CHAPTER 31

Mentalizing in Psychotherapy

Jon G. Allen, Ph.D.

Peter Fonagy, O.B.E., Ph.D., F.B.A.

We define mentalizing technically as the natural human imaginative capacity to perceive and interpret behavior in self and others as conjoined with intentional mental states, such as desires, motives, feelings, and beliefs. In plain language, we characterize mentalizing as attentiveness to thinking and feeling in self and others—or, in shorthand, as holding mind in mind.

Although it does not appear in many current dictionaries, mentalizing has been in the lexicon for two centuries and in the Oxford English Dictionary for the past century. French psychoanalysts introduced the concept into the professional literature in the second half of the twentieth century (Lecours and Bouchard 1997), and mentalizing came into the English professional literature on the brink of the final decade: Morton (1989) construed enduring impairments of mentalizing as the core deficit in autism, and Fonagy (1989) proposed that more transient impairments of mentalizing associated with profound insecurity in attachment relationships play a key role in the developmental psychopathology that contributes to borderline personality disorder. This proposal was the wellspring for the development of Mentalization-Based Treatment (Bateman and Fonagy 2006).

This chapter is not intended to promote a brand of psychotherapy but rather to acquaint clinicians with the value of considering mentalizing in understanding psychopathology and conducting psychotherapy, regardless of their theoretical approach or preferred treatment modalities. We begin with an explication of mentalizing, its various dimensions, and overlapping concepts. Then we review the development of mentalizing in attachment relationships, including developmental failures contributing to later psychopathology. In this developmental context, we advance the thesis that effective psychotherapy entails a natural pedagogical process that rekindles the patient's openness to interpersonal influence and thus unblocks obstacles to social learning that stem from a history of social adversity. With this developmental frame, we describe Mentalization-Based Treatment (MBT) for borderline personality disorder (BPD) and summarize the results of controlled research on its effectiveness. Given the developmental thesis we articulate regarding the pedagogical process of psychotherapy, BPD was a natural domain for the development of a mentalization-based approach to treatment. Yet, given the pervasive influence of social adversity on the development of psychopathology, along with the cardinal importance of social learning in its amelioration, we have expanded our purview beyond BPD. Accordingly, we articulate our view that mentalizing plays a crucial role as a common therapeutic factor in diverse psychotherapies as applied to a broad range of psychiatric disorders. We conclude by considering directions for future research. In covering such a wide territory, we are hitting the highlights; we intend this chapter merely to be a gateway into the burgeoning literature on mentalizing and related developments in attachment theory and research.

Facets of Mentalizing and Related Concepts

Mentalizing is an umbrella term that encompasses many facets (Allen et al. 2008), outlined in Table 31-1. Therapists must attend to the multifaceted nature of mentalizing, because individuals' mentalizing capacity varies along several dimensions, and there are significant individual differences in the nature of this variability that relate to psychopathology. Linking different conceptual dimensions of mentalizing to activation in somewhat distinct brain regions contributes to the accurate parsing of these dimensions (Fonagy et al. 2012).

Most fundamentally, we distinguish mentalizing in relation to self and others. Plainly, some individuals are more adept at interpreting others' mental states than their own, whereas others can be more attuned to their own mental states and relatively indifferent or oblivious to those of other people. Learning to differentiate mental states of self and others is a complex developmental achievement, and this differentiation can break down in the context of interpersonal stress. As research on mirror neurons attests (Iacoboni 2008), brain regions that respond similarly to observing, acting, and feeling equip a person for emotional resonance and contagion; this capacity for resonance develops into true empathy only in conjunction with inhibitory processes in more advanced brain regions that permit perspective taking and reflection on the differences between self and other. As we explain to patients in educational groups, individuals must project their own experience when mentalizing in relation to others, but they also must recognize their projections as such and attend to differences in experience and perspectives.

We also distinguish between explicit and implicit mentalizing. Explicit mentalizing is relatively controlled, predominantly taking the form of narrative; people routinely tell stories to others and themselves about their mental states, the reasons for them, and their history. These stories are more or less elaborate, ranging from simply putting feelings into words to creating more complex autobiographical narratives. Explicit mentalizing, like consciousness more generally, permits mental time travel: people mentalize not only about the present (e.g., exploring reasons for current feelings) but also about the past (e.g., reconstructing the basis for a prior interpersonal conflict or impulsive action) and the future (e.g., anticipating the best way to address a relationship challenge). Thus, as in psychotherapy, individuals use explicit mentalizing to learn from past mistakes in the service of interacting more effectively in the future.

Source. Adapted from Allen JG: Restoring Mentalizing in Attachment Relationships: Treating Trauma With Plain Old Therapy. Washington, DC, American Psychiatric Publishing, 2013, p. 29. Used with permission.

In contrast, implicit mentalizing is relatively automatic, procedural, and nonconscious, such as in turn-taking in conversation, adapting voice tone and posture to others' emotional states, and taking others' knowledge into account automatically (e.g., not referring to Jane when the other person has no idea who Jane is). In general, people rely on implicit mentalizing when all goes smoothly in interactions, whereas explicit mentalizing exemplifies the function of consciousness and deliberation more generally. Individuals mentalize explicitly when they encounter novel or inexplicable behavior (in self or others) and when deliberately addressing and resolving intrapsychic or interpersonal conflicts.

We also distinguish cognitive and affective mentalizing, in relation to which individual differences are plainly evident. Extreme imbalance in either direction poses challenges for psychotherapy. For example, relying on cognition, obsessive and intellectualizing patients might be adept at generating explicit reasons for their own or others' behavior, but such insight—devoid of any real emotional meaning—does not promote change. Conversely, patients who are more prone to being flooded with affect (e.g., as in BPD) are employing implicit processes conducive to emotional contagion and impaired self-other differentiation. For patients at both ends of this spectrum, mentalizing emotion—thinking and feeling about thinking and feeling—is a crucial therapeutic goal.

Finally, we distinguish external and internal mentalizing. External mentalizing entails responsiveness to external, observable aspects of behavior—most prominently facial expressions, but also voice tone and posture. In contrast, internal mentalizing requires inference and imagination in the service of understanding the mental states conjoined with external behavior (i.e., desires, feelings, beliefs, and relationship proclivities). As evident in the context of BPD (see section "Mentalization-Based Treatment" later in chapter), implicit, affective, and external mentalizing can lead to problematic interpersonal behavior—for example, when a patient responds to the therapist's momentary frown of puzzlement as an indication of hostile rejection, convinced that the therapist is eager to terminate the therapy. Such implicit responses call for therapeutic explication in which the therapist's perspective can be brought to bear on the patient's experience.

Implicit in the foregoing discussion are individual differences in mentalizing capacity or skill, as highlighted in Table 31-2. Our psychotherapeutic efforts are directed toward identifying areas of mentalizing deficits and improving mentalizing skills in these domains. To a great degree, skillful mentalizing entails flexible integration of the multiple facets of mentalizing that we have just delineated: balancing focus on self and others; integrating cognitive and affective mentalizing; being able to link external behavior with internal mental states; and relying on implicit and intuitive mentalizing while engaging explicit and reflective mentalizing when confronting problems or engaging in more complex interactions (e.g., in challenging negotiations or psychotherapy).

Given that mentalizing is fundamental to human relationships—relating to oneself as well as relating to others—it is little wonder that mentalizing overlaps in various ways with many cognate concepts, including empathy, psychological mindedness, observing ego, insight, theory of mind, mind reading, social cognition, metacognition, social intelligence, and emotional intelligence. The term reflective functioning bears especially close kinship to mentalizing in being a well-established measure of mentalizing capacity (Fonagy et al. 1998), based on assessments of the arena in which mentalizing is most challenging—namely, narratives regarding childhood attachment relationships, a common component of psychotherapeutic discourse.

The distinction between mentalizing and mindfulness bears particular attention insofar as the two concepts are easily confused and conflated. Moreover, mindfulness has become extremely popular and is likely to be far more familiar to clinicians and patients who question the difference when they hear about mentalizing. Our view of the relations between these two concepts is summarized in Table 31-3. Most simply, mindfulness refers to present-centered attention, which can include attention to mental states in self or others—mindfulness of mind. In contrast, mentalizing also includes reflection and interpretation, typically in the form of narrative. In our view, mindful attentiveness to mental states is a necessary condition for skillful mentalizing. Mindfulness and mentalizing overlap in two key respects: First, both literatures emphasize the need to distinguish between mental states and the reality they represent. Second, both literatures advocate a nonjudgmental, open-minded attitude of curiosity and inquisitiveness about mental sates in oneself and others, which we call the mentalizing stance.

Readers might wonder, with all the cognate concepts, what is the justification for adding another, and an unusual word to boot—mentalizing. None of these concepts has an exact synonym, and they spring from diverse clinical and research traditions. As discussed in the next section, mentalizing has the distinct advantage of being embedded in attachment theory and research, which anchors it in developmental psychopathology. In addition, stemming from mentalization, mentalizing has the advantage of a verb form; we advocate to patients—and therapists—that mentalizing is something they must do—more consistently and skillfully.

Development of Mentalizing in Attachment Relationships

As reviewed elsewhere (Allen et al. 2008), we employ a simple principle that links development to the core task of psychotherapy: mentalizing begets mentalizing, and attachment relationships are the primary context for developing mentalizing. Conversely, nonmentalizing begets nonmentalizing; hence, traumatic attachment relationships result in impaired mentalizing, as BPD exemplifies.

A far more refined account (Gergely and Unoka 2008) can be condensed as follows: infants begin to develop a sense of self (and self-awareness) through a complex process of emotional mirroring. The mother, for example, mentalizes her infant's emotion and expresses this emotion in her face and demeanor, in effect representing (i.e., re-presenting) the emotion to the infant in such a way that the infant gradually links his internal experience to his mother's representation of it. The mentalizing mother responding to her infant's frustration does not express her frustration with the infant but rather expresses his frustration for him to see in her face, hear in her voice, and feel in her touch (e.g., intermingling an expression of frustration with an element of caring and concern). Later, in mentalizing interactions, the mother puts the child's emotions (and her own) into words. Ultimately, through mentalizing narratives, the relational contexts for emotional feelings are explicated.

Research on intergenerational transmission of attachment patterns and mentalizing (or nonmentalizing) embedded in them provides the most solid footing for a mentalizing approach to psychotherapy. Fonagy et al. (1991) employed the Reflective Functioning Scale (Fonagy et al. 1998) to assess quality of mentalizing in mothers pregnant with their first child, who were also interviewed about their attachment relationships with their parents in childhood, using the Adult Attachment Interview (Hesse 2008). A high level of mentalizing is associated with attachment security in these relationships and is evident in valuing attachment as well as being able to provide a rich and emotionally authentic account of the relationships. This narrative coherence is coupled with a capacity to reflect on the relationships (e.g., understand the reasons for parents' feelings and behavior) and their developmental impact on the self. To examine the relationship between parental mentalizing in the Adult Attachment Interview and subsequent infant attachment security Fonagy et al. (1991) employed Ainsworth's Strange Situation (Ainsworth et al. 1978), which entails moderately stressful parent-child separations and reunions in a playroom. In short, securely attached infants are more or less distressed by the separation; regardless, at the point of reunion, they seek contact and comfort from their mother and then, reassured, they return to play. Mothers' mentalizing capacity in relation to their own attachment history predicted their infants' attachment security in relation to them (Fonagy et al. 1991). These findings generalized to fathers (Steele et al. 1996).

A subsequent line of research has revealed a straightforward account of this intergenerational transmission process (Fonagy et al. 2008): parents who are securely attached to their parents, in part by virtue of their mentalizing capacity, mentalize in their interactions with their infants, enabling their infants to become securely attached to them. This finding is commonsensical: why would an infant seek comfort from a parent who does not mentalize—that is, who does not mindfully and empathically hold the infant's mind in mind? Moreover, infants who are more securely attached develop better mentalizing capacity in childhood. For example, they are more adept at inferring beliefs and more empathic in relating to their peers. Again, this is common sense: by virtue of being mentalized (and eventually engaging in discourse about mental states), children become better mentalizers in a natural pedagogical process.

Gergely and Csibra (2005; Csibra and Gergely 2011) propose the pedagogic stance to designate our uniquely human predisposition to teach and learn new and relevant cultural information in an efficient way, as summarized in Table 31-4. In contrast, for example, to the arduous process of trial-and-error learning, cultural knowledge—no matter how painstakingly acquired by our species, groups, or individuals—can be transmitted rapidly through pedagogy. This evolved capacity for social adaptation is biologically conserved. To navigate the social world, we must be open to learning about new objects, expected behaviors, and social contexts. Concomitantly, we must be able to correct our ideas, beliefs, expectations, and fantasies in light of communications from others as well as to learn from the situations we create and find ourselves in. This kind of adaptation is essential in infancy, and it is part and parcel of the developmental progression throughout life, including specific developmental phases such as early childhood and adolescence that require particularly intensive instruction and learning from caregivers and others. In short, we all benefit from inheriting an evolutionarily selected interpersonal channel for acquiring information about the world that we can trust—in effect, a biologically designed epistemic superhighway for the rapid and efficient transmission of socially maintained information that is essential for survival and adaptation in a human community.

In infancy, special cues trigger the pedagogic stance of learning from caregivers in the role of teachers. These cues signal the child that the information that the caregiver is about to transmit is trustworthy and generalizable beyond the current situation (Gergely 2007). These ostensive communicative cues in infancy include eye contact, raised eyebrows, addressing the recipient by name, special voice tone (motherese), and turn taking. These different cues are all ways of marking the interaction as special by signaling that the caregiver is paying attention to the infant's subjectivity in the context of intention to communicate (Fonagy et al. 2007).

This pedagogical template for social learning continues to hold beyond infancy. That is, we humans continue to require special triggers to open our minds so that we can take in new information about the world. If we are to learn from them, when others seek to communicate with us, they must first establish their credentials as trustworthy social pedagogues by showing that they are interested in our minds. Only then does the epistemic superhighway open up. Our feeling that the other person can see the world from our perspective (i.e., when they mentalize us) is the basis for epistemic trust and opens up our wish to learn about the world. Hence, epistemic trust is a precondition for learning about the social world through the pedagogical route. In our view, the attachment system serves the evolutionary function of establishing general epistemic trust in the social world by producing an expectation that others will respond to us in a sensitively responsive and psychologically attuned way—that is, enabling us to feel that we are known. There is a well-established body of evidence showing that securely attached children are more cognitively open and flexible than those who are insecurely attached, and this cognitive capacity is reflected in superior academic performance (Thompson 2008). Concomitantly, as Bowlby (1988) also asserted in the context of psychotherapy, security in attachment relationships is conducive to exploring one's own and others' mental states. In sum, the experience of feeling thought about promotes the sense of safety needed to think and learn about the social world in interactions with others throughout life. Most pertinent to our concerns in this chapter, epistemic trust, established on the basis of the clinician's mentalizing effort, is a precondition for effective psychotherapy, which promotes openness to social influence.

At the opposite extreme, trauma in attachment relationships contributes to the intergenerational transmission of impaired mentalizing capacities (Fonagy et al. 2007). With compromise of a sense of feeling understood—and epistemic distrust—comes a disrupted capacity for social learning. The most profound form of parental insecurity in the Adult Attachment Interview regarding parents' childhood attachment, classified as Unresolved-Disorganized, is evident prototypically in lapses of the coherence of discourse associated with the intrusion of unresolved traumatic childhood experiences (Hesse 2008). Such lapses are associated with impaired mentalizing in the context of attachment. Infants of parents classified as Unresolved-Disorganized are at higher risk for showing the most severe form of insecure attachment in the Strange Situation, namely, disorganized attachment. Infant disorganized attachment behavior (Main and Solomon 1990) is anomalous in showing extreme conflict (e.g., screaming in protest when the parent leaves the room and then running away when the parent returns) as well as in frankly confused or disoriented behavior (e.g., wandering around the room as if lost or entering into dissociative, trance-like states). Liable to have their own traumatic attachment history evoked in response to their infant's attachment needs or distress, profoundly insecure parents become frightening or frightened and unable to mentalize; in turn, their infants are liable to feel frightened and unable to seek solace in the relationship. In the context of separation and reunion, the infants' attachment needs are simultaneously heightened and thwarted, and the infants are left in an impossible situation of fright without solution. Infant attachment disorganization, the converse of secure attachment, is associated with impaired mentalizing capacities in childhood, a fundamentally problematic legacy of attachment trauma.

Disorganized attachment in infants, related to unresolved trauma in parents, was first discovered to occur in relation to frank maltreatment (Main and Solomon 1990). Subsequent research has revealed more subtle disturbances in parents' attachment discourse and parent-child interactions that are associated with disorganized attachment. That is, infant disorganization relates not only to parents' trauma-related lapses (including dissociative states) in attachment interviews but also to more pervasive indications of hostile or helpless states of mind throughout the interviews (Mel-nick et al. 2008). In addition, infant disorganization is associated not only with frank maltreatment—abuse and neglect—but also with more pervasive disturbance of emotional communication in parent-infant interactions (Lyons-Ruth and Jacobvitz 2008) and a more general disabled caregiving system (George and Solomon 2011).

Beebe et al. (2010) provided a dramatic demonstration of what we construe as mentalizing failures associated with infant disorganization. These researchers instructed mothers to play with their 4-month-old infants and made second-by-second ratings of videotaped interactions for a period of 150 seconds. They subsequently assessed infant attachment in the Strange Situation at 12 months. At the 4-month point, future disorganized infants showed relatively high levels of distress, and, most significantly, their mothers tended to turn their attention away from their infants' distress, respond with incongruent emotion (e.g., smiling or showing surprise), or loom unpredictably into the infant's space. Notably, the mothers of future disorganized infants were not generally less responsive or empathic; rather, they were misattuned when their infants were in distressed states—that is, they were psychologically unavailable when their availability was most needed.

We construe the crux of attachment trauma as being left psychologically alone in unbearable emotional states. Such experience precludes the development of mentalizing when it is most urgently needed, resulting in a threefold cascade of developmental liabilities, as highlighted in Table 31-5. Fonagy and Target (1997) initially articulated the adverse consequences of attachment trauma in proposing a dual liability: such trauma 1) evokes extreme distress and 2) undermines the development of the capacities to regulate distress—namely, the capacity to develop secure attachments, which requires mentalizing. We now propose that attachment trauma creates a further and most profound liability in its potential to close the epistemic superhighway that allows individuals to learn about the social world. One particularly pernicious consequence of social trauma may be the destruction of trust in social knowledge of all kinds. Once epistemic trust is destroyed and the mind is closed to processing new information, the behavioral repertoire of traumatized individuals becomes rigid and inaccessible to change through the mere presentation of fresh information. Although this rigidity makes it more difficult for the individual to adapt and survive, in the context of social adversity it must be understood as self-protective. Attachment trauma engenders an aversion to mentalizing insofar as awareness of the parent's fear, hatred, sadism, or indifference is extremely painful and threatening by virtue of leaving the child in danger without protection. In such instances, mentalizing the parent's psychological unavailability exacerbates attachment needs and the plight of being in a state of fright without solution. This plight is self-perpetuating: without a capacity to develop epistemic trust through entertaining a feeling of being understood, the capacity to learn from experience comes to exclude many forms of learning through human communication.

The ample developmental benefits of secure attachment have been thoroughly demonstrated in research from childhood (Sroufe et al. 2005) to adulthood (Mikulincer and Shaver 2007). Conversely, attachment trauma and disorganization have been shown to relate to developmental psychopathology from childhood (Carlson et al. 2009) to adulthood (Lyons-Ruth and Jacobvitz 2008). Moreover, disorganized adult attachment also is associated with diverse adult psychopathology (van Ijzendoorn and Bakermans-Kranenburg 2008). Although childhood attachment trauma is best regarded as a nonspecific risk factor for a wide array of later psychopathology, there is one exception: infant disorganization, which includes dissociative behavior, is associated with dissociative symptoms in childhood, adolescence, and early adulthood (Carlson 1998). More broadly, various forms of psychopathology can be linked to the three pre-mentalizing modes of experience summarized in Table 31-6.

The cognitive-dynamic model we have advanced has far-reaching clinical implications. In effect, evolution has prepared the human brain for knowledge transfer by communication (now including the century-old invention of psychological therapy); we humans are ready to learn from others about ourselves, just as we are ready to learn from them about the social world. To the extent that we find the meaning of our own subjective experience within the social world (i.e., within the other) and not simply in self-reflection, we are eager to learn about our own opaque mental world from those around us through mentalizing dialogue. Reaching out to a trusted confidant to make sense of puzzlingly intense distress about an interaction is a commonplace example of such mentalizing dialogue. The epistemic mistrust that follows trauma entailing intense social adversity, maltreatment, or abuse impinges on this natural disposition to learn through such dialogue. Persons with a history of extreme social adversity are hard to reach by means of ordinary communication, posing enormous challenges for psychotherapy, the goal of which is enduring change in the capacity for social understanding.

Source. Adapted from Allen JG, Fonagy P, Bateman AW: Mentalizing in Clinical Practice. Washington, DC, American Psychiatric Publishing, 2008, p. 91. Used with permission.

If we therapists are to work effectively with traumatized individuals in psychotherapy, we must consider not only the "what" but also the "how" of learning. Before learning can begin, negative expectations about the trustworthiness or value of human communication must be radically shifted. Toward this end, the psychotherapist must create a social situation that aims largely to open patients' minds by establishing a relationship in which they feel their subjective experience is being thought about empathically so that they can begin to trust the social world again. If a secure attachment relationship is the marker of trustworthiness, the establishment of such a relationship with the patient is a critical precondition for change. Psychotherapists' sensitivity and psychological attunement is paramount, not because it enables them to delineate the specific content of the patient's mind with pinpoint accuracy, but rather because it generates epistemic trust. Such trust opens up the patient not only to therapeutic influence but also—more importantly—to the influence of the wider social network to the extent that this experience of being known and open to new learning generalizes to other relationships. Thus, it is not what is taught in psychotherapy that brings change; rather, effective psychotherapy rekindles the evolutionary capacity for learning from others, which is crucial to the lifelong development and refinement of social cognition.

Mentalization-Based Treatment

As noted in this chapter's introduction, MBT was originally developed for the treatment of BPD. The core symptoms of BPD—emotional dysregulation, impulsivity, self-destructive behavior, and unstable relationships—are embedded in highly insecure (i.e., preoccupied and disorganized) attachment relationships and severe mentalizing impairments. More specifically, patients with BPD show marked impairments in the explicit, internal, and cognitive facets of mentalizing: they are reactive to external-behavioral cues (e.g., a grimace or a yawn), they have difficulty linking such cues appropriately to internal mental states, and they are subject to implicit mentalizing and emotional contagion concomitant with impaired capacity for explicit, reflective thinking (Fonagy and Luyten 2009). The following vignette illustrates such nonmentalizing reactivity and the therapist's efforts to reestablish mentalizing.

Alice sought psychotherapy in her late 20s for depression embedded in turbulent relationships with her parents and boyfriends since her early adolescence. She had started and quit psychotherapy twice previously, stating that it had been a waste of time and therapists only wanted her money.

Despite her apparent cynicism about psychotherapy, Alice seemed reasonably engaged in the first two sessions, showing some awareness of her pattern of moving quickly into romantic relationships, becoming infatuated and then increasingly frustrated and disillusioned with her partners' flagging attentiveness. She began the third session stating that she was in a particularly "foul mood," and she attributed this mood to the therapy, which she said amounted only to rehashing all her "messed up" relationships, rubbing her nose in her failures. The therapist frowned, leaned back, paused to think, looked at her intently, then said, "That sounds grim." Alice bristled, protesting, "You've given up on me! This therapy is going nowhere, and the way you're glaring at me tells me you're going to blame it all on me."

The therapist leaned forward and said, "Sorry Tve learned that I seem to stare when I'm thinking, and that can be off-putting." Alice responded, "You got that right!" The therapist continued, "I wasn't aware of glaring at you. It's interesting that you thought I intended to blame you because, when I paused, I was thinking that I'm not giving you enough help and starting to wonder what we might do differently" Alice's tone softened a bit, but she replied, "That doesn't change the fact that you've concluded I'm beyond help." The therapist responded, "I wonder if you're equating my feelings with yours—maybe you feel like giving up and interpreted my comment about this 'grim' situation as indicating that I see you the way you see yourself." Alice responded, "Sometimes I'm convinced I'm beyond help—I've even thought about killing myself. Why wouldn't you believe therapy is pointless?" The therapist responded, "I don't know how successful we will be, but I'm encouraged that you're speaking up about your frustrations with this process, and you're also willing to listen to me. So maybe you won't quit before we figure out what might be of help."

In such instances as these, when mentalizing collapses, patients' behavior is governed by prementalizing modes (see Table 31-6). In the psychic-equivalence mode, as Alice's response exemplifies, they feel complete conviction in their perceptions and interpretations, unable to consider multiple perspectives or adopt the as-if mode of thought. Alternatively, in the pretend mode, their experience becomes dissociated from reality and, losing grounding in reality, their perceptions can be highly distorted. Finally, in the teleological mode, action takes the place of thought, as their anger is expressed in self-destructive action, and caring must be conveyed in touch rather than gaze, demeanor, and words.

It is easier for us therapists to empathize with the apparent inaccessibility of patients with BPD to social influence (including psychotherapy) if we respect their inability to detect and respond to ostensive cues signaling our interest in their subjective experience and our perspectives on it. Such cues would normally generate epistemic trust and open the individual to learning from trusted others. What appears as rigidity in persons with BPD is a combination of a failure of a key reflective (i.e., mentalizing) capacity coupled with an inability to respond openly to—and to learn from—human communication.

Although there are multiple developmental pathways to BPD, a nonmentalizing family environment makes an important contribution. Such family relationships marked by impaired emotional communication are not conducive to coherent discourse regarding feelings, thoughts, needs, motives, and different perspectives. Such interactions also do not exemplify the mentalizing stance of empathic and mindful concern. Such an environment sets the stage for a developmental cascade that eventuates in BPD (Carlson et al. 2009). To summarize:

One developmental path to impairments in mentalizing in BPD is a combination of early neglect, which might undermine the infant's developing capacity for affect regulation, with later maltreatment or other environmental circumstances, including adult experience of verbal, emotional, physical and sexual abuse, that are likely to activate the attachment system chronically. (Fonagy and Luyten 2009, p.1366)

Bateman and Fonagy developed MBT to provide a comparatively mentalizing-rich and trustworthy interpersonal environment in which these core deficits in social cognition can be rectified. In its original iteration (Bateman and Fonagy 1999), MBT was developed in the context of a day hospital program centered on individual and group psychotherapy but also including expressive therapies (e.g., involving artwork and writing). Patients attend the program 5 days a week, and the maximum length of stay ranges from 18 to 24 months. Subsequently, Bateman and Fonagy (2009) established an 18-month intensive outpatient program consisting of once-weekly 50-minute individual psychotherapy sessions coupled with once-weekly 90-minute group psychotherapy sessions. In both programs, the individual psychotherapist is separate from the group therapist. Both programs were designed with common features of effective treatments for BPD in mind (Table 31-7).

The overall aims of MBT, a highly straightforward treatment approach, can be summarized simply:

It is a therapy to enhance capacities of mentalization and to make them more stable and robust so that the individual is better able to solve problems and to manage emotional states (particularly within interpersonal relationships), or at least to feel more confident in doing so. Our intention with the patient is to promote a mentalizing attitude to relationships and problems, to instill doubt where there is certainty, and to enable the patient to become increasingly curious about his or her own mental states and those of others. (Bateman and Fonagy 2012, p. 274)

The mentalizing focus is guided by the most prominent mentalizing impairments in patients with BPD: interventions are aimed at slowing down the patient in the face of emotional reactivity by encouraging explicit thinking about internal mental states, while shifting fluidly to maintain a balance of mentalizing in relation to self and others. Although MBT has substantial roots in psychoanalysis, the mentalizing approach does not specify the content of the treatment process; rather, the content is guided by the patient's concerns, albeit with a focus on interpersonal problems and attachment relationships in particular. Importantly, consistent with our developmental thesis regarding the natural pedagogical process, the treatment does not focus on acquiring insight but rather on enhancing openness to influence and mentalizing skill for the sake of effectiveness in interpersonal and intrapersonal problem solving.

Our developmental thesis is consistent with the fact that different therapeutic approaches are effective in the treatment of BPD, as is also true for many other psychiatric disorders. Feeling reliably understood, perhaps for the first time, the patient is ready to hear the therapist's message and to engage in a process of learning and change. However, we should entertain the possibility that it may not be the therapist's specific observations and suggestions that are of greatest potential in the healing process. Given the research evidence that many theoretical approaches and therapeutic modalities are effective for this group of patients, it is highly likely that change comes about through the mere fact of establishing trust and interpersonal understanding in the consulting room that serves to clear barriers on the epistemic superhighway. Patients leave the consulting room with a mind that is able to learn—that is, to absorb new information and integrate it into their current and past patterns of thought. With the benefit of effective psychotherapy, they are able to continue the process of psychological exploration and learning with partners, parents, friends, and colleagues. The information to which they are exposed may not necessarily be new; rather, previously imparted information from these various sources was mistrusted, because the biological clue for internalization—epistemic trust—could not be triggered in the absence of being able to feel understood by others.

In the interest of establishing trust and promoting interpersonal learning, MBT includes significant attention to transference and countertransference in a qualified sense: along with other relationships, the patient-therapist relationship is addressed in the service of improving mentalizing. Patients and therapists think together about their relationship, comparing and contrasting their perspectives. Continuous and perfect alignment of perspectives would not promote learning; therapy invariably entails a fluid process of alignment, misalignment, and realignment of perspectives. The therapist must grasp the patient's experience with reasonable accuracy much of the time while also challenging the patient's perspective by bringing in another point of view. Moreover, the therapist also must exemplify openness and flexibility by responsiveness to the patient's point of view, for example, when inevitably the therapist's comments will be off the mark. This approach requires a high degree of transparency on the part of the therapist, which serves as a model of transparency for the patient—being able to speak directly and forthrightly about the experience of the relationship: "The patient needs 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 and Fonagy 2006, p. 93, emphasis added).

The following clinical vignette illustrates the process of mentalizing the transference and of minds influencing minds.

Bertha, a physician in her mid-50s, was hospitalized on an emergency basis after a 6-month spiral into depression that was precipitated by a contentious marital separation, compounded by increasingly confrontational disputes with a partner in her group practice—all exacerbated by binge drinking that culminated in an overdose. After she was stabilized, she was transferred to specialized inpatient treatment during which she received psychotherapy.

Bertha denied that her overdose was a suicide attempt; rather, she said she merely wanted to knock herself out for a time to escape from the pain of feeling continually berated and left alone to fend for herself. Despite disavowing suicide, she acknowledged that when she took the overdose, she would not have minded if she died. By the time she was stabilized and was provided with respite from relentless stress, she was horrified that she could have died, especially because of the potential impact of her suicide on her two children and the implications of her self-destructive behavior for a brewing custody battle. Accordingly, Bertha agreed that her safety after discharge from the hospital should be a prominent focus for the psychotherapy.

Bertha's long history of self-defeating behavior was a focus for psychotherapy and came to the fore in the context of impending discharge when she faltered in developing a concrete safety plan that included identifying individuals from whom she might seek help in a crisis. In the context of a generally collaborative relationship, the therapist evoked a rift in the alliance when he pointed out that Bertha was repeating her "self-defeating" pattern in "procrastinating" regarding planning for her safety when she left the hospital. Bertha took umbrage and protested angrily, "I've been working my ass off in treatment!" She added that she was afraid she would not have the support she needed when she left the hospital, and she maintained that she was not being "self-defeating" but rather being "brutally realistic" in raising doubts about her safety, given her "poor track record" in safeguarding her welfare over the course of her lifetime. Expressing her puzzlement forthrightly, she said she could not understand where the therapist was coming from.

Taken aback by Bertha's challenge of an observation that seemed self-evident to him, the therapist responded to her request to explain himself. He stated that he was responding to what seemed to be Bertha's "balking" at working on a plan and that he now was aware that his frustration was a reflection of his anxiety about her safety going forward—anxiety that the two of them obviously shared. He then said that—whether or not Bertha was being self-defeating—he was feeling defeated. This led to a mutual recognition of how he was resonating with Bertha's struggle with her own feeling of being defeated by her recurrent depression and alcohol abuse, as well as her relentless self-criticism. Responding to the therapist's feeling of defeat, she acknowledged that others—including her husband and partner—repeatedly had felt defeated by her behavior. In the course of this reflection, Bertha and the therapist shared the experience of minds being influenced by minds, and they were freed up to explore the barriers to Bertha's identifying durable sources of support.

Broadly, the ideal outcome of MBT is the patient's internalizing the mentalizing stance from the therapeutic process, the crux of which is an enduring inclination to explore and understand mental states with an open-minded attitude of curiosity. In other words, epistemic trust must be (re)established so that patients can be open to learning about their own and others' mental states. Of course, once established, such mentalizing will flourish only in the context of reciprocity and mutuality. In patient education groups conducted in a therapeutic milieu that cultivates this stance, patients commonly inquire, "You've got me trying to mentalize. Now tell me how to get my spouse to do it!" We have only one general answer: "Mentalize." Trying to force another person to mentalize, ironically, is nonmentalizing. We adhere to the developmental principle that mentalizing begets mentalizing. The best way to encourage mentalizing in the other person is to adopt the mentalizing stance. This is precisely what therapists aspire to do in MBT. Hence, tide answer to the question, "How do I get my patient with BPD to mentalize?" is "By mentalizing."

Bateman and Fonagy have examined the effectiveness of MBT for treating BPD in a series of randomized controlled trials, with patients receiving treatment as usual in the community serving as comparison groups. The day hospital program has been investigated in a series of outcome studies, culminating in an 8-year followup study (Bateman and Fonagy 2008), the longest follow-up of treatment for BPD conducted to date. In comparison with treatment as usual, MBT decreased suicide attempts, emergency room visits, inpatient admissions, medication and outpatient treatment utilization, and impulsivity. Far fewer patients in the MBT group than in the comparison group met criteria for BPD at the follow-up point (13% vs. 87%). Moreover, in addition to symptomatic improvement, patients in the MBT group showed greater improvement in interpersonal and occupational functioning. Similarly, the intensive outpatient program proved more effective than structured clinical management for BPD at the end of the 18-month treatment period (Bateman and Fonagy 2009). Compared with treatment as usual, the outpatient treatment resulted in lowered rates of suicidal behavior and nonsuicidal self-injury as well as fewer hospitalizations; in addition, the MBT group showed improved social adjustment coupled with diminished depression, symptom distress, and interpersonal distress.

Mentalizing as a Common Factor in Psychotherapy

Decades of psychotherapy research have shown a consistent finding: compared with control conditions, many brands of psychotherapy are demonstrably effective, but it is difficult to show consistently that any particular brand is more effective than any other. Long before the amassing of extensive evidence, Frank (1961) presciently proposed that "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 to those that distinguish them from each other" (p. 104).

Whereas differences among brands generally carry limited weight, extensive evidence attests to the substantial impact of the quality of the patient-therapist relationship on outcomes (Norcross 2011). Most notably, consistent evidence attests to the importance of the therapeutic alliance (Horvath et al. 2011) as well as the capacity to repair ruptures in the alliance (Safran et al. 2011). Our approach is entirely consistent with this emphasis on the therapeutic relationship, for which we use the language of mentalizing in the context of a secure attachment relationship. Bowlby (1988) summarized this approach elegantly in construing the therapist's role as providing "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" (p. 138). When one of us (Allen) made the observation in a trauma-education group that "the mind can be a scary place," a patient replied, "Yes, and you wouldn't want to go in there alone!" Bowlby might have applauded.

Taking a cue from Frank (1961), we have proposed immodestly that mentalizing is "the most fundamental common factor among psychotherapeutic treatments" (Allen et al. 2008, p. 1). With countervailing humility, we also have asserted the corollary: "mentalization-based treatment is the least novel therapeutic approach imaginable" (Allen and Fonagy 2006, p. xix, emphasis added). In our view, mentalizing is what psychotherapists do—with Oldham's (2008) caveat, when they are doing their job. Thankfully, one need not know the concept to mentalize, although we believe that understanding the concept facilitates doing so by focusing attention to the crucial process. How could one conduct psychoanalysis, psychodynamic psychotherapy, interpersonal psychotherapy, cognitive therapy—or even behavior therapy—without mentalizing? And how could a therapist conduct any of these treatments without inviting the patient to mentalize? The behavior therapist must know the patient's view of the problem, and changing behavior can promote mentalizing (e.g., exposure to feared interpersonal situations can alter appraisals of their dangerousness as well as increase understanding and acceptance of one's emotional reactions).

Accordingly, in addition to being the fulcrum for a structured approach to the treatment of BPD, the mentalizing approach can be viewed as a distinctive style of psychotherapy as might be practiced by many generalists, as contrasted with the more specialized, disorder-centered treatments. Our experience in conducting workshops for psychotherapists in diverse clinical settings and in varied parts of the world suggests that this mentalizing style of psychotherapy has wide appeal. In part, this appeal stems from the commonsensical quality of the approach; once one gets past the esoteric word mentalizing, there is nothing unusual about it. We employ one basic technique: mentalizing conversation. We explicitly encourage therapists to be ordinary and natural. We relieve them of the need to be the expert on the patient's mind. We commend a not-knowing stance, consistent with our understanding of the opacity of mental states, including one's own mental states.

If our experience is any guide, this approach to psychotherapy sounds easy—until one tries to do it consistently. As is true for patients, mentalizing is easily derailed for therapists, and for the same reasons: attachment insecurity, intense affect, defensiveness, and aversion to awareness. Moreover, although the mentalizing approach is not tied to a particular body of theory regarding personality and psychopathology, conducting psychotherapy—especially with patients who experience severe and chronic psychiatric disorders—requires a great deal of professional knowledge. Given the close developmental ties of mentalizing to attachment relationships, knowledge of attachment theory and research is especially valuable, and this literature is vast. Moreover, although the mentalizing approach is neither highly structured nor prescriptive, it is not freewheeling: sound treatment must be based on an explicit formulation that guides the treatment—ideally, a written formulation provided to the patient based on a collaborative process of understanding (Allen et al. 2008). The following clinical example illustrates the potential value of such a formulation.

Carl, a second-year medical student, was referred for inpatient treatment after being placed on medical leave. With his prospective career seriously threatened, he felt he had "nowhere to go," and he was hospitalized after he plummeted into suicidal despair.

Carl said he had derived no benefit from previous therapy but thought he would give it another try "in sheer desperation." He stated adamantly that he had been plagued with anxiety as long as he could remember and that he had "thought about every imaginable strategy for coping" for years. He stated flatly that in light of his long experience in trying to "outwit" his anxiety, the best any therapist might do is "scramble to catch up" with his thinking, while invariably remaining behind. In effect, he had nothing to learn and was impervious to influence.

Despite his forthright skepticism and pessimism about the process, Carl discussed the childhood development of his anxiety forthrightly and poignantly. Carl's anxiety was all too conspicuous, and he said his father adopted a "drill-sergeant" approach to curing him of it. For example, Carl was afraid of the dark and even through adolescence he slept with a light on. His father went into his room at night after he was asleep to turn off the light, leaving Carl to awaken in terror. Carl learned to "stuff" his feelings in his family, a pattern that continued into his adulthood. His friends were more like acquaintances, he dated only sporadically, and he had no emotional confiding relationships.

The therapist quickly adopted Carl's pessimism about being able to outthink him and, after a few initial sessions, he made a serious blunder. Although Carl had revealed a great deal about himself, he continued to express frustration and disappointment about the failure of the therapy to relieve his anxiety. Intending to address the relationship implications of Carl's insistence that the best any therapist could do was aspire to catch up with Carl's understanding (but never improve upon it), the therapist acknowledged feeling "inadequate" in the process. Carl immediately responded with marked despair, stating, "Right now I feel more hopeless than ever before in my life! You're telling me you can't help me." The therapist, feeling discouraged and guilty, with his own mentalizing capacity compromised, was unable to engage Carl in any productive reflection about the interaction throughout the rest of the session. His only effective intervention was urging strongly that Carl come back for another session, which Carl said he was willing to do.

In the interim between sessions, the therapist wrote a two-page, single-spaced narrative formulation in an effort to rescue the process. The formulation began by stating the therapist's intention to address the "impasse" in their work so as to find a way to move forward. The formulation acknowledged the therapist's feeling of inadequacy and raised the possibility that the therapist was "resonating" with Carl's feeling of inadequacy in coping with his anxiety.

The formulation summarized what the therapist had learned about the developmental origins of Carl's anxiety. It delineated the psychological and relationship factors contributing to the suicide attempt, emphasizing how Carl had come to feel utterly alone in despair. The formulation agreed with the futility of trying to "outthink" Carl or, indeed, of any aspiration to help Carl "think his way out" of the anxiety. Instead, the formulation raised the possibility that Carl's emotional pain might be alleviated somewhat if he were to feel less alone with it. It made the point that, his aversion to closeness notwithstanding, Carl had confided openly and emotionally in the therapist about the problems that culminated in his suicidal state. It noted also that Carl had made initial efforts to confide in some of his peers in the hospital and had commented that merely knowing that others struggled in similar ways had been somewhat reassuring to him. Moreover, with the help of his social worker, he had begun to "open a dialogue" with his parents, who—to his surprise—had responded helpfully to his plight. In effect, the formulation pointed to the importance of attachment relationships in ameliorating his anxiety as well as the value of feeling and expressing his emotions as a potential way forward.

At the beginning of the next session, the therapist apologized straightforwardly for Carl for the "clumsy" and "hurtful" way he had approached the "challenges" of psychotherapy and their work together. He stated that he wanted to get the therapy "back on track" and that he thought it might be helpful for him to summarize his thinking about the therapy in writing. He invited Carl to read the formulation, and Carl did so with great concentration—underlining different passages as he went. When he finished, he looked up and declared, "That's about right." Specifically, having experienced glimmers of benefit from the therapeutic milieu in the hospital, he agreed with the broad point that the treatment as a whole would better be focused on feelings and relationships than on thinking. He commented that the formulation had offered what he had been wanting—that is, a different perspective on managing his anxiety.

We have introduced potential confusion in proposing mentalizing as both a specialized brand of therapy (i.e., MBT for BPD) and a common factor in psychotherapy. In the latter context, mentalizing is an integrative approach to psychotherapy—transtheoretical, transdiagnostic, and applicable to multiple treatment modalities. In this regard, mentalizing is consistent with the expansive applications of other therapeutic approaches—psychoanalysis, interpersonal psychotherapy, cognitive therapy and mindfulness practice. In our view, MBT and related attachment research has provided the context of discovery in which we have refined our understanding of the psychotherapeutic potential of a fundamental psychological and interpersonal process—indeed, the process by which we humans establish and maintain relationships as well as understand ourselves. As discovered over two decades ago in the context of BPD (Fonagy 1989), mentalizing provides a unique window into the realm of developmental psychopathology. This window is continually opening wider.

In collaboration with colleagues, one of us (Allen) began to explore the broader applicability of mentalizing in clinical work with patients at The Menninger Clinic, which specializes in intensive, multidisciplinary inpatient services for patients with complex, treatment-resistant psychopathology—a treatment approach that can be essential to interrupt entrenched treatment stalemates such as Carl's vignette exemplified. A history of attachment trauma is ubiquitous in this patient population. As is characteristic of the field of psychiatry more generally, the treatment is eclectic, employing a number of therapeutic modalities (i.e., individual, group, and family therapy, along with psychoeducation) and theoretical frameworks (i.e., ranging from psychodynamic to cognitive-behavioral). To bring conceptual coherence to this diverse practice, we educate patients and staff members about mentalizing in the context of attachment relationships as an overarching goal of treatment.

Concomitant with the appreciation of its generic role in psychotherapy, the wider applications of mentalizing are becoming increasingly systematic and formalized. For example, the mentalizing approach is being extended in diverse clinical settings nationally and internationally to the treatment of depression, substance abuse, eating disorders, trauma, and antisocial personality disorder. In addition, beyond its applications to individual and group therapy, mentalizing is being applied to family therapy as well as parent-infant and parent-child interventions. This burgeoning of interest in diverse applications is consistent with our view of mentalizing as a common factor in psychopathology and in psychotherapy.

Directions for Future Research

As discussed above in the section "Mentalization-Based Treatment," MBT rests on a solid evidence base as a treatment for BPD (Bateman and Fonagy 2008, 2009). Yet, although the interventions are designed to promote mentalizing, a measure of mentalizing was not included in the assessment of treatment outcomes in these studies. Ironically, the most direct evidence for enhanced mentalizing in psychotherapy comes from Transference-Focused Psychotherapy, a treatment approach also intended to promote mentalizing (Kernberg et al. 2008). Clarkin et al. (2007) compared the effectiveness of Transference-Focused Psychotherapy with that of Dialectical Behavior Therapy and supportive therapy in treating BPD. Although these three treatment approaches were generally equivalent in effectiveness, Transference-Focused Psychotherapy had a greater positive impact on the proportion of patients showing secure attachment after treatment as well as on improvements in mentalizing as reflected on the Adult Attachment Interview (Levy et al. 2006).

Vermote et al. (2010) studied changes in mentalizing over the course of a hospital-based treatment program modeled after MBT. They did not find overall improvements in mentalizing or any relation between improved mentalizing and treatment outcomes. However, a more fine-grained analysis (Vermote et al. 2011) revealed two clusters of patients: a stable cluster showed gradual and steady improvement in mentalizing over the course of treatment, whereas a fluctuating cluster showed increases and decreases, likely related to changes in the treatment alliance. Thus, overall improvement pertained only to one subset of patients.

Parent-infant and parent-child interventions make up one of the most promising arenas for demonstrating the benefits of enhancing mentalizing. A wide range of programs are designed to enhance maternal sensitivity, and some are designed with an explicit focus on mentalizing: the therapist facilitates mentalizing in the mother regarding her own thoughts, feelings, and developmental history, and assists the mother in mentalizing her child's experience as well as the emotional impact of their interactions as they relate to attachment. A few research-based programs illustrate. In a study of depressed mothers engaged in toddler-parent psychotherapy, Toth et al. (2008) aspired to enhance mothers' awareness of the impact of their interactions with their child as well as help mothers to appreciate the impact of their earlier relationships on these interactions. Compared with mothers in a control group, those in the intervention group showed improved mentalizing, and their infants showed improved attachment security—although the infants' improved security was not directly related to mothers' improved mentalizing. Sadler et al. (2006) developed the Minding the Baby program for high-risk mothers; preliminary results indicate that the program improved parental mentalizing and reduced the likelihood of infant disorganized attachment. Suchman et al. (2012) reported findings from two intervention programs for mothers with a history of trauma and substance abuse. In the residential program, mothers' mentalizing capacity was assessed during pregnancy and again when their infant was age 4 months. The intervention was associated with an increase in maternal mentalizing at the 4-month point, and mentalizing was associated with higher levels of responsiveness to the infant. In the outpatient substance-abuse treatment program, a 12-week adjunctive mentalizing intervention was associated with higher levels of maternal mentalizing as well as contingent responsiveness in mother-infant interactions.

In sum, the evidence base for a mentalizing approach to psychotherapy is diverse and growing. The broad developmental principles—that mentalizing begets mentalizing and, conversely, that nonmentalizing begets nonmentalizing—are grounded in research. In addition, the effectiveness of MBT in the treatment of BPD is well established through controlled, long-term follow-up research for a day hospital program (Bateman and Fonagy 2008) as well as in initial outcome research for an intensive outpatient program (Bateman and Fonagy 2009). To date, however, the evidence that psychotherapeutic interventions improve mentalizing, although heartening, is spotty; moreover, evidence that enhanced mentalizing relates directly to treatment outcomes is sparse. We are in accord with Kazdin (2007) that the challenge for psychotherapy research is to better understand the mechanisms of change, ideally in relation to developmental processes. Based on attachment research, we believe that a focus on enhancing mentalizing in the context of attachment relationships in a variety of contexts—with individual therapists, groups, couples, families, and children—is a promising direction for identifying mechanisms of change and has wide clinical applicability.

Key Clinical Points

• Mentalizing is multifaceted: Although we advocate a broad focus on mentalizing in psychotherapy, clinicians must attend at any given moment to particular facets that are impaired; primary distinctions are self versus others, implicit versus explicit, internal versus external, and cognitive versus affective.
• Mentalizing begets mentalizing: Psychotherapeutic practice builds on the finding that parental mentalizing in relation to the parents' attachment history as well as the child is conducive to the child's developing secure attachment and enhanced mentalizing capacity in what can be construed as a natural pedagogical process.
• Mentalization-Based Treatment (MBT) is effective: Long-term follow-up research on treatment of borderline personality disorder shows MBT to decrease an array of core symptoms and treatment utilization while improving interpersonal and vocational functioning.
• Mentalizing is a common psychotherapeutic factor: Core principles developed in MBT to promote mentalizing can be applied within diverse theoretical frameworks and for different treatment modalities; promoting mentalizing in the context of attachment constitutes a refinement of therapeutic practice based on venerable research demonstrating the prominent contribution of the patient-therapist relationship to treatment outcomes.
• Mentalizing applies to diverse psychopathology: Although mentalizing-focused treatment was developed to ameliorate deficits in social cognition commonly associated with borderline personality disorder, such deficits are evident in an array of psychiatric disorders for which mentalizing approaches are being developed, including substance abuse, eating disorders, depression, trauma, and other personality disorders.

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Suggested Readings

Allen JG: Mentalizing in the Development and Treatment of Attachment Trauma. London, Karnac, 2013

Allen JG: Restoring Mentalizing in Attachment Relationships: Treating Trauma With Plain Old Therapy. Washington, DC, American Psychiatric Publishing, 2013

Allen JG, Fonagy P, Bateman A: Mentalizing in Clinical Practice. Washington, DC, American Psychiatric Publishing, 2008

Bateman A, Fonagy P: Mentalization-Based Treatment for Borderline Personality Disorder: A Practical Guide. New York, Oxford University Press, 2006

Bateman A, Fonagy P (eds): Handbook of Mentalizing in Mental Health Practice. Washington, DC, American Psychiatric Publishing, 2012

Fonagy P: Attachment Theory and Psychoanalysis. New York, Other Press, 2001

Fonagy P, Gergely G, Jurist EL, et al: Affect Regulation, Mentalization, and the Development of the Self. New York, Other Press, 2002

Holmes J: Exploring in Security: Towards an Attachment-Informed Psychoanalytic Psychotherapy. New York, Routledge, 2010

Jurist EL, Slade A, Bergner S (eds): Mind to Mind: Infant Research, Neuroscience, and Psychoanalysis. New York, Other Press, 2008