Handbook of Mentalization-Based Treatment (Book Review)

Author:  Allen, Jon G. and Peter Fonagy
Publisher: Wiley
Reviewed By: John Auerbach, Volume XXIX, No 4, pp. 26-30

Mentalization is an ungainly term, and I have also sometimes found it an overused one. I have also long thought, however, that it is a necessary one, and in reviewing these two works on the topic, I have had this belief confirmed. It is no secret that there is rising tide of reductionism in psychology and psychiatry, and though I have sometimes found that the term mentalization can itself be used to oversimplify the complexities of psychoanalytic and psychodynamic thought, it is nevertheless an important concept because, in its very name, it asserts the centrality of mind, rather than brain or behavior, in our understanding of what it means to be human. Although this term was used in French psychoanalysis in the 1960s to differentiate somatic excitations from symbolic mental contents (see Lecours & Bouchard, 1997), Fonagy (1991, p. 641) introduced mentalization into Anglophone psychoanalytic discourse by defining it as "the capacity to conceive of conscious and unconscious mental states in oneself and others"—in short, as the understanding that both oneself and others are creatures with minds. In many other publications, most importantly the magisterial Affect Regulation, Mentalization, and the Development of the Self (Fonagy, Gergely, Jurist, & Target, 2002), Fonagy and colleagues too numerous in this context to name argued that mentalization refers to the capacity to understand minds, both one’s own and those of others, and therefore to recognize that human behavior is motivated by mental states–by things like thoughts, beliefs, feelings, and desires. They further argued that various forms of psychopathology, most notably borderline states but many others as well, can be understood as involving failures in mentalization, in the understanding of mind. These are notions that seem commonplace and almost trivial within the psychoanalytic ghetto, but they are radical ideas outside of the psychoanalytic world, where psychopathology is quickly reduced either to brain diseases treated with medications or to behavior disorders treated with manualized psychotherapy protocols. In context of this widespread reductionism but also recognizing that psychotherapeutic efficacy is still a matter of empirical evidence, not of therapist conviction, Bateman and Fonagy (2004) developed a manualized program for mentalization-based treatment of borderline personality disorder, a program that does justice to both the standards of scientific research and the complexities of clinical work. But most practitioners, psychoanalytic or otherwise, are unlikely to want to set up their own mentalization-based programs for treatment of borderline psychopathology, and most nonpsychoanalytic practitioners are likely to have little patience for, never mind comprehension of, the conceptual abstractions of Fonagy et al. (2002). What was needed, therefore, were discussions of mentalization for everyday clinicians, especially for the vast majority of the clinical world that has little or no interest in an approach that touts unapologetically its origins in psychoanalysis. The two books reviewed here, the first one edited by Jon Allen and Peter Fonagy, the second written by Jon Allen, Peter Fonagy, and Anthony Bateman, take on this precisely this task and they do it well. I shall discuss the latter work (Allen, Bateman, & Fonagy) first, however, because I think it will be easier for readers to understand mentalization and its clinical implications if we begin with a broad overview, rather than with the presentation of a series of chapters (Allen & Fonagy).

Allen et al.’s Mentalizing in Clinical Practice is a clear and comprehensive introduction to mentalization and its relationship to psychotherapeutic practice. Although it is not a treatment manual, it is close enough to such in its spirit and design that many readers of this review may feel uncomfortable with it. But I, living in a small Appalachian city where I teach psychodynamic psychotherapy to predoctoral interns who, with each passing year, have less and less exposure to psychoanalytic ways of thinking, use this particular volume as one of three textbooks for a half-year seminar on psychodynamic psychotherapy. Its strength is that it grounds the concept of mentalization in various relevant research literatures (i.e., theory of mind, attachment, neurobiology, psychotherapy) in a way that is inviting and comforting to a generation of young clinicians raised on manualized treatments while at the same time leaving no ambiguity that the underlying roots of this approach are psychoanalysis and attachment theory. The book begins with a discussion of these conceptual roots, although its introductory chapter attempts to connect the mentalizing approach to cognitive therapy, interpersonal therapy, and client-centered therapy as well.

The next several chapters of this book are devoted to extensive reviews of research literatures relevant to the concept of mentalization, and although I found them to be both quite readable and simultaneously essential to an understanding of how mentalization works, readers who are interested mainly in clinical material may find them frustrating. Nevertheless, in these chapters, Allen et al. explain that mentalization is a multifaceted ability involving both explicit processes (e.g., when a person explains the thoughts and feelings that motivate his or her actions) and implicit ones (e.g., when one person automatically and almost effortlessly decodes these motivations from another’s facial expression or voice tone). The authors differentiate mentalization from related terms like mindblindness, mindreading, theory of mind, metacognition, reflective function, mindfulness, empathy, emotional intelligence, psychological mindedness, and insight. They argue that much of psychotherapy involves the mentalization of emotion, that is, the understanding of emotions and emotional states as having meaning. In a chapter on developmental psychology, they review the extensive empirical literature on the links between early interpersonal relationships and the growth of various cognitive capacities underlying mentalization. They present the arguments, now well known in the psychoanalytic literature, that mentalization is promoted by secure attachments and by parenting that involves contingent marked mirroring of, or responsiveness to, the child’s emotional states (i.e., by parenting that recognizes the child’s affects as meaningful and responds contingently to them) and that failures of mentalization lead to prementalizing modes of cognition like psychic equivalence (i.e., the equation of one’s mental states with reality), pretend (i.e., the dissociation of these mental states from reality), and teleological (i.e., the expression of mental states through action or somatization) of representation.

A brief chapter on neurobiology describes the roles of several brain structure, particularly mirror neurons, the anterior cingulate, and the medial prefrontal cortex, in the genesis of mentalization. Mirror neurons, which are found in the brains of primate species, especially in the ventral premotor cortex, are activated not only in performing an action but in observing another perform it and are thought to be one of the substrates of emotional resonance and empathy. The latter two structures, which constitute overlapping areas of the brain, are considered the mentalizing regions proper. They are involved in the awareness of emotions in both self and others and in the interpretation of complex interpersonal situations. The authors note that the activity of these anterior aspects of the brain (the anterior cingulate and the medial prefrontal cortex) is often inhibited under conditions of emotional arousal (e.g., under conditions of fight or flight). In other words, we lose the capacity to mentalize, that is, to understand emotions and interpersonal complexities, precisely when we need it most; and a history of trauma seems to lower the threshold at which emotional arousal causes mentalization to switch off. These prefrontal areas of the brain also seem to be deactivated when certain intense attachment states (i.e., romantic love, maternal love) are present, apparently because, in love relationships, the need for careful interpersonal assessment is reduced, and this is why, the authors tell us, love is blind!

The second half of Mentalizing in Clinical Practice is devoted to clinical implications. There are chapters describing mentalizing interventions in psychotherapy and applying these interventions to the treatment of attachment trauma, borderline personality disorder, and dysfunctional families. One chapter describes the use of mentalization in a group psychoeducational program in inpatient treatment, and another describes the use of mentalization in an effort to decrease violence and bullying in schools. Of particular import, I believe, is the chapter on the mentalization-based psychotherapy of borderline personality because it is a brief, clinically based overview of a psychodynamic treatment program that, like Clarkin, Yeomans, and Kernberg’s (2006) transference-focused psychotherapy, actually has some significant empirical support for its efficacy. This is no small matter in an age in which it is commonly thought that the only evidence-based approach to the treatment of borderline patients is dialectical behavior therapy and that, despite a recent meta-analysis to the contrary (Leichsenring & Rabung, 2008), there is no scientific evidence in support of the clinical effectiveness of psychodynamic treatments.

Most readers, however, will be concerned more with the authors’ specific technical recommendations for psychotherapy in general, not just in the treatment of borderline conditions, and here they will find many agreements with those typically found in traditional psychoanalytic and psychodynamic approaches but also many significant disagreements. One important area of agreement is that the authors recommend taking a curious, inquisitive, not-knowing stance, basically a position of wonderment with regard to mental states, both the patient’s and the therapist’s and an attitude that authors note even (or perhaps especially) highly experienced clinicians have trouble maintaining beyond a few minutes. Nevertheless, the authors note this stance, which is highly congruent with Freud’s advice regarding evenly hovering attention and Bion’s regarding the eschewal of memory and desire, provides clinicians the best chance of using mentalizing interventions and achieving mentalizing goals. The authors’ second recommendation, consistent with their grounding in attachment theory, is to provide a secure base from which patients can explore mental states, both their own and those of the therapist.

In this approach, therefore, therapist’s activity is focused not at making interpretations but at helping the patient to become curious about minds. Thus, the transference or, more broadly, the patient–therapist interaction is a central focus of the treatment, but rather than interpreting the transference, the therapist endeavors to help the patient wonder how it is that he or she and the therapist might come to differing perspectives on what is happening in the room. Indeed, the emphasis in mentalization-oriented therapy on perspective taking, on asking patients to compare their perspectives on the world with those of others, brings this treatment approach close in certain respects to cognitive therapy, although the former’s focus on the immediate therapeutic relationship and on coming to understand not just thoughts or beliefs but emotional and affective states, on what Fonagy et al. (2002) term mentalized affectivity, keep this approach psychodynamic. On the other hand, psychodynamic clinicians might have difficulty with the authors’ advice to avoid free association and the exploration of fantasy, particularly about the therapist. It is unclear whether the authors mean these kinds of interventions should never be used in a mentalization-focused approach or instead whether they mean for this recommendation to apply only to precariously organized patients (e.g., borderline personalities), for whom most approaches nowadays recommend considerable therapist activity, structure, and support, as opposed to the use of more quintessentially psychoanalytic interventions (i.e., free association, transference interpretation). Despite my concerns regarding these particular recommendations, what convinces me that the clinical approach advocated by Allen et al. is within the psychoanalytic tradition broadly construed (just applied to new contexts), is the book’s fifth chapter, "The Art of Mentalizing." In this chapter, they state, "The activity of mentalizing—doing it any given moment—is an art, not a science" (p. 149). The authors go on to present as exemplars of expert mentalizers the psychoanalysts Hans Loewald and Daniel Stern and the novelist Iris Murdoch, the clear implication being that mentalizing cannot be learned from a manual.

If Allen et al. give readers a broad clinical overview of the mentalization concept, Allen and Fonagy’s Handbook of Mentalization-Based Treatment enables the reader to focus in depth on a variety of topics relevant to mentalization. The book contains 16 chapters, and in this context I can discuss them only in brief, unfortunately giving many, if not most, of them short shrift, although I can state that almost all are of high quality and that a few are outstanding. To my taste, the best chapters in the book are those that raise significant conceptual questions. These are in the front of the volume and include, not surprisingly, Fonagy’s chapter on mentalization and social development but also theoretical chapters by Allen and by Holmes that give a broad overview of mentalization and that situate the concept within the broader context of clinical psychology (Allen) and psychoanalysis (Holmes), Gabbard, Miller, and Martinez’s discussion of the neurobiology underlying the mentalization deficits in borderline personality disorder, Björgvinsson and Hart’s presentation of the links between mentalization and cognitive-behavior therapy, and Lewis’s chapter on mentalization and dialectical behavior therapy. Fonagy’s chapter, summarizing the developmental arguments made at length by Fonagy et al. (2002) on the links between affect regulation and mentalization and discussing in detail the research evidence linking intact mentalization to secure attachment and impaired mentalization to trauma and to insecure attachment, is by itself worth the price of the book, and in the present context; I can scarcely do justice to its breadth. I can mention that, in this chapter, Fonagy also lays out the research evidence for some of the previously mentioned paradoxical aspects of the links between attachment and mentalization, specifically, for why certain intense attachments (e.g., romantic love and maternal love) cause mentalization to be switched off.

For most readers of this review, the most interesting chapters of this particular book are likely to be the aforementioned discussion by Holmes of the relationship between psychoanalytic theory and mentalization and a more clinically based chapter by Munich on how one might integrate a mentalization-based approach into a traditional dynamic psychotherapy, and I found both to be of high quality, with Holmes’s being among the best in the volume because of its integration of clinical material with multiple psychoanalytic perspectives, both British and French, and with the empirical literature on attachment and developmental psychopathology. From my perspective, however, the most interesting chapter is that by Björgvinsson and Hart because, as I read them, they are in fact radical behaviorists, not cognitive-behaviorists, followers more of Skinner than of Beck, and as an intersubjectivist, I believe that we are likely learn more from dialogue with those who do not necessarily share our assumptions about the world than we do from dialogue with those with whom we more readily agree. Actually, it is also my contention that psychoanalysis is closer in its outlook to radical behaviorism than it is to cognitive behaviorism, but that is another matter. Björgsvinsson and Hart propose that cognitive therapy, with its close attention to automatic thoughts and with its request of the patient to examine these thoughts in careful, dispassionate, and collaborative manner, is a mentalization-based therapy par excellence. Although they make a strong case for this conceptual overlap, they do not mention the matter of mentalized affectivity, of the understanding of emotional states in the emotional present, and I believe this to be a crucial issue in the divide between cognitive approaches and dynamic approaches. In a related vein, they state that, from their behavioral point of view, the benefit of feeling loved by one’s significant other is the security of the predictability that one’s partner will continue to behave lovingly in the future, but they dismiss far too easily the problem that most of us with reasonably intact mentalizing capacities can tell, via emotional resonance (and its behavioral correlates), when the other’s emotions are not behind in their actions, when the other might be acting "lovingly" but is not genuinely feeling loving. Another issue not adequately dealt with in their chapter is that the concept of mentalization necessarily entails the concepts of mind and of mentalistic explanation—in short, of intentionality in the philosophical sense of that term (see, e.g., Dennett, 1987)—and it is difficult to square this view with a perspective that regards cognitions and emotions simply as behavior, rather than as acts of meaning (see Bruner, 1990). Nevertheless, Björgsvinsson and Hart’s chapter is one that truly challenges those of us with psychoanalytic perspectives to think more deeply about our assumptions, and I will mention that Lewis’s chapter on dialectical behavior therapy does an excellent job of presenting a radical behavioral approach that takes very seriously the matter of emotional regulation and of demonstrating its correspondences with the focus on mentalized affectivity in mentalization-based therapy.

The remaining chapters in the volume focus on new treatment and prevention models inspired by the mentalization concept, and some of these models are also discussed by Allen et al. Several of the chapters are descriptions of the mentalization-based treatment approaches now in use at the Menninger Clinic, one of the few remaining psychoanalytically oriented treatment facilities left in the United States. These papers, on family therapy, milieu therapy, and psychoeducation, are clinically intriguing, especially to those of who, like me, work in institutional settings, and with some empirical research, the programs they describe might prove to be worthy rivals to the increasingly limited offerings that currently pass for institutional mental health treatment in the United States. Unfortunately, no research on these programs in presented in the chapters on treatment efforts at Menninger. One chapter is a brief summary by Bateman and Fonagy of their aforementioned empirically supported mentalization-based partial hospital program for borderline personality disorder, and another is a description by Sadler, Slade, and Mayes of their "Minding the Baby" home visitation program intended to teach mentalization-based parenting skills to high-risk first-time parents living in the inner city of New Haven. Preliminary results, as reported in the chapter, suggest a decrease thus far in high-risk behavior and growth in home stability. Of particular interest is Twemlow and Fonagy’s chapter on the Peaceful Schools Project, a mentalization-based approach to decreasing violence and bullying in schools, because the decreases in bullying and violence associated with this intervention indicate that the mentalization concept has application for larger social systems, not just the dyads and small groups that are the main settings in which psychotherapy is practiced.

In sum, then, the two books reviewed here are important attempts at bringing the concept of mentalization to a wider audience, for example, to nonpsychoanalytic clinicians or to psychoanalytic clinicians looking for something more immediately practical and useful than Affect Regulation, Mentalization, and the Self, crucially important though that book may be. They are well worth reading, even though they are not typical reading fare for a psychoanalytic audience. If I have problem with these volumes, however, they are the concerns that I raised at the beginning of this review, namely, that mentalization is an ungainly term and, in these books, unfortunately also an overused one. The term mentalization ultimately refers to the idea that humans are beings with thoughts, feelings, wishes, and desires, and in reading these books, I often found myself wishing that their authors would use these plain words to describe our mental acts, not so bloodless and abstract a term as mentalization or even, although it is better in verb form, mentalizing. These complaints aside, I still find these volumes to be worthy contributions to our literature and to the increasingly necessary attempt to demonstrate the relevance of psychoanalytic ideas in the reductionistic intellectual climate in which we currently find ourselves.

John Auerbach

Bateman, A. W., & Fonagy, P. (2004). Psychotherapy for borderline personality disorder: Mentalization-based treatment. New York: Oxford University Press.
Bruner, J. (1990). Acts of meaning. Cambridge, MA: Harvard University Press.
Clarkin, J. F., Yeomans, F. E., & Kernberg, O. F. (2006). Psychotherapy for borderline personality: Focusing on object relations. Washington, DC: American Psychiatric Publishing.
Dennett, D. C. (1987). The intentional stance. Cambridge, MA: MIT Press.
Fonagy, P. (1991). Thinking about thinking: Some clinical and theoretical considerations in the treatment of a borderline patient. International Journal of Psycho-Analysis, 72, 639-656.
Fonagy, P., Gergely, G., Jurist, E. L., & Target, M. (2002). Affect regulation, mentalization, and the development of the self. New York: Other Press.
Lecours, S., & Bouchard, M. A. (1997). Dimensions of mentalization: Outlining levels of psychic transformation. International Journal of Psycho-Analysis, 78, 855-875.
Leichsenring, F., & Rabung, S. (2008). Effectiveness of long-term psychodynamic psychotherapy: A meta-analysis. Journal of the American Medical Association, 300, 1551-1565.

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