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Abstract

The aim of the article is to try to integrate the clinical work, theoretical knowledge, and scientific research in the context of the latest mentalization theories. The theoretical and practical basis for considerations on mentalization is Otto Kernberg's concept of personality organization and the psychotherapy system for patients with personality pathology − Transference Focused Psychotherapy (TFP). In the article, the issue of diagnosis of patients' mentalization along with the level of personality organization is discussed. Possible mentalization disorders appearing in the patient-therapist relation (pseudomentalization, concrete mentalization and lack of mentalization) are also described. Moreover, the latest research on mentalization in the context of psychodynamic psychotherapy is presented, concerning two aspects of mentalization: as the function of the therapist and the patient. The last part of the article refers to the importance of mentalization as a therapeutic factor in TFP. Conclusions: Mentalizing can be seen as a certain independent attitude, a specific meta-theoretical basis of the therapy, followed by techniques resulting from a specific paradigm. Psychodynamic psychotherapy is intended to provide maximum comfort of mentalizing for both the patient and the therapist.
PSYCHOTERAPIA 4 (187) 2018
pages: 5–17
Monika Jańczak
MENTALIZATION IN CLINICAL PRACTICE
− A PSYCHODYNAMIC PERSPECTIVE
Institute of Psychology, Adam Mickiewicz University in Poznań
mentalization,
Transference Focused Psychotherapy,
psychodynamic psychotherapy
Summary
The aim of the article is to try to integrate the clinical work, theoretical knowledge, and scientific research in the
context of the latest mentalization theories. The theoretical and practical basis for considerations on mentalization
is Otto Kernberg's concept of personality organization and the psychotherapy system for patients with personality
pathology − Transference Focused Psychotherapy (TFP). In the article, the issue of diagnosis of patients’
mentalization along with the level of personality organization is discussed. Possible mentalization disorders
appearing in the patient-therapist relation (pseudomentalization, concrete mentalization and lack of mentalization)
are also described. Moreover, the latest research on mentalization in the context of psychodynamic psychotherapy
is presented, concerning two aspects of mentalization: as the function of the therapist and the patient. The last part
of the article refers to the importance of mentalization as a therapeutic factor in TFP. Conclusions: Mentalizing
can be seen as a certain independent attitude, a specific meta-theoretical basis of the therapy, followed by
techniques resulting from a specific paradigm. Psychodynamic psychotherapy is intended to provide maximum
comfort of mentalizing for both the patient and the therapist.
Introduction
This paper is inspired by the intention to integrate and give form to the triangle of
clinical work−theoretical knowledge−research in the area of mentalization. Whereas research
on mentalizing seems to have a well-established status in the Polish and international literature,
there are still few studies besides the mainstream publications by Fonagy, Allen, and their
team − showing how to use this body of knowledge when working with patients. The
theoretical and practical basis for reflections on mentalizing will be Otto Kernberg's concept
of personality organization and his system of psychotherapy for patients with personality
pathology Transference-Focused Psychotherapy (TFP), which is one of the most popular
types of psychodynamic psychotherapy in Poland, discussed in both research and clinical
contexts [1].
The concept of mentalization has been defined and its meaning has been analyzed many
times in the Polish literature. For the most comprehensive presentation, the reader is referred
to the book edited by Cierpiałkowska and Górska [2]. For the purposes of the present paper, I
will present only the key elements of the concept of mentalization. Mentalizing is a mostly
unconscious representational mental process which consists in identifying and understanding
one’s own and other people’s behaviors as stemming from intentional mental states. It involves
6 Monika Jańczak
the basic ability to differentiate between internal and external reality and to generate
representations of one’s own and other people’s mental states. It is, therefore, a process of
transforming the non-mental into the mental, which makes it the opposite of acting-outs or
somatization, the most “tangible” manifestations of nonmentalizing. One of the functions of
mentalization is to explain and attribute meaning to behaviors. But apart from its important
role in interpersonal functioning, authors emphasize its intrapsychic aspect associated with
self-regulatory processes; mentalization is associated with the ability to regulate emotions and
with the maintenance of a stable self-image. Mature, optimal mentalization presupposes the
awareness of the symbolic and dynamic nature of mental states and a stable motivation to
identify them, as well as the ability to use advanced regulatory strategies in response to difficult
experiences. An important element of mentalization is the ability to decenter – that is, to
describe other people’s mental states independently of one’s own perspective and engagement
in the relationship with the person one is “mentalizing about.” It is associated with the ability
to keep one's distance from the egocentric perspective defined by the contents of one’s inner
experience. To sum up, it is possible to distinguish three main functions of mentalization: (1)
navigation in the social world, (2) navigation in one’s own inner world, (3) regulating the social
world and the inner world as well as maintaining an appropriate connection between them. It
seems obvious that mentalizing is of great significance for the process of psychotherapy, from
both the therapist’s and the patient’s perspectives. What is important, mentalizing is an
interactive process; in the context of psychotherapy, it manifests itself in two forms: as the
therapist’s function and as the patient’s function.
Mentalizing is one of the psychotherapist’s main tasks during the session. In the
psychotherapist's office, we mentalize ourselves and the patient as well as “meta-mentalize”
the mentalizing and nonmentalizing which we experience and which manifests itself in the
therapeutic relationship. Mentalizing is an indispensable element of all professional actions
that a therapist engages in. We engage in mentalization when we understand the patient’s
feelings connected with the history and experience he or she shares and when we help the
patient gain an understanding of other people’s behaviors, particularly by enhancing his or her
ability to decenter. We mentalize when we diagnose problem areas and discuss them with the
patient; we also mentalize when we monitor our own countertransference-based feelings and
use them to help the patient. Mentalization works when we are able to stop and reflect on what
is going on during the session, even when faced with one’s own and/or the patient’s strong
emotional arousal.
The patient’s mentalization is activated from the very first moments in the therapist’s
office, when the patient explains the reason for deciding to undergo therapy. The patient
mentalizes when telling his or her story, including the relationships with significant others,
when discussing these people’s attitude to him or her and to the problem, and when identifying
his or her own emotions and thoughts about the experiences being discussed. Finally, the
patient activates mentalization when looking for links between his or her own and other
people’s symptoms, thoughts, emotions, and behaviors, and when he or she reflects on the
therapeutic relationship and the therapist.
This brief outline does not cover all the situations in which mentalizing takes place in
the patient–therapist relationship. It can easily be observed that this is not a new phenomenon
in psychotherapy, which has been pointed out many times by Fonagy and Bateman [3]. As the
Mentalization in clinical practice − a psychodynamic perspective 7
authors of Mentalization-Based Treatment (MBT) point out, mentalizing has always been an
inseparable element of psychotherapy in every paradigm. With regard to psychodynamic
psychotherapy, Barreto and Matos [4] name two main research centers investigating
mentalization: one of them is the Canadian authors grouped around Marc-André Bouchard,
associated with Freudian psychoanalysis and drawing on Bion’s theory [5]; the other one is
Peter Fonagy’s British team, drawing on the developmental perspective, neuropsychology, and
social cognition theory [3]. Even though it is the latter group that can be given the credit for
the full bloom of the concept of mentalization worldwide in the last 20 years, it is hard to resist
the impression that references to the assumptions of contemporary and classic psychoanalysis
can more easily be found in the work of Bouchard’s team. Kernberg’s team, by contrast, has
been on the sidelines, at the same time integrating the concept of mentalization with their
assumptions on many points. In the two texts cited below, this author directly refers to
mentalization and discusses its place in the contemporary object relations theory [6, 7].
Mentalization assessment in the context of individual psychodynamic psychotherapy
Mentalizing at different levels of personality organization
In the psychodynamic literature, disturbed mentalization is usually mentioned as one of
the main symptoms of pathology in borderline patients [2, 3, 8]. Based on the available
literature, it is also possible to formulate certain hypotheses concerning mentalization in
psychotic and neurotic individuals, but they certainly require further empirical verification.
Psychotic personality organization (PPO)
Although in recent years PPO has practically disappeared from Kernberg’s theory in
favor of functional psychoses, I decided to describe the group of psychotic patients here as
those who are distinguished by distorted reality testing. So far, the only study in which
researchers have measured the level of mentalization
1
in individuals undergoing a psychotic
crisis has been the study by McBeth et al. [9], with a sample of 34 patients hospitalized during
the first phase of psychosis. The mean mentalization level in this group turned out to be low,
but it was not the lowest possible level, which would have meant a total lack of mentalization.
The severity of mentalization disturbances was associated with the patients’ attachment style
– subjects with an avoidant attachment style had the lowest levels of mentalization, including
a total lack of it. This is a very interesting result, suggesting the heterogeneity of the group of
patients diagnosed with psychotic disorders in the context of mentalization deficits. The
question of how this observation should be understood in the context of personality
organization levels remains open – it cannot be excluded that the subjects’ personality
organization levels varied. Despite the lack of studies on the mentalization level in the
psychodynamic sense in psychotic patients, there is extensive literature on deficits in
mentalization understood as a theory of the mind or as metacognitive skills (for a review of
1
The study concerned mentalization in the psychodynamic sense, as understood also in this paper – measured,
in this case, as a reflective function in the Adult Attachment Interview.
8 Monika Jańczak
research, see: [10]). What emerges from these studies is a picture of a serious deficit in
mentalizing capacity, but there are doubts regarding the permanent nature of these
disturbances. Although there are studies suggesting their temporary character, dependent on
the level of psychosis symptoms, the majority of reports show a permanent decrease in
mentalizing capacity in psychotic patients, which manifests itself both during active psychosis
and in the period of remission [10]. Based on the cited studies and the clinical experience of
therapists working with psychotic patients, it can be said that the group of psychotic individuals
is diverse in terms of the ability to mentalize. This conclusion is reflected in the evolving
understanding of psychotic patients in Kernberg’s theory [11]. Kernberg questions the
existence of structural PPO criteria, which allows him to stress the heterogeneity of this group
of patients, also in terms of the personality structure that accompanies psychosis, which may
manifest itself at different levels of organization. It can be concluded that, on the one hand, a
certain group of psychotic patients is observed to have a serious deficit in the ability to
mentalize, while on the other hand, there is a diverse group of patients with symptoms of
psychosis whose personality structure may be better integrated and, consequently, whose
mentalization is less disturbed (e.g., borderline patients with temporary psychotic regression).
Individuals belonging to the former group are patients who are incapable of reflection on the
mind regardless of external factors: the circumstances or the person they mentalize about
(namely, of whether the person is, for instance, a romantic partner or a stranger, such as a shop
assistant). According to the deficit model, these people are characterized by a lack of certain
functions responsible for mentalization because in the course of their development the
processes responsible for its proper functioning were blocked. As a result, these people are
unable to acknowledge the symbolic nature of mental states. In their experience, mental states
are either perceived as real “things,” with feelings and thoughts meaning as much, or as little,
as their physical outcomes – or experienced as totally out of touch with reality. The low level
of mentalization in these individuals can often be treated as a stable personality trait, not subject
to change depending on the context. On the other hand, however, there is a large group of
patients with symptoms of psychosis who will function similarly to individuals with borderline
personality organization when it comes to mentalizing ability.
Borderline personality organization (BPO)
There are many studies on mentalization and related functions (social cognition, theory
of mind) in individuals with personality disorders, but the majority of these studies concern
borderline personality disorder, which obviously limits the possibilities of generalizing their
findings to the entire BPO. Nevertheless, there are also studies devoted strictly to BPO as
understood by Kernberg [2, 8, 12]. The most general finding of those studies is as follows:
individuals with borderline personality organization exhibit different levels of mentalization
depending on a number of factors (method of measurement, time and context of measurement,
the subject’s characteristics) [cf. 13]. On the one hand, the group of people with BPO is
heterogeneous in terms of mentalization levels − there certainly is a need for further research
in this area, in which an attempt will be made to define these differences using variables such
as: type of attachment, type of symptoms and nosological diagnosis, specific experiences in
life (e.g., a trauma or corrective relationship at some stage of life). On the other hand, based on
Mentalization in clinical practice − a psychodynamic perspective 9
research and the available literature, it can be concluded that mentalization disturbances in
individuals with BPO are conflict-based rather than deficit-based, which results in these
people’s mentalization level changing across contexts. In other words, mentalizing in
borderline individuals is a dynamic and fluid function, which may manifest itself in different
ways in the same person depending on various factors the activation of internal
mentalization-related structures may enhance, weaken, or even completely block it. To use the
language of Kernberg’s theory, depending on the activation or deactivation of a particular self–
object dyad, associated with a particular kind of affect, the level of mentalizing capacity is
expressed in a manner specific to a particular person in relation to this dyad. It is, therefore,
possible to imagine a situation in which a BPO patient applies massive distortions in the case
of his or her own or other people’s mental states, but only for certain specific object relations,
activated, for example, in the relationship with the therapist or with a romantic partner. In a
different context, involving the lack of activation or the activation of a different dyad (e.g., one
experienced by the patient as good and safe), these distortions may not occur at all, or they may
take a different, less destructive form.
Neurotic personality organization (NPO)
A consolidated identity and a relative lack of primitive defense mechanisms result in
NPO patients having a well-developed self-reflection ability and a well-developed
understanding of the symbolic nature of thoughts and mental states, which makes their ability
to mentalize relatively mature. According to Kernberg, mature mentalization is associated with
the achievement of certain developmental steps, related precisely to identity consolidation and
the ability to enter into relationships based on dependence and gratitude. So far, the issue of
mentalization in neurotic patients has seldom been addressed in the literature. Preliminary
studies of individuals with personality organization higher than borderline suggest that these
individuals may exhibit certain temporary problems with mentalizing [14]. More studies in this
area are definitely needed, but it can be assumed that individuals with NPO are characterized
by a relatively high level of mentalizing capacity, which manifests itself in an accurate and
valid inference of their own and other people’s mental states in most situations. Nevertheless,
certain difficulties in mentalizing may appear; they are not chronic and take a temporary form,
usually induced by heavy stress or emotional arousal. They remain isolated to a given patient’s
specific area of difficulty, which means they occur exclusively in the area identified as marked
by conflict (e.g., they may manifest themselves in the occupational context but not in an
intimate relationship, or the other way around).
Different faces of pathological mentalizing observed in the patient–therapist relationship
Although mentalization disturbances can take very different and complex forms, the
classification developed by Fonagy and colleagues makes it possible to usefully divide them
into three large groups. These are: nonmentalizing (a reflection of the teleological mode),
concrete mentalizing (a reflection of psychic equivalence), and pseudomentalizing (a reflection
of the pretend mode) [Fig. 1]. They occur in individuals with pathological personality structure
– namely, in psychotic and borderline individuals, as well as, temporarily, in neurotic
10 Monika Jańczak
individuals. According to the developmental model, pathological mentalizing modes originally
emerged in the early stages of the child’s development and had an adaptive function in that
period, but with time they should be replaced by mature mentalization [3]. In individuals with
mentalization disturbances, they continue into adult life and are a source of difficulties
observed in their intrapersonal and interpersonal functioning. In the literature, they are referred
to as “modes” – ways of experiencing the inner world, which convey their global nature and
the fact that they dominate the emotional and relational functioning of people with personality
pathology.
Figure 1 Mentalization disturbances observed in psychotherapy
Pseudomentalizing is difficult to diagnose during psychotherapy; this refers particularly
to one of its types, which Fonagy calls overactive mentalization. In this situation, paradoxically,
we may observe a high level of elaboration and expression of mental states by the patient;
however, this stems from the reflection on mental states, and its only function is for the patient
to maintain a defensive distance from his or her own experience. This type of
pseudomentalizing can be diagnosed when, despite the patient’s long and sometimes complex
story about his or her inner experience, full of metaphors and digressions, the therapist is left
with a sense of emptiness, disorientation, and confusion, often accompanied by the inability to
empathize with the patient's experience. This manner of functioning during sessions is
characteristic of some narcissistic and obsessive-compulsive patients, who can devote plenty
Mentalization in clinical practice − a psychodynamic perspective 11
of time and effort, both in and out of session, to the analysis of their emotions and experiences;
their analysis, however, is based on isolation mechanisms and does not lead to insight. Instead,
it leads to an impasse in therapy and a sense of frustration in both the patient and the therapist.
This kind of primitive mentalization is often aided by more mature defense mechanisms, such
as intellectualization and rationalization.
Another type of pseudomentalizing is destructively inaccurate mentalization. It is
relatively easy to diagnose due to its hostile and destructive nature. The patient does not attempt
to identify the therapist’s true mental states and freely replaces them with others, at the same
time believing them to be true and feeling as though they were true (thus engaging in projective
identification). This usually manifests itself in an attitude full of accusations, demands, and
aggression. A somewhat less destructive type is intrusive mentalization, in which the patient is
certain that he or she “knows” what the therapist feels and thinks, but this knowledge is based
only on the patient’s projections and is impervious to doubt or reflection on the validity of this
experience.
Concrete mentalizing consists in equating internal and external reality in the patient’s
experience − his or her mental experience becomes an external fact. What the patient feels is
true and justified because it is confirmed by the intensity and plausibility of his or her
experience: “If I feel that my therapist is neglecting me, then this is the case indeed.” Thoughts
and feelings are not hypothetical or subject to modifications; they are unambiguous and certain.
Concrete mentalizing usually manifests itself in the form of paranoid transference, when the
therapist is constantly experienced as hostile and unsatisfying. The patient is unable to process
and reflect on the overwhelming and acute sense of danger and experiences intense negative
emotional states as if they were reality; everything the therapist does confirms the patient in
this terrifying experience. Another manifestation of concrete mentalizing is narcissistic
transference, with the expression of the patient’s grandiose self, which – equally destructively
– makes it impossible to really experience the therapeutic relationship.
The last type of mentalization disturbance described by Fonagy is nonmentalizing,
which, in some sense, consists in negating the existence of one’s own and other people’s inner
mental world. Actions are understood as their physical outcomes, while internal states do not
play any role in the understanding and interpretation of behavior. Emotions and thoughts exist
only when they are expressed in actions. The patient is unable to process his or her experience
but is only able to get rid of it – for example, in the form of acting-outs (self-inflicted injuries,
suicide attempts, outbursts of aggression). Likewise, the therapist is experienced in a way that
that stems from his or her physical activities and their outcomes (“If you have no time for an
additional appointment for me, it means you want to get rid of me”). This is the most primitive
manifestation of mentalizing disturbances.
Assessment of the patient’s mentalization level in the consultation process
An important starting point for the work on mentalizing is the assessment of the
patient’s mentalization level, which is yet another component of the comprehensive
psychodynamic assessment performed in the course of consultation. Although Kernberg does
not refer directly to the mentalization level in his personality organization level criteria, and
12 Monika Jańczak
although mentalizing seems to pervade most of his structural criteria, the aspect of personality
organization that relates the most directly to mentalizing is social reality testing. As in the case
of mentalizing, in a healthy personality, reality testing is usually stable, whereas in neurotic
individuals it may temporarily decrease in the areas of conflict, in borderline individuals it is
sometimes seriously disturbed, particularly in certain types of close relationships, and in
psychotic individuals both its social and non-relational aspects are disturbed [11].
Mentalization assessment during psychotherapy may take two kinds of course it may be
performed in a less structured way, with the patient’s ability to mentalize being assessed post
factum, based on the information about the patient’s functioning acquired during the session as
well as based on general impressions in contacts with the patient and his or her history, or it
may be performed in an intentional and more formal way, with the therapist asking the patient
questions aimed at assessing his or her mentalizing capacity. This kind of intentional
assessment of mentalization can also be performed based on Kernberg’s structured interview
[15], since questions concerning the representation of object relations and identity yield very
good material for the assessment of mentalizing – both about oneself and about others. Another
method useful in the preliminary assessment of the patient’s mentalization level can be the
request to describe an example conflict situation between the patient and his or her significant
other (this is a procedure used in research, but in can be useful also in the clinical context [cf.
8]). Assessing the patient’s answers to this kind of open-ended questions, it is possible to
establish whether and how the patient responds to mental states, whether the patient is able to
recognize and tries to understand his or her own and other people’s mental states, whether he
or she has the ability to decenter, whether he or she is motivated to mentalize, and whether he
or she uses the knowledge about mental states to regulate his or her own behavior and
interpersonal relations. Is it possible to observe indicators of prementalizing modes of
functioning, such as excessive certainty about other people’s mental states or a tendency to
give empty intellectualized accounts of one’s own inner experience?
These general questions can be supplemented with more concrete ones, focused on
more precisely determining the ability to recognize mental states (what does the patient
think/feel and what do the people he or she speaks about think/feel?), the ability to link
emotions and thoughts with behavior (why does he/she feel/think something? is there a cause-
and-effect perspective in the story?), and the general level of inner experience integration (is it
possible to understand the patient’s inner experience and empathize with him/her? does the
patient build a consistent narrative, referring to the contradictions and dynamic nature of mental
states?). The final stage is the assessment of how the patient copes with difficult experiences
and of whether he or she uses primitive regulation strategies, such as acting-outs and avoidance,
or more advanced strategies, such as the use of knowledge about other people’s mental states
to regulate the intrapersonal and interpersonal context [cf. 16]. This kind of comprehensive
assessment of the patient’s mentalization in the initial stage of therapy may have considerable
diagnostic value, enabling differential diagnosis of the personality organization level,
particularly in those cases in which it is difficult to make classification decisions. It also helps
to adjust therapeutic interventions to the patient’s level of mentalizing, which can contribute to
their better adjustment and, consequently, to their greater effectiveness in the process of
treatment.
Mentalization in clinical practice − a psychodynamic perspective 13
The application of mentalization theory in individual psychotherapy in the context of
transference and countertransference
Research on mentalizing in the patient–therapist relationship
In the literature on object relations theory, mentalization as a function of the therapist
and psychotherapy has been addressed much more often than mentalization defined as the
patient’s ability. Studies reveal a significant relationship between therapists’ high mentalizing
capacity and better outcomes of psychodynamic psychotherapy [17], as well as the usefulness
of brief mentalization training for inexperienced therapists for a better coping ability in their
work with difficult borderline patients [18]. Interestingly, according to the preliminary study
by Diamond et al. [19], the therapist’s mentalization level differs depending on the patient
which means that mentalization during therapy is an outcome of interaction, dynamic and
specific to a given therapeutic relationship rather than merely to a given therapist.
As early as in the 1990s, a Canadian team of researchers [20] distinguished three levels
of therapists’ mentalizing, defined as ways of coping with mental states during the session. The
first two of them are triggered as defense strategies against the anxiety associated with the
activated transference. The first one is the
obje c tiv e - rat i ona l sty l e
, in which the therapist
becomes a distanced observer of the relationship with the patient and remains emotionally
disengaged, focusing on theoretical categories and relying on general psychotherapeutic
knowledge, thus remaining, in a way, out of contact with and out of relation to a specific
patient. The maintenance of this kind of defensive intellectual dialog leads to an impasse in
therapy and should be spotted in time in the process of supervision. The second non-optimal
way of the therapist’s mentalizing is the
reac t ive s t yle
, in which the therapist is an
unconscious participant in a game of transference and countertransference and becomes
incapable of understanding the mechanisms enacted in the relationship, yielding to projective
identification and enacting the primitive states activated in countertransference; he or she may
feel anger at or irritation with the patient as well as adopt an attitude full of criticism [20]. The
main aim is to get rid of difficult emotional states rather than to acknowledge and analyze them.
The therapist in this case is “too close,” while in the objective-rational style he or she is “too
far” from the patient’s experience.
The opposite of these two defensive styles is the
refl ecti v e st y le
, which is
mentalization in the strict sense. The therapist is both a committed participant in the therapeutic
relationship and its careful observer, capable of containing and processing the patient’s difficult
experience. The therapist’s basic activity is experiencing, reflecting on, transforming, and
giving meaning to inner experience [4]
2
. Interestingly, research shows that it is the less
experienced therapists who use the reflective style more often compared to more experienced
ones [21]. The classification proposed by Bouchard’s team was confirmed in the research
conducted by Rizq and Target [22]. Another interesting classification of therapists’
mentalization levels was developed by Barreto and Matos [4], who described five ways of
2
Two other mentalization styles were later distinguished within the reactive style (mature and primitive defense
mechanisms), and a concrete style of mentalizing was described in which there is no awareness of one’s own mind
[5].
14 Monika Jańczak
understanding the psychotherapeutic process, manifesting themselves in the therapists’ ways
of speaking about the session when it is over.
In several studies, researchers have also examined changes in the patient’s level of
mentalizing capacity in the course of transference-based psychotherapy. The results show that
TFP causes a significant increase in this level, as opposed to other therapies examined in the
study [19, 23, 24]. What is important, improvement in mentalization was associated with the
increasing level of personality integration.
The studies outlined in this section show, on the one hand, that working with
transference results in a special way in an improvement of patients’ mentalizing capacity, and
on the other hand − that it gives a special role to mentalizing as a function of a good therapist
and therefore constitutes an important mechanism involved in effective treatment.
Mentalization as a healing factor in Transference-Based Psychotherapy
Kernberg [7] understands work on mentalization as developing one of the specific
mechanisms of change in psychodynamic psychotherapy – namely, building a realistic picture
of the self and others as well as integrating self and object representations. What happens in
the course of therapy is the reconstruction of mentalization disturbances specific to a given
patient in a situation that involves the activation of specific self–object–affect representations.
Next, the disturbances are diagnosed and discussed as part of the transference–
countertransference relationship. This is a necessary introduction to further interventions aimed
at changing the internalized self–object representations. In a different study, Kernberg [6]
refers to this advancing interpretive process simply as “phases of mentalization development.”
The focus on mentalization is an important element here, leading to in-depth interpretation but
not replacing it and not taking over its function. Moreover, in the course of therapy, thanks to
mentalizing, through an empathic and patient attitude in explaining the patient’s mental states,
his or her experience is constantly clarified, which “facilitates the cognitive framing of the
patient’s own affective experience” [7, p. 63] and results in the regulation of violent and
intensive experiences in his or her relationship with the therapist. Mentalization “training” is
the first step towards the acknowledgment that the therapist and the patient have distinct and
different minds, and that the experience of these differences does not have to mean the end of
the relationship. Apart from performing the function of catalyzing and enabling the process of
interpretation, better mentalizing capacity becomes a valuable acquisition for the patient as an
element indispensable in regulating his or her own internal and interpersonal world. The patient
gradually acquires and enhances mentalizing capacity when he or she is able to retrieve
contrary emotional states of the self in moments of strong emotional arousal during the session
[7], i.e. when interpretation leads to a decrease in the level of splitting. According to Kernberg,
proper mentalizing is the capacity for self-reflection even in conditions of intense negative
emotional states. A patient who has this ability is already a patient with an integrated
personality structure.
To sum up the place of mentalization in TFP, it is possible to distinguish at least three
areas in which it manifests itself: (1) the therapist’s mentalization as a precondition of the
containment of the patient’s states during the session; (2) mentalizing in the patient–therapist
relationship as an introduction to interpretation; (3) the patient’s increasing mentalization as an
Mentalization in clinical practice − a psychodynamic perspective 15
instrument of integrating and regulating his or her own experience. These refer, respectively,
to mentalization as the psychotherapist’s function, to mentalization as the interaction between
the patient and the therapist, and to mentalization as the patient’s important autonomous
ability
3
.
Conclusion
Mentalizing can be treated as an independent attitude and a kind of meta-principle of
therapy, to be applied with techniques stemming from a specific therapy paradigm. As has been
stressed many times by Fonagy, it is a process that therapists of all orientations have always
been using but did not necessarily call mentalizing [3]. A therapist who supports his or her
patients’ mentalizing is consistently focused on mental states and encourages them to explore
their own and other people’s (the therapist’s, significant others’) mental states. He or she
devotes a considerable amount of time to the exploration of different points of view, while
recognizing the value of the patient’s individual perspective. A mentalizing therapist calmly
accepts the fact that he or she is not an expert in the patient’s mind but a kind of companion in
the complicated exploration of their own and other people’s inner world. It is important for the
therapist to adopt an attitude of curiosity and uncertainty, conducive to the enhancement of the
patients’ understanding of their own experience. What is also stressed is the value of the
therapist’s reliance on common sense and genuine exchange with the patient in order to
maintain a close and engaged dialog with him or her. Psychodynamic psychotherapy is
supposed to ensure maximum comfort of mentalizing to both participants of the interaction;
the therapist becomes free from the pressure to react directly and focuses on his or her own
observations and emotional responses, monitoring countertransference from a “third-party”
point of view [7]. What is important is the focus on the present, on the “here and now,” and the
stable direction from explanation – clarification and confrontation − to interpretation. There is
no doubt that mentalizing is one of many variables significant for therapy. We can choose how
to call this process and where to place emphasis when analyzing the complex mechanisms that
make up the process of effective psychotherapy.
References
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3
This understanding of mentalization in the process of psychotherapy highlights the differences between
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for a discussion of this issue the reader is referred to Kernberg [6].
16 Monika Jańczak
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Mentalization in clinical practice − a psychodynamic perspective 17
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E-mail address: mmarszal@amu.edu.pl
... obrazu zaburzeń mentalizacji w grupach klinicznych, a także u zdrowych osób w określonych warunkach obniżających mentalizację (por.Colle i in., 2020). Być może w przyszłości uda się opisać determinanty różnego rodzaju zaburzeń mentalizacji i przedstawić ścieżki rozwoju, np. związane z wczesnodziecięcą relacją przywiązania, dla każdego z nich (por.(Jańczak, 2018a). Ponadto, w ostatnim czasie coraz więcej uwagi poświęca się kulturowym uwarunkowaniom mentalizacji i różnicach w jej przejawach i zaburzeniach pomiędzy osobami pochodzącymi z różnych kręgów kulturowych (np. między indywidualistyczną kulturą Zachodu a kolektywistyczną kulturą Wschodu, por. (Aival-Naveh i in., 2019;Greenberg i in., 2017;R ...
... w celu określenia zmian w mentalizacji w odpowiedzi na psychoterapię lub inne oddziaływania psychologiczne. Niektórzy autorzy wskazują na użyteczność narzędzi samoopisowych do klinicznej diagnozy mentalizacji w celu uzupełnienia opisu funkcjonowania pacjenta lub zaplanowania odpowiednich metod interwencji (Beaulieu-Pelletier i in.,2013), jednak wydaje się, że do tego celu dużo lepiej sprawdzają się innego typu metody, zwłaszcza wywiad kliniczny(Jańczak, 2018a; Luyten i in., 2019). Głównym ograniczeniem związanym ze stosowaniem tej grupy metod jest określanie poznawczo-afektywnych reprezentacji na temat mentalizowania, a nie pomiar poziomu mentalizacji per se, co jest powszechnym zarzutem wobec kwestionariuszy mierzących abstrakcyjne konstrukty psychologiczne (por. ...
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**** To jest robocza, polska wersja ebooka **** Jańczak, M. O. (2021). What’s on your mind? A Guide for Mentalization Assessment in Adults. Wydawnictwo Rys. http://doi.org/10.48226/978-83-66666-85-6
... Unfortunately, the validity of the RFQ in grasping these two types of mentalization difficulties has not been impervious to scrutiny (see Chapter 8; e.g., Müller et al. 2020). However, this is unsurprising, given the deceptive nature of hypermentalization which, is sometimes confused with correct mentalization even in a psychotherapist's office (Bateman et al., 2019;Jańczak, 2018a). However, most of the available tools measure only hypomentalization: the lack of motivation to recognize mental states or the incorrect assignment of mental states. ...
Book
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The theory of mentalization, put forward by P. Fonagy over twenty years ago, indubitably remains one of the most dynamic concepts to have developed in clinical psychology in recent years. In this book, I explore the theoretical and empirical aspects relevant to the assessment of mentalizing. In the first part, the issues and challenges that researchers face when planning to measure mentalization are discussed. The second part presents an overview of the most prevalent research tools, describing how they are administered, how the results are calculated and interpreted, their psychometric properties, and their research applications. It is my earnest hope that this book may serve as a practical guide for students and researchers interested in measuring mentalizing.
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Researchers have been striving to explore the functioning of patients with borderline personality disorder from the perspective of their capacity to mentalize. Analyzing the expanding body of literature, it is nevertheless difficult to reach a clear conclusion. There are studies that confirm mentalization deficits in this group; however, there are also reports suggesting better or at last equal mentalizing in borderline individuals compared to controls. This paper discusses a hypothetical explanation of these contradictory results by analyzing three fundamental issues. It is assumed that: (1) different aspects of mentalization are measured in studies – some of them are disordered, while others remain intact in borderline individuals; (2) mentali­zation can be understood not only as a trait but also as a state, and its level may differ in the same person depending on measurement conditions; (3) the borderline group is heterogeneous in terms of mentalizing because other variables determine the level of this capacity.
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This study investigated the relationship between two therapist attributes (reflective functioning and attachment style) and client outcome. Twenty-five therapists treated a total of 1001 clients. Therapists were assessed for reflective functioning and attachment style using the Adult Attachment Interview and the Experiences in Close Relationships Scale. Clinical outcome was measured using the Outcome Questionnaire (OQ-45). Data were analysed using hierarchical linear modelling. Results indicated that therapist reflective functioning predicted therapist effectiveness, whereas attachment style did not. However, there was evidence of an interaction between therapist attachment style and therapist reflective functioning. Secure attachment compensated somewhat for low reflective functioning and high reflective functioning compensated for insecure attachment. Possible implications for the selection of therapy training candidates and therapist training are discussed.
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Borderline personality disorder is associated with deficits in personality functioning and mentalisation. In a randomised controlled trial 104 people with borderline personality disorder received either transference-focused psychotherapy (TFP) or treatment by experienced community therapists. Among other outcome variables, mentalisation was assessed by means of the Reflective Functioning Scale (RF Scale). Findings revealed only significant improvements in reflective function in the TFP group within 1 year of treatment. The between-group effect was of medium size (d = 0.45). Improvements in reflective function were significantly correlated with improvements in personality organisation. © The Royal College of Psychiatrists 2015.
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Abstract This study examined whether training can increase the reflective function (RF) of novice therapists about patients with Borderline Personality Disorder (BPD). A total of 48 students in clinical psychology were randomly assigned to mentalization training or didactic training. Their RF regarding patients was assessed with the Therapist Mental Activity Scale (TMAS: Normandin, Ensink, & Maheux, 2012). The RF of trainees assigned to the mentalization training improved significantly, while participants who received traditional didactic training actually became significantly less reflective. These findings show that brief mentalization training can help beginner therapists develop their mentalization capacities with challenging patients.
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Empirical evidence supporting the inclusion of mandatory training therapy for therapists is sparse. We present results from a mixed methods study designed to interrogate how counselling psychologists' attachment status and levels of reflective function (RF) intersect with how they experience, recall and describe using personal therapy in clinical practice. Results suggest that securely-attached, or earned secure participants with ordinary or marked levels of RF used their therapy to manage feelings evoked by difficult or challenging clients. Insecurely-attached participants with lower levels of RF found therapy valuable in terms of behavioural modelling, but not in managing complex process issues. Negative case analysis found that high levels of RF may not be uniformly advantageous for therapists. The study concludes with a brief discussion of issues relating to epistemology, validity and reflexivity.
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As a construct, the elaboration of countertransference experience (ECE) is intended to depict the implicit and explicit psychological work to which therapists submit their experiences with clients. Through ECE, defined as a mentalizing process of a particular kind, therapists' experiences are presumed to acquire and increase in mental quality and become available for meaning-making and judicious clinical use. In this paper, we claim that such an ongoing process facilitates engagement with common therapeutic factors, such as the therapeutic alliance and countertransference management, enhancing therapist responsiveness in psychotherapy. We synthesize relevant literature on countertransference, mentalization, and, in particular, therapists' mentalization, informed by a systematic literature review. As a result, we propose a model for assessing ECE in psychotherapy, comprising 6 diversely mentalized countertransference positions (factual-concrete, abstract-rational, projective-impulsive, argumentative, contemplative-mindful, and mentalizing), 2 underlying primary dimensions (experiencing, reflective elaboration), and 5 complementary dimensions of elaboration. Strengths and limitations of the model are discussed. (article available at http://onlinelibrary.wiley.com/doi/10.1002/cpp.2177/full) 2019 APA Division 29 Donald K. Freedheim Student Development Award
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Chapter
The assessment and diagnosis of personality disorders for clinical intervention and research purposes is at crossroads. The diagnostic criteria for the personality disorders in DSM-IV TR Axis II are a listing of symptoms in search of a unifying assessment of personality dysfunction. The utilization of the diagnosis of these criteria has resulted in an advance in the reliability of personality disorders, but it has become evident that there are numerous difficulties in the personality disorder diagnoses made by the criterion-based, atheoretical approach of Axis II. The major problem involves the heterogeneity of the patient groups selected by the categorical system without any rating of severity of dysfunction. While a categorical approach to diagnosis focuses on the presence or absence of the disorder, based on a number of fulfilled criteria or symptoms, a dimensional approach also assesses the severity of symptoms or dimensions of personality pathology. As patients seen in clinical practice tend to present with different levels of severity of pathology, a dimensional approach provides the clinician with a diagnosis more reflective of the clinical picture, which also includes an assessment of strengths and deficits on each of the dimensions. The clinical usefulness of the categorical system has been seriously questioned [1]. The proposed changes in DSM-V define personality disorders as a failure to develop self-identity and capacity for adaptive interpersonal functioning, focus on the assessment on personality disorder prototypes, and provide a severity rating of personality disorder functioning. These proposed changes are congruent with the object relations view of personality pathology and call attention to the need for reliable diagnostic instruments based on psychodynamic object relations theory. In this chapter, we describe such an instrument, which provides evaluation of core dimensions of personality functioning emphasized by the DSM V Personality Disorders Task Force (www.dsm5.org)