our setting with “anger”]

Use “I” statements

example of i statements bateman fonagy
Example of “I” Statements (Bateman & Fonagy)

“You are angry with me”


“The way you are frowning makes me think that you may be feeling angry about something and I am wondering what that may be about”

mentalizing the transference
Mentalizing the transference

validating the patient’s experience of the patient-therapist interaction

exploring the current patient-therapist relationship

accepting and exploring enactments, including the therapist’s own contribution and the therapist’s distortions

collaborating in arriving at an understanding

presenting an alternative perspective

monitoring and exploring the patient’s reaction

transference work transparency
Transference work: transparency

The patient has to find himself in the mind of the therapist and, equally, the therapist has to understand himself in the mind of the patient if the two together are to develop a mentalizing process. Both have to experience a mind being changed by a mind (Bateman & Fonagy)