Mentalization and its Discontents

I have been reading works on mentalization (some of them discussed here) for at least five years now, not long after I discovered how much of it was rooted in attachment and, more distantly, psychoanalytic theory. This theory and therapy come from England and the work of Peter Fonagy and Anthony Bateman, whom I respect enormously for their decades of work and research. 

Not long after, I made another discovery--this time  stateside: the work of Paul Lysaker (and others) on metacognition. I was more or less propelled into exploring both concepts and their clinical applications as I began taking on more severe cases of borderline personality disorder and especially schizophrenia and first-episode psychosis. (I had investigated DBT training but found its main manual profoundly off-putting and knew that operating from a manual--which also ruled out most CBT approaches--was antithetical to my own long therapeutic psychoanalysis and all my clinical instincts deriving therefrom.)

In 2022 I was able to do some training with Lysaker not long before his very unexpected and early death in 2023. I have since read at least twice his book, co-authored with Reid Klion, Recovery, Meaning Making, and Severe Mental Illness (Routledge, 2017). It is a dense but rich book and pays re-reading if you regularly treat, as I do, schizophrenic patients. (The MERIT institute founded by Lysaker recently put on a training for those who work with psychotic disorders, and I found it a very valuable refresher.) 

But unlike the metacognitive therapy outlined in the above book, which takes pains to be concrete in its discussions of clinical technique, all the works on mentalization I have read to date seem rather vexingly to follow the same format: great (and, after the first serving, increasingly tedious) lashings of history, theory, and review of the empirical evidence--which is very impressive indeed--of mentalization-based therapy (hereinafter: MBT), and often a good bit of detail on how to structure mentalization-based group therapy, but little to nothing on how this actually might play out in individual psychotherapy. 

This lack of focus on individual application bedevils every book on the topic I have read to date. I am now increasingly certain that this is a virtue of the mentalizing approach, but I will also say that the lack of discussion of individual technique is--if not a weakness--a significant lacuna. As a result, I have been forced to figure out, moment by moment in a session, how to try to help a patient mentalize, but I have never been much satisfied with this approach even though it does bear some fruit. Surely, I keep telling myself, there must be a wide array of much more effective clinical techniques of which I am--as so often happens--ignorant? Surely my on-the-spot efforts must be pretty weak sauce when set aside some smart list of sturdier and more effective applications developed by someone more experienced than I? 

In search of an answer to that question I have read such numerous and hefty volumes as those discussed here as well as others like this one, with very limited utility. Most recently I read Elliot Jurist's Minding Emotions: Cultivating Mentalization in Psychotherapy (Guilford, 2018), which never even bothers to turn to its titular challenge until well over half-way through the book. Only on p.97 (out of 168pp) does Jurist get around to asking "How can mentalization be enhanced by psychotherapy?" His answer is "mentalized affectivity," drawn from Fonagy's co-authored 2012 collection, Handbook of Mentalizing in Mental Health Practice, which I read some time back and found very little that was new or helpful in it after having read so many other extremely similar books by Fonagy and increasingly others. After six paragraphs on this mentalized affectivity, we are off to the races again with the next section on the psychometrics of measuring reflective function and then the rest of the book fails to address the question directly, instead offering some interesting history of mentalization as seen in earlier works of French psychoanalysis, and then in Winnicott and Bion. 

Thus I admit, in frustration, that in none of these books have I found the handy applications for individual treatment I have long wanted. I understand--to be sure--that mentalization, properly done, has a certain dynamic and creative nature to it so that it cannot always be prescribed in set forms in advance, but should arise organically inside the working alliance, and this, for me, is in actual fact a very attractive virtue of this approach; but at the same time all of us, no matter how creative or clever we think we are in the moment, can always benefit from the experiences of others and learn new techniques from them. 

In search of such enrichment, I picked up, and have now read twice, Carla Sharp and Dickon Bevington, Mentalizing in Psychotherapy: A Guide for Practitioners (The Guilford Press, 2022), 210pp. It repays re-reading and is, of all the books noted on here, the one that has done the most work to make itself practical and useful to the provider of individual psychotherapy. 

Amusingly and encouragingly the book begins with an incredibly humble and self-effacing foreword from Fonagy himself. He notes more than once that "it is undoubtedly the most clearly written and most easily accessible depiction of MBT that is available to date. ....I am deeply grateful to the authors...for doing something I know I could never have delivered"! 

That is not, I'm happy to report, merely the hyperbole typical of book blurbs by prominent scholars: it really is born out in the text which is indeed written with clarity and cogency and simplicity that sacrifices nothing of substance. 

The Mentalizing Stance:

Happier still I can report that it confirms my sense of the "withholding" nature of mentalization guidebooks insofar as--the authors readily admit early in the book--"mentalization-based interventions, by design, abandon specific techniques in favour of a generic therapeutic stance" (p.2). This mentalizing stance is, and cannot but be, non-authoritative and based not in the superior expertise of the clinician, but in the attachment relationship s/he has with the patient. This stance, embedded in that relationship, is what "drives therapeutic change" (p.xviii). We will return to this later. 

Necessary Virtues in the Clinician:

This stance requires at least five virtues (my word)--or what the authors call "personality characteristics" of the psychotherapist (p.4). These are:

• High cognitive flexibility
• Humility
• Adaptability
• Low rigidity
• High tolerance of uncertainty. 

In addition, the authors several times plainly and unapologetically admit that the mentalizing therapist is going to be more active in session than a classical psychoanalytic stance might encourage. (Lysaker's metacognitive therapy for psychosis also says and requires this.) The chief task for the clinician is to put his or her mind on the table and make it less opaque. This, I hasten to add, is not a recommendation to engage in wanton self-disclosure about any old thing. Instead, it is showing, by sincere and humble example, your own openness to learning with--and from!--the patient, to collaborating together on the problem of other minds and the dangers of thinking too much or too little (or not at all). 

Negative Capability:

The clinician must model what Bion (borrowing the phrase from the poet Keats) famously called "negative capability." (Bion develops this in his "Notes on Memory and Desire" and other words, discussed here. I know Bion is often disdained as a difficult read, as indeed he can be, but that short essay is invaluable, as are his two major essays from the 1950s on the psychotic mind. Everyone should read all three.) That is to say, the clinician must show a genuine ability to tolerate and be comfortable with uncertainty, ambivalence, ambiguity, and must not race to draw hasty and absolute conclusions. In modeling all this, the clinician is showing the patient how to live with ambivalence, but also how to collaborate together in finding out more about certain things in ways that increasingly abound with an often hitherto inaccessible or non-existent curiosity and playfulness. 

At the start of ch.2, the authors give us a succinct definition of mentalizing which they quote from Fonagy and others, stressing that it is an "imaginative mental activity" that tries to interpret human behavior as a result of "intentional mental states" (p.16). The authors reiterate the importance of understanding intentionality, saying that our thoughts and actions are not random but contain meaning which we need to discern.  Why be concerned about the mental activity and states of others and ourselves? The authors respond by noting that mentalizing is "profoundly about social connection" (p.28). An inability to mentalize is a recipe for isolation, loneliness, and a host of other problems. 

Mentalizing, as all authors in the field make clear, is not merely, nor only, an intellectual or cognitive activity--trying to figure out what I, or others, think. It is also, and equally important, about trying to discern and understand affective states as well--emotion and feeling. 

Slow Down!

How do we do all this? Here, in line with the best research in good psychotherapy, the authors note that it requires pacing and pausing: "if you commit to mentalizing, you commit to slowing down your interactions with others." Doing so allows us to understand them better, but also to understand ourselves better as well. From this the authors develop a practical rule that is especially useful when working with couples: one partner needs to stop and "reflect on what they want the other person to hear rather than what they want to say" (p.36). 

Developmental Difficulties:

Though he is not quoted, a Bionian theory of mind seems clearly operating in the background here as the authors reflect on how mentalizing develops, or fails to develop, from infancy onward. (For more on this, see Bion's "The Psycho-Analytic Study of Thinking," The Psychoanalytic Quarterly 82:2 (2013); originally published in 1962). In brief, an infant's mind only develops by interacting with a mentalizing mother or primary caregiver. The health of the developing infantile mind is directly affected by the mentalizing capacity of the caregiver. Weaknesses in the caregiver can be transmitted to the infant often through two major challenges: hypermentalizing or hypomentalizing. Both of these are common psychological struggles, and show up in all personality disorders. Both of these are problematic insofar as they rob the developing mind of the capacity for healthy independent agency--to become what the authors call an "agentic learner" (p.83). 

Measuring Mentalizing:

Though she died shortly before Fonagy's research really attracted attention, Nina Coltart's chapter on the nine signs of "psychological mindedness" (which I treated here) bear strong resemblance to mentalization. Her stress was on assessing for these before agreeing to take a patient into treatment, which is something I always do. I have on a number of occasions declined to take certain people into treatment when I could not see any signs of such mindedness. The few times I ignored my misgivings and agreed to try treatment did not end well when it became clear that self-reflection was really beyond a particular person and we were not making any progress. Sharp and Bevington argue that you should assess for mentalizing capacity not just during an intake process, but "throughout a session and throughout the course of therapy" (p.85). You are looking for the patient's overall capacity, but also their predominant mentalizing style (hyper/hypo) and their ability to mentalize both parts of the self-other, cognitive-affective, internal-external, and automatic-controlled dyads. 

None of us remains in only one state for very long, and so ongoing assessment of "Where are we now?" remains important in each session--not unlike the close monitoring of each session Betty Joseph advocated so many years ago now. Joseph talked about "pseudo-cooperation" with the clinician in session, and mentalization talks about pretend forms of mentalizing in similar ways. 

A Non-Technical Stance:

As I noted above, it has long haunted me that mentalization therapy remains non-specific with regard to clinical technique. Some of that is wise and inevitable, but it does not remove from one's mind the questions "Am I doing it well enough?" and "Are there other--more effective-- ways I could or should be doing this?" The authors returns to this later int he book noting that clinicians do not have to assess for every part of the patient's mentalizing style at every minute and "in a precise way" (p.95). 

When trying to make such assessments, simple questions will suffice: 

• Why do you think he said that?
• If your spouse/child/friend/boss were in the room, what do you think s/he would say about that?
• Could you make sense of why she did that?
• What do you think was probably on his mind before he blew up at you? 
• If we were watching this together on a screen as a movie, what would we be seeing? 

The point of trying to encourage mentalizing, and correct for unhelpful ways of doing it, or not doing it at all, is to return a sense of agency to the patient--especially those marked by personality disorders--but to do so in a way that helps us appreciate how and why "minds...are at play," that is, they are not "trapped in their fixed beliefs" but can be explored from a variety of angles (p.105). 

An additional and ongoing task here is for the clinician to point out instances of when the patient or others are engaged in healthy mentalization. This includes confession by the clinician of when we were not engaged in the right kind of mentalizing activity or failed to do so entirely. This is regularly referred to as putting your mind on the table and I have consistently found it helpful for patients to see that--especially my psychotic patients in a severe state of splitting and totalized, paranoid thinking with little to no ability to trust anything or anyone. For me to admit to doubt, or unsolved questions, and to be able to tolerate those is not a small thing for a psychotic person to witness. 

Some Additional Guidelines:

Regularly in several books, I have seen the following recommendations, some hinted at above:

Slow down! Mentalizing takes time. 

Call for a pause when needed--time to "rewind the tape." I have done this in sessions that were getting overheated with patients with borderline personality disorder. Any time I feel myself getting overwhelmed and losing a mentalizing stance, I will explicitly ("I need a moment here to think about what's going on") take time to recover before allowing the session to continue.

Interrupt: do not allow a long non-mentalizing or non-productive monologue to go on. Disrupt and redirect. I felt, and sometimes still feel, a bit rude when I do this, but I'd estimate that in 90% of cases, the patient has actually appreciated the redirection. And don't just take this from me or these authors but consider also Karen Maroda's new and wonderful book--which I'll review on here soon--advocates for doing so as well. 

Do not mentalize for the patient but instead invite them to do so.

Mentalize the patient's mind, especially, Sharp and Bevington say, when the patient is not mentalizing: "the most powerful way to invite, stimulate, or reawaken mentalizing in another mind...is to mentalize that mind." I regularly do this by saying something like "If I were you..." or "I was trying to imagine that fight from your perspective, and this is what crossed my mind." Very often this is quite effective, but on the occasions when it is not, we find out valuable information nonetheless. As the authors say, we still help the patient in our failures by showing our "enthusiasm to notice and learn from [our] failings" (p.124). 

Other phrases to use here, which I have found very effective, include what I call the "standard prefaces":

"This may seem totally off the wall, but I was just thinking of...."

"I don't know why this crossed my mind, but I was wondering about...." (My second analyst used this phrase with some regularity when we were trying to puzzle out parts of a dream.) 

"I don't know if this will make sense or help, but the word that came to mind for me was...."

Engage in Contrary Moves: If the patient is predominantly stuck in cognitive mentalizing, push for more affect; and vice versa. If they are struggling inside their own minds, push them to get outside by asking something like "What would your husband think about that?" If they are absolutely certain about something, mentalize the issue yourself in such a way that they see your own doubts and capacity to be comfortable with something less than total certainty. And finally, if affect in the room is too high or heated in the moment, then your contrary move is to change the subject until things cool off a bit because high affect makes mentalizing much more difficult. It requires, as psychotherapy so often does, finessing the degree of affect so that some is aroused, but not too much. 

In sum, Sharp and Bevington maintain, the "mentalizing stance is what drives therapeutic change" (p.147). 

Let us turn next, and finally, to another recent book by three German scholar-clinicians: Josef Brockmann, Holger Kirsch, and Svenja Taubner, Mentalizing in Psychodynamic and Psychoanalytic Psychotherapy: Basics, Applications, Case Studies (Routledge, 2025). Like the book by Sharp and Bevington, this one has a self-effacing preface from Peter Fonagy and then an introduction from the authors who ask Why Another Book on Mentalizing?

Their answer to that is that psychoanalytic practice differs most clearly from mentalizing therapy with regard to clinical technique and the level of activity of the clinician in session, and so this book sets out in part to explore those differences, suggesting that they are more of degree than kind in most cases.

Before doing that, the book commendably begins where the Sharp and Bevington book left off: by focusing on the question of the mechanisms of therapeutic change. These German authors assert that "improved mentalization creates a mental buffer between feelings and actions, allowing reflection on conflicting interpersonal experiences and complex affects. Patients learn to think before they act--to reflect befor they act" (p.10). Thus conceived, mentalization "indeed represents a significant change mechanism of psychotherapy" (p.12). A little later they will sharpen this point somewhat: "Mentalizing the therapeutic relationship is seen as the central mechanism of change" (p.30). 

Mentalizing the therapeutic relationship, as part of the change process, must include explicitly and regularly asking for feedback. Quoting the well-known but I think often ignored research on how much clinicians overestimate our effectiveness, these authors say that no good mentalizing clinician will want to fall into the trap of assuming they are doing well without verification of the same. 

For change to happen, these authors review the basic foundations of any successful therapeutic relationship: a strong working alliance; a "therapeutic setting pursuant to trust"; a theory or model of psychological disturbance or disorder; a model of change; and a set of techniques to pursue and enact that change. 

On that question of techniques, as I have noted already, mentalization therapy offers some but not many, and in every case strongly encourages clinicians "to explore creative ideas to improve mentalization" in each session (p.31). These authors then recommend many of the approaches noted above, but they also make explicit something only hinted at in other works on mentalization: psychotherapy is a "communication system" and mentalization, as a part of that, is always going to be concerned with communication both interpersonally and intrapsychically. 

They return to this point at the end of the book, reiterating that "psychotherapy as a threefold communication system" involves a theory of therapy, the actions of mentalization, and finally "restoring social learning (epistemic trust)" (p.157), a theme which shows up increasingly in the literature in the last decade, especially with regard to psychotic patients, delusional patients, and borderline patients. 

These two helpful books are good for both newcomers and those of us who need occasional or regular refreshers.