On Mentalizing and Attachment

I have been aware for some time of the work of Peter Fonagy in England. But it was only more recently that I discovered his American colleague Jon G. Allen. Both have written about "mentalizing" as important in therapy. The pair of them have teamed up together with Andrew Batemen to write Mentalizing in Clinical Practice (APA Books, 2008). I mined this book for some good insights, and was not disappointed. Herewith a few of them:

Mentalizing: What Is It?

In their introduction they offer several quick, simple definitions of mentalization, including:

holding mind in mind

attending to mental states in yourself and in others

understanding misunderstandings

seeing yourself from the outside while seeing others from the inside

In the concluding appendix, they return to offer another simple definition of mentalizing: "You are mentalizing when you're aware of what's going on in your mind or someone else's" (311). Examples of this might include asking yourself "Why did I do that?" or "Why did she say that hurtful thing?" 

Practical Recommendations:

These authors offer some very practical recommendations in trying to increase the capacity for mentalization in patients: take your time; don't rush this; don't get out of step with your patient. If in doubt, confirm first (the patient's thoughts/experiences) and challenge later. 

Why do this? Why is mentalizing important? They find that its lack is almost always related to an attachment failure, early abuse or trauma, or substance abuse. Restoring the ability to mentalize can be both healing in itself but also open up further depths to be explored in therapy. The whole point of therapy is to open up alternate interpretations and to insert spaces where there were none before. This extends to allowing and encouraging the pt. to mentalize the transference: to look at this relationship now and imagine what might be going on in the therapist's mind while also discussing what is going on in your mind as a patient. 

Without Memory or Desire:

These authors offer what I would characterize as some very Bionian counsel: Be very at home in not knowing, not having memory or desire. Do not be an expert, for you are not an expert in the patient's mind! 

If you are trying to be mindful of their mind, then they recommend that the therapist make contrary moves: if the patient is excessively introspective, invite them to consider how another mind might see something; if they are obsessed with how others see it, invite them to offer their own thoughts from their own mind. 

As you and they offer such thoughts, watch the adverbs! Avoid using such terms as clearly, only, obviously, just, etc. If your patient uses them, you might want to challenge them gently, especially if such adverbs precede significant minimization of major events or issues or pain. 

Ask for feedback if a conflict is brewing: What have I just said/done that seems to be making you more and more agitated and upset?

I read Mentalizing in Clinical Practice after having finished Allen's Restoring Mentalizing in Attachment Relationships: Treating Trauma With Plain Old Therapy. Let me next offer some comments about this book which was also valuable. 

I confess that anyone who uses the phrase "plain old therapy" is going to command my attention rather immediately and easily. I further confess my ever-increasing lack of interest in, and sometimes scorn for, the mad rush of a lot of people to coin and then copyright acronyms and to trademark modalities. Allen has little interest in such things, and I am at one with him here. 

Neither of us, however, is willing to dismiss evidence or defend things merely because we have theoretical preferences. I do not doubt for a moment that in some cases some of these things (DBT, EMDR) work, but it seems clinical psychology is engaged in a frenetic and relentless chase after commodification of its services in a way that is profoundly off-putting, and usually for one of two reasons at least: either much of what is proffered is just needlessly complicated manual therapy like DBT, or recycled earlier approaches. 

In the foreword to this book, Peter Fonagy says that "plain old therapy [is] a mentalizing relationship in which the therapist's empathy allows the patient no longer to feel alone in emotional pain" (xiii). This approach, both he and Allen recognize, antedates all forms of psychotherapy, going back thousands of years and still being practiced today in regular forms of relationship with friends and family who help us by and with their empathy as we struggle. 

This approach, he further recognizes, has much in common with the ever-popular mindfulness today, but he distinguishes them thus:

Mindfulness is attention to and acceptance of present experience

Mentalizing is attention to and acceptance of mental states (mindfulness of mind).

Trauma and the Failures of Attachment:

For Allen, as for Fonagy, a failure of mentalizing often lies behind trauma, attachment failures, and substance abuse. What these situations have in common is that the person is left psychologically alone in distress, and so much find maladaptive ways of coping, including substances, disorganized attachment, or other personality disorders. 

In traumatic failures of attachment, especially situations of childhood abuse and neglect, those attachment failures always get re-enacted in other relationships, showing that re-enacting is always a failure of mentalization (what Freud called "remembering" in his invaluable essay "Remembering, Repeating, and Working Through").

Allen uses an interesting metaphor in working with severely traumatized patients: what were and are their "islands of security"? Find them, explore them, and then see if you can get them off the tiny island and onto a more secure mainland in their own mind. 

Importance of I Statements:

Two final words of counsel I found helpful, and have already seen work well in my consulting room: the first (which other therapists I have read, including Yalom, also recommend) is to give voice to struggles in the session and relationship by using I statements: e.g., "I seem to wonder if we are not going around in circles" and leave it at that. This method often sees the patient pick this up and elaborate, or adopt your view and allow themselves to be carried forward. 

Another effective version of such a statement that I have used with success marries what Allen recommends with what Nina Coltart also recommends: take cool soundings from the counter-transference, paying special attention to images or nick-names that your unconscious throws up. I have found myself saying things like "I have this image of you in mind" or "I'm wondering why I want to give you the nick-name of Invisible Man." Both of these opened up new depths and directions to be explored. 

Minds inside Minds:

Finally Allen notes that the patient has to be able to find him/herself in the therapist's mind just as the therapist has to be in the patient's mind. I think the former might be especially important around those notoriously destabilizing transition moments--a summer holiday or Christmas break, say. For some patients the knowledge that their therapist holds them in mind outside the session can be helpful and healing in itself, especially if they had no significant early attachment figures.