On Mentalization

I can't remember when or where I first came across Peter Fonagy's work on mentalization, but I'm glad I did because--when distilled down, which is my sole task below--it's clinically useful. Fonagy has on many occasions teamed up with other co-authors, including Anthony Bateman and Jon Allen. These three wrote a helpful book I discussed here. There is also a forthcoming volume later this August that I am keeping an eye on. 

In addition to reading the two books at that link, I have now finished re-reading two more, discussed below. Much as I like these authors and their books, they make high demands of the reader by writing often densely layered and very lengthy, detailed books with not a little repetition and redundant material in them. (It seems every book begins with enormous background on mentalization, somehow diffident about the reader's likelihood of having encountered this material before.) Ruthless and unapologetic academic editor that I am and have been for more than twenty years, I have no problem in saying that both books could have been cut down by at least 20%.  

But let not that detract from the considerable achievements amply on display in, first, Psychotherapy for Borderline Personality Disorder: Mentalization Based Treatment (Oxford UP, 2004), and then Mentalization-Based treatment for Personality Disorders: A Practical Guide (Oxford, 2016). The latter admits of wider application, though even here the authors concentrate almost entirely on borderline and anti-social personality disorders. I have found, however, that deficits in mentalization show up in nearly every condition--some more than others--and assessing for the ability to mentalize (perhaps especially with couples) is a useful part of my intake process when I'm looking for the nine signs of "psychological mindedness" Nina Coltart first so helpfully laid out. 

In what follows, I have continued my usual method of ransacking without apology and plundering with good cheer to extract material for use in my consulting room on a daily basis. I have therefore left behind all the vast quantities of material in both books on the underlying theory of mentalization, its relationship to attachment theory, and its comparisons to other approaches, including DBT, Kernberg's transference-focused treatment, and other modalities. 

In Psychotherapy for Borderline Personality Disorder, the authors begin by noting some of the important qualities of the psychotherapist, which they group under the rubric of "high boundaries" (p.xxiii). They don't elaborate on this much but seem to suggest--as others, such as Kernberg have long argued--that treating BPD requires a certain level of firmness, regularity, and stability in the clinician and this must be clearly and regularly communicated to the patient and firmly maintained. This is made more explicit later in the book (pp.169f) when the authors argue in favour of keeping the frame firmly in place. 

After a very great deal of preliminary and comparative material, the authors finally, in ch.7, turn to "Strategies of Treatment" and here note that 

the mentalizing stance is an ability on the therapist's part to question continually what internal mental states both within his patient and within himself can explain what is happening now (p.203). 

The authors further recommend that given such a focus on the here-and-now and the I-and-thou relationship, clinicians should recognize from the outset of treatment that countertransference enactments will happen, and to treat these in a "non-self-persecutory" way. 

Later in the book the authors (here echoing but not explicitly discussing others, it seems to me, including Kohut and Winnicott) suggest that "a focus in the mind of the therapist about the interpersonal aspects of treatment will ensure that a similar process begins to develop in the mind of the patient" (p.265).

Later in the book, in a section on "establishment of stable representational systems," the authors recommend that in individual sessions, clinicians should do several things, here paraphrased and summarized thus:

i) Continually encourage the patient to explore their understanding of the motives of others;

ii) Identify what effects such an understanding has on the patient's sense of self and his or her relationships;

iii) Use the transference to bring to light evidence that conflicts with the patient's own consciously articulated or claimed motives;

iv) Challenge faulty interpretations or distortions by the patient in light of the contrary evidence provided by the transference and counter-transference, including whether and how the patient participates in the session.

Let us turn now to the newer and much richer book, Mentalization-Based Treatment for Personality Disorders. 

Definitions and Deficits:

The book begins with defining mentalization and noting the problems created by mentalizing deficits. The authors claim that "mentalizing is a fundamental psychological process that has a role to play in all major mental disorders" (my emphasis). They further define it thus:

mentalizing is the ability to understand actions by both other people and oneself in terms of thoughts, feelings, wishes, and desires; it is a very human capability that underpins everyday interactions. 

Stated more succinctly, "mentalizing is seeing ourselves from the outside and others from the inside" (p.5).  

Deficits in a capacity for mentalizing mean there can be:

• no robust sense of self
• no constructive social interactions
• no mutuality in relationships, and
• no sense of personal security

Moving beyond a general and universally applicable definition of mentalization, Bateman and Fonagy now get more specific in what makes up (or thwarts) mentalization, including

Four Components of Mentalizing:

Different types of psychopathology are linked to impairments in one or more of the following forms of mentalizing:

1) Automatic vs. controlled
2) Mentalizing the self vs. others
3) Mentalizing internal vs. external features
4) Cognitive vs. affective mentalizing.

Controlled vs. Automatic:

The former is more conscious, deliberate, painstaking, and time-consuming; it is a deliberate reflective function often done in session. The latter happens with great speed, often barely consciously. A sign of good health is the ability to move between these two modes with facility. 

Cognitive vs. Affective:

The former is more intellectual in nature and can lead to "mind-reading" and what they will later call pseudomentalizing. The latter can result in an "oversensitivity to emotional cues" and a feeling of being overwhelmed by emotions. One wants a mixture of both for there to be healthy mentalizing. 

Unhealthy or at least unhelpful mentalizing, that is non-mentalizing, typically manifests in three  

Non-Mentalizing Modes:

Ideally in doing an intake, one assesses for mentalization as part of taking a larger history in which special attention to attachment history should be paid. Later in the book the authors recommend some tools if you wish, including the Reflective Functioning Scale they developed in the late 1990s. (I have used a version of it only 2 or 3 times and found it rather unwieldy.) There is also a relatively simple check-list available here from the Anna Freud Centre. 

As you are assessing, you want to watch out for non-mentalizing, which typically shows up in three forms:

Psychic Equivalence: this is where there is a kind of fusion between my mind and the world, so that they are taken to be coterminous. What is thought is taken to be real--too real, and thus overwhelming for some, leading to a collapse in ability to mentalize; doubt is suspended; and little ability to see any other perspective is present; typical of the very primitive infantile mind up to c. 20 months. 

Teleological Mode: this is where states of mind are conceivable and believable only if there is some sort of physical demonstration of them; this is an overly concretized attempt at thinking that may lead to acting out precisely to provoke the very physical demonstrations the patient feels are lacking. In essence, thoughts and minds do not exist here: only actions are real. 

Pretend Mode: derealization and dissociation are forms of pretend mode; children who invent pretend friends or entire fantasy worlds are clear examples of this failure to mentalize. 

The authors here return again to some discussion of pseudomentalization or hypermentalization. This they note--and my clinical experience confirms--is often characteristic of borderline patients. In both cases, they attempt to talk about states of mind, but do so in an abstract, ethereal way that tends to involve agonizingly lengthy descriptions of extraneous material with little real feeling or affect involved (except, often, paranoia). Opaqueness is never respected when in a pseudomentalizing mode. 

One classic hallmark indicating that you are in the presence of one or more of the above non-mentalizing modes is that of projective identification: the splitting off of undesired parts of the self, and their subsequent externalization in others. 

Internalized Self-Images:

The authors here note that those who struggle to mentalize may not have themselves 'been mentalized' as it were by their primary caregivers when young children. There has been, they say, a lack of "parental mirroring" (p.20) in place of which the child internalizes the image of the caregiver as part of their self-representation. This is so obvious in one of my toughest cases, where selfobject deficits are massive and widespread to a degree that sometimes shocks me. 

For me one way to start to bring this to light consists in listening with that "third ear" to the patient's language. You can usually get a sense when they slip into a different register, or use a hackneyed phrase in a too-facile fashion whereupon I pounce: "Whose language is that?" I usually ask, because it certainly does not feel indigenous to the person before me. Then gradually the two of us can begin to piece together rather alien introjects from others that are almost invariably savage and self-destructive. 

This lack of mirroring can lead to what the authors a little later call "epistemic mistrust" (p.26) in compensation for which some engage in epistemic vigilance, leading to a kind of furious hypermentalizing, which is a form of pseudomentalizing. One way clinicians can help patients move through and past this is by showing your mind: this is not an occasion for indulging in gratuitous self-disclosure, but a very focused intervention in which you talk about how you mentalize the patient both in and out of the session, and how you mentalize the session and even moments between the two people in the room. You are gently giving an example of another mind and its capacity for distance-taking and perspective-forming, as well as its limits and its acceptance of uncertainty. 

This cannot be done too definitively, however. A key part of mentalization is opaqueness: the recognition that minds are never 100% transparent and accessible to us and you must therefore be relatively comfortable with not knowing certain things, or knowing them incompletely. If you can convey to the patient your own relative comfort with not knowing things completely, this can function as an edifying example for them initially to borrow and then to immitate en route to recovering their own capacity to mentalize. 

Good Mentalizing about Others:

The authors briefly highlight things to watch out for that may be taken as signs of high levels of good mentalization (p.117). In such people, one finds that they can, when considering the thoughts and feelings of others, readily recognize and acknowledge:

1) Opaqueness: I can never totally know what others are thinking, but neither am I totally baffled: some things can very plausibly be discerned.

2) Absence of Paranoia: I can acknowledge others' thoughts, including angry and hostile ones, without thinking they necessarily have it in for me.

3) Contemplation and Reflection: I can reflect in a relaxed way on the minds of others without becoming compulsive about doing so. 

4) Perspective-Taking: I can placidly accept that things look very different based on the other's upbringing, culture, history, social context, and other factors. 

5) Genuine Interest: I can be curious about others' thoughts both for their content but also their form. 

6) Openness to Discovery: I can hold myself back from overspeculating in an attempt at omniscience, being pleased at new discoveries or having my assumptions challenged and changed. 

7) Forgiveness: I can tolerate and forgive someone once I recognize that, say, they acted in ___ fashion because their mind was clouded by grief or pain from their broken leg or whatever.

8) Predictability: I can be generally comfortable most of the time with most people in believing that their actions are predictable given knowledge of what they think and feel. 

Good Mentalizing about Myself:

In addition to the above, Bateman and Fonagy give us a further 8 characteristics or hallmarks of healthy mentalization about myself, which always involves humility and moderation, and a healthy comfort with limits and not knowing. It also requires prompt and non-defensive acknowledgement of one's errors. 

As with the above, I use their terms below in italics, but supply my own summary and examples:

1) Changeability: As I change, I can change my views of others. 

2) Developmental Perspective: As I developed and develop, my views of others changed and can still change. 

3) Realistic Skepticism: I see that my own feelings are sometimes confused and confusing. 

4) Acknowledgement of Preconscious Function: I see that at any given time I may not be aware of all my feelings, especially in conflictual situations. 

5) Conflict: I know that within me are sometimes incompatible ideas and feelings.

6) Self-inquisitive Stance: I have good-natured curiosity about myself. 

7) An Interest in Difference: I want to discover how minds different from my own work. 

8) Awareness of the Impact of Affect: I recognize and affirm that affect can distort my self-understanding. 

Finally (this having gone on much longer than I expected!), I have extracted from across the book what I will call 

Clinical Strategies

"Paying attention to your patient's mind is at the heart of mentalizing" (p.185), both authors reassure us. Your job is to be the "monitoring clinician" who is also the overtly self-correcting clinician, saying such things as "How was it that I so badly misunderstood you?" and thereby showing the patient your own capacity to reflect on your own lapses in mentalization. Authenticity and transparency are indispensable for your success: the patient must have access to your mind in a real way.

Stop, Rewind, Explore: This is something I have found very useful. If you are suddenly thrust into a non-mentalizing mode, or a rupture develops, the job is explicitly for you to call a halt in the session and ask to go back to where you think things seized up or went off the rails. Rewind to that point, and begin again from there to see if you can recover. I was very nervous the first time I did this with a borderline patient, but it turned out to make a huge difference and I was relieved and gratified. 

Typically early in the treatment one begins with the following strategies in this order, but these can be used again, and may have to be used again, after ruptures or mistakes:

1) Empathic Validation: always start here and do not go further if this is not established, or re-established after some kind of rupture. 

2) Basic Mentalization: clarification and exploration chiefly but with some limited and judiciously chosen challenge (which should be used sparingly in more severe borderline cases). 

    a) Challenge can take several forms, the more light-hearted the better in most cases (what they call counterintuitive, "whacky," and humourous or mischievous statements). In more serious cases, however, including suicidal ideation or boundary violations by the patient, challenge involves "frank but fair" discussion in which the clinician should feel no compunction about being direct, resolute, and authoritative, seeking firmly to preserve the patient and treatment from what may be a dire or even lethal threat.  

3) Basic Mentalization: focus on identifying affect

4) Mentalizing the Relationship. Later in the book the authors clarify that mentalizing the relationship involves here-and-now dynamics between this patient in this moment with me as the clinician; it does not involve mining the transference for clues about childhood attachment patterns or problems with parents.

I end here. There is much more material in the book--chapters on mentalizing groups, families, and systems--but I have the remnants of a lovely day to go enjoy.

Desire: An Enigma Wrapped In Riddles Inside Mystery

Introduction:

I learn such things on Twitter. 

I forget to whom exactly to give credit for introducing me to Galit Atlas and her book, The Enigma of Desire: Sex, Longing, and Belonging in Psychoanalysis (Routledge, 2016). It may well have first been Adam Rodriguez, but I know it was even more forcefully Taylor Zimmerman, whom I met with great delight in Indianapolis in April at the celebrated day with Jonathan Shedler. Over the coffee hour and in subsequent correspondence, Taylor strongly encouraged me to read Atlas, so I am grateful to him as to Adam. 

Atlas is the third person in an ongoing series of clinicians in whom I am finding much wisdom with regard to erotic dynamics in psychotherapy, especially in the transference and countertransference. The first of these was, and is, Andrea Celenza, about whom I first wrote here, and more recently here. 

She and Glen Gabbard are arguably the two leading scholar-clinicians writing on sexualized boundary violations in professional contexts, including clinical and clerical contexts. Given the power of their writings, and the fact these topics are almost universally ignored in all training programs, and even by licensed professionals, I am at the point now where I just flatly tell anyone who asks, and even more who don't, that they should buy all of Gabbard's books and all of Celenza's and read them. Were I in charge of training programs in this country for future clinicians of all sorts, I would absolutely make these two authors mandatory reading. 

Into this group I now can bring Galit Atlas, who writes in a different style and with a different focus than Gabbard and Celenza, but with them is still broadly in the field--hitherto often terribly overlooked or denied--of erotic dynamics in treatment. Her book, The Enigma of Desire, puts me in mind of another recent treatment by another psychoanalyst, Carlos Dominguez-Morano (whose utterly irreplaceable Belief After Freud should also be required reading, not least by Christians still talking bollocks about Freud), The Myth of Desire: Sexuality, Love, and the Self, which I have to go back and re-read. 

Right, down to business. 

Atlas on Maternal Erotics:

Atlas begins punchily enough in her introduction by arguing that "In treatment, adopting the role of a nurturing mother can function as the therapist's way to avoid the erotic material that emerges between her and the patient." This I take to be just another version of the important warning (echoed by Shedler, Maroda, McWilliams, and many others) that being too much of a "container" (Bion) or providing little more than a "holding environment" (Winnicott) will mean you ultimately fail your patient who is there because something is wrong and something needs to be changed, not merely contained. 

A second related warning follows from this later in the book (p.80): "our patients' traumatized self-states may collude with our own in order to protect the tender parts of the self, the other, and the treatment from damage by the aggressive parts." (This, of course, is reason #23689 for the psychotherapist to have had his or her own in-depth and intensive long-term psychotherapy, and to engage in regular supervision and consultation.)

Also early in her book Atlas makes plain her own debts to what she calls Kleinian mothers, who have led her to be able "to trust the mind to lead us to the most unknown truths and to believe that the ability to tolerate those tensions allows us to live and to love." She also mentions her debts to Laplanche and Kristeva, and Jessica Benjamin, especially this: "I do not believe we can definitely know what belongs to us and what belongs to our patients." 

This point, of course, puts one in mind of Thomas Ogden's celebrated notion of the analytic third, and of the inability, as he has also recognized, to know where the patient's experience ends and the clinician's begins. 

The Erotics of Writing:

There is a sensuous quality to Atlas's writing itself, not least in her case studies, which are presented here in ways that are less stilted and bloodless than one so often finds. That is to say, there is still a warm pulse in the people she writes about. 

Moreover, and more interesting for me who has long loved to write and cared deeply about the felicities and rewards of style, and who has often felt a flush of excitement in the exchange of ideas, she openly acknowledges that "While writing, I found myself...swinging from feeling overaroused and exposed to using ideas as a way to distance, process, and regulate" (p.30). Lest we miss the point, a bit later she quotes a famous 1989 paper of Ronald Britton in which he recounts a patient demanding: "'Stop that fucking thinking'!" From this Atlas deduces that "thinking is a form of the therapist's internal intercourse" (p.32). Just so! 

I can relate to that outside the consulting room, but also in, which she captures with equal candor: "I notice the movement between moments of sexual stimulation and arousal to use of theory....I believe we often experience the same movement as analysts trying to regulate ourselves and our patients when the erotic pervades the analytic space" (p.30). Guilty as charged! (If I find myself becoming very theoretical, or subjecting the patient to a lecture, than I know my intellectualized defenses have led to such an enactment, and, following Fonagy's counsel, I need to rewind the session back to the point where I was able to mentalize before the defenses were, uh, aroused.)

The Enigmatic and the Pragmatic:

The unique contribution that Atlas make, so far as I can see at this point, is her stress on what she calls Enigmatic and Pragmatic knowing. Much more could be said about this, but I don't want to give all of the book away, so suffice it for me to say that the enigmatic and pragmatic are tied to her dual understanding of the origins of, changes in, and different desires manifested in sexuality: "the erotic comes into existence when the sexuality that at the start was based exclusively on nourishment and satisfaction of hunger moves away from the functional and toward play" (p.41). 

Do not, she warns later, be too enchanted (as some of us who love Winnicott are inclined to be) by notions of play, for these, too, can be used to displace certain important things: "playfullness can be a seductive way to express erotic and aggressive contents...but it's important to note that it can also serve to obstruct erotic transference and countertransference" (p.81). Yes it can, as I've noticed in some sessions after the fact, and not without some chagrin! 

Sexual Longing and Erotic Manifestations and Their Dangers:

Her mention of the erotic obstructing transference material takes us back onto more familiar ground, also covered by Gabbard and Celenza, and then by David Mann, whose two books on the topic I began last weekend, and about which I will have a very great deal to say later (O lucky reader!). 

Rightly does Atlas note early in the book that "sometimes we underestimate how dangerous it feels to be part of a dyad." I try to remind myself of that at least a few times a week, and (for some reason) it always happens at the last turn of the corridor immediately before bringing a patient into my consulting room. In those seconds as I usher them in, I cast my mind back to the first time I ever met with a psychotherapist (a pastoral counselor as I recall) in my teen years (to discuss sexual matters, too!), and how anxious I felt: I try to get a feel for whether this person with me is also a bit anxious, which is an entirely understandable feeling for, as Atlas continues a bit later, "being a patient is a dangerous position" for the patient may feel "he is forced back into the powerless position of being a child to a seductive mother who penetrates and excites him, feeds him but also controls his food and will certainly abandon him, leaving him overexcited, humiliated, and alone" (p.37). 

Strong stuff! No wonder people on Twitter lose their bloody minds when you speak such thoughts aloud; no wonder my undergrads had a collective meltdown at the mention of any hint of anything remotely "erotic" in the therapeutic relationship; no wonder even licensed professionals shy away from these discussions at best, and at worst become amusingly and revealingly hyper-defended. 

Why would anyone submit to this humiliating penetration and abandonment? Later she notes some of its rewards: "Allowing yourself to be penetrated means embracing a more fluid structure that is based on unsolidified boundaries....This is not exclusively a feminine process" (p.69). Indeed not. 

Precisely my attraction to psychoanalytic thinking, starting with Freud, more than three decades ago now was because it seemed to be quite at home with the idea of the fluidity, the complexity, the ambiguity and ambivalence--the sheer messiness--of human sexuality. I have always been highly suspicious of anyone who wants to put it into neat boxes, or map it out on a linear continuum or Kinsey scale. None of us is ever "straight." 

Before going further, she reminds us that for many of us, we had (referring to Kohut) no "mirroring" of the erotic and sexual growing up: "sexual feelings are unique in that caregivers systematically ignore them and they are therefore unmirrored" (p.115). This will and will not show up in a variety of ways in life, and in therapy. 

For some this lack of mirroring can leave the terror of such feelings in place, and that is where you must begin in therapy: "are there ways to listen for, and to, the unique accents of the language of sex." And if those accents are ones of fear, then, nodding towards Bion, Atlas says that an early task of the second mind in the room is to help the first mind bear to think about those fearful desires and terrifying thoughts.

As you think about them, some of the difficulty of such feelings comes from the fact that "sexual longing presupposes a sense of loss and a hope of refinding." 

That refinding is not a straightforward path from infantile attachment to adult sexual longings. It is often much more complicated than that, and thus the clinician needs to proceed with due caution: "the secret psychoanalytic touch is always about tolerating the erotic in the room while not adding to the stimulus." 

Earlier, she notes that we can and probably should do more than that: "we try to hold the unknown darkness with them, tolerate the 'too muchness' of excitement, joy, horror, and shame." Later she will speak of the "suffering of pleasure, of the excess that the body and the mind cannot contain," to which some might give the name "lust" while others (here Melanie Klein) prefer to speak of "human yearning for an 'unattainable perfect internal state'." 

Enactments Made and Redeemed:

Atlas is making what seems to me a very significant advance on how we think about therapeutic enactments. That word is almost universally taken as a sign of danger and enactments seem almost always to be treated sternly. This mirrors, it seems to me, the early Freud and his unidimensional warnings about the dangers of transference and countertransference especially. Only after 1950 did we start to get some limited reflection on what positive things countertransference might contain, and only much later--that is, within the relational movement of which Atlas is a significant part--do we start to see people recognize that countertransference can often be a positive good and contain much valuable information.

Similarly, Atlas is, in the last section of the last chapter of her book, opening up new territory by arguing that enactments are not just "a return of past dissociated memories but rather as the threshold for the introduction of emergent ways of being, of an opening toward new relational possibilities" (p.150). Enactments thus "work toward the future."

They do more than that, as becomes clear in her attempted definition: "enactments may well be a central means by which patients and analysts enter into each other's inner world and discover themselves as participants within each other's psychic life" (p.150). This does not guarantee, of course, that all enactments will always have a positive outcome, but it does begin to help them lose some of their fear, just as we have overcome fear from a century ago of countertransference as a sign of an insufficiently analyzed analyst. 

A concluding word that reminds us of how demanding our vocation as psychotherapists is, for we "must straddle a paradox, always skeptical, questioning, seeking hidden meanings, searching for unconscious dynamics at play, the trailing edge, a hermeneutics of suspicion--while also, paradoxically, trusting unconscious process and surrendering to the continuous flow of the enactive dimension of analysis, relying on a hermeneutics of faith" (here referencing Ricoeur).