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What is Mentalizing and Why Do It?. Jon G. Allen, Ph.D. The Menninger Clinic Baylor College of Medicine jallen@menninger.edu. Collaboration. The Menninger Clinic Baylor College of Medicine Human Neuroimaging Laboratory at Baylor Anna Freud Centre University College London

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what is mentalizing and why do it

What is Mentalizing and Why Do It?

Jon G. Allen, Ph.D.

The Menninger Clinic

Baylor College of Medicine

jallen@menninger.edu

collaboration
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
for further information
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).

overview
Overview

Defining mentalizing

Attachment and the development of mentalizing

Mentalizing impairments in psychiatric disorders

Promoting mentalizing in treatment

part i

Part I

Defining mentalizing

defining mentalizing
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
origins of mentalize
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)

a capsule history three waves of mentalizing
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
broad scope of mentalizing
Broad scope of mentalizing

thoughts

feelings

self

others

empathy

mentalizing implicitly versus explicitly
Mentalizing implicitly versus explicitly

perceived

nonconscious

nonverbal

unreflective

e.g., mirroring

interpreted

conscious

verbal

reflective

e.g., explaining

IMPLICIT

EXPLICIT

mentalizing as an umbrella term
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)

complaint
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
mentalizing emotion
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
brain areas associated with mentalizing
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”

from mentalizing to defensive fight or flight
From mentalizing to defensive “fight-or-flight”

posterior-subcortical capacities

automatic simple habitual

switch point

prefrontal capacities

executive complex flexible

low arousal

high arousal

part ii

Part II

Attachment and the development of mentalizing

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

EVOLUTIONARY BIOLOGY

MENTALIZING

ATTACHMENT

PSYCHOANALYSIS

NEUROBIOLOGY

THEORY OF MIND

PHILOSOPHY

ethics

philosophy of mind

mentalizing links to other domains of knowledge20
Mentalizing: links to other domains of knowledge

EVOLUTIONARY BIOLOGY

MENTALIZING

attachment

THEORY OF MIND

PHILOSOPHY

PSYCHOANALYSIS

NEUROBIOLOGY

ethics

philosophy of mind

core functions of attachment
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)

intergenerational transmission overview
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

non mentalizing begets non mentalizing

insecure attachment

intense emotional distress

Non-mentalizing begets non-mentalizing

non-mentalizing interactions

part iii

Part III

Mentalizing impairments and psychiatric disorders

vicious circles
Vicious circles

Substance abuse

Depression

Anxiety

Trauma

Personality disorders

psychiatric symptoms

impaired mentalizing

resilience from vicious to benign circles
Resilience: from vicious to benign circles

psychiatric symptoms

improved mentalizing

impaired mentalizing

improved functioning

vicious circles in deliberate self harm
Vicious circles in deliberate self-harm

SELF

OTHER

abandonment

alarm & anger

unbearable emotional state

EXPRESSIVE FUNCTION

self-harm

concern

tension relief

slide28

Pushing the pause button: mentalizing

abandoned/stressed

unbearable emotional state

mentalizing

self-harm

constructive coping

bearable emotional state

part iv

Part IV

Promoting mentalizing in treatment

developmental science informs mentalizing therapists learning from parents
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

the gist of psychotherapy
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 wouldn’t want to go in there alone!”

slide32
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

the mentalizing stance attitude
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
mentalizing programs for borderline personality disorder
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
parallel contributions to mentalizing meeting of minds

attachment & arousal

developmental history

mentalizing

Patient

attachment & arousal

current functioning

mentalizing

mentalizing

current functioning

attachment & arousal

Family

mentalizing

developmental history

attachment & arousal

Parallel contributions to mentalizing: Meeting of minds
why mentalize
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”)