Mentalization theory and its roots in attachment theory

Authored by Henry Strick van Linschoten

Another important theory strongly influenced by attachment theory is the construct of “mentalizing”, originally described by Fonagy (1991). Mentalizing refers to the capacity to understand mental states (beliefs, desires, intentions, thoughts, and feelings) in oneself and others. It was originally put forward based on clinical observation and research on the “reflective function” scale of the AAI as the potential mediating factor between attachment and mental health (Fonagy et al., 1991a; 1991b2002). Fonagy has stressed that being able to mentalize entails being able to adopt the “intentional” stance (Dennett, 1987): Mental states are always intentional in that they are always about something (e.g. I am angry about this or that). Jon G. Allen, an American psychologist who has embraced the concept, has added that in clinical practice mentalizing can involve mentalizing symptoms, in the sense of giving something a mental quality (Allen et al., 2008). A recent book on mentalizing is Bateman & Fonagy (2012). Although mentalizing was originally developed to explain borderline personality disorder, this book extends the concept to a number of other psychiatric presentations.

Mentalizing is thought to develop through secure attachment relationships (Fonagy et al., 2002). Mentalizing has a number of implications for the development of human beings. The capacity to develop a mind capable of understanding itself and others is not a given, but a hard-won developmental acquisition that is the outcome of secure attachment relationships. In this framework attachment is not simply seen as a behavioural system developed to ensure proximity to caregivers, but as a vehicle for ensuring that the infant will have the opportunity to develop their own mind. The purpose of mentalizing is therefore to enable the development of self-regulation and affect regulation. Paradoxically, the activation of the attachment system leading to either hyperarousal or hypoarousal is assumed to switch off mentalizing. Instead, being in a secure relationship with a caregiver allows the child to be relaxed enough to begin exploring their own and others’ minds.

Dimensions of mentalizing

Mentalizing is a multidimensional concept (Bateman & Fonagy, 2012) and overlaps with some existing, well known psychological constructs. Mentalizing is a capacity that involves a number of dimensions: Self versus other, implicit versus explicit, objective versus subjective, past versus present versus future.

  • Mentalizing the self. This involves the capacity to know one’s own mental states. It is similar to mindfulness, a concept recently imported into cognitive behavioural therapy from a Buddhist context that involves paying purposeful and focused attention to the present moment. Mentalizing however is a function of the autobiographical self and refers to paying attention to the past, present and future.
  • Mentalizing the other. This involves the capacity to fathom the mental states of another. It is broader than Theory of Mind, which is more focused primarily on cognitive understanding.Mentalizing implicitly versus explicitly: Implicit mentalizing is an automatic process unlike explicit mentalizing that involves effortful attention and hard work. Under situations of stress, mentalizing is more likely to become implicit, requiring the regulation of arousal toward a tolerable window in order to restore the capacity to think purposefully and intentionally (Bateman & Fonagy, 2012).
  • Mentalizing in time. Mentalizing involves the capacity to embed past, present, and future understanding of oneself and others within the individual’s autobiography or, as Holmes (2010a)suggests, to developing narrative competence.

The development of mentalizing

A detailed account of the precise developmental framework for the emergence of mentalizing can be found in Fonagy et al. (2002). We will examine what occurs when mentalizing is lost and pre-mentalistic modes of functioning emerge. Fonagy and Target (1995; 1996; 1997; 20002007a2007bTarget & Fonagy, 1996) have attempted to understand the development of psychic reality in children. They postulate an initial mode of mentalizing they refer to as “psychic equivalence”. They point to Freud’s development of the concept of psychic reality which arose out of his shift from an external, trauma-focused aetiology of the neuroses to an internal, fantasy-driven one. For the child who is younger than 18 months old, the psychic equivalence mode predominates. This mode of functioning involves the assumption that what is internal is external and vice-versa. Fantasy is therefore equated with reality, a process that can result in feelings of profound terror, as internal states are assumed to represent reality. At 18 months the child achieves the capacity to enter the “pretend mode” of mental functioning. In the pretend mode fantasy is decoupled from reality so that mental states are assumed to have no connection to reality and the child is able to pretend play. This can bring relief from the concreteness of the psychic equivalence mode. It is not until the age of three to four years that a child becomes able to begin integrating these two modes of mental functioning into a truly mentalistic stance where reality is neither “too real” nor “too unreal”.

Pre-mentalistic modes were assumed to be particularly observable in borderline clients when, due to trauma-driven insecure activation of the attachment system, their mentalizing capacities are switched off (Bateman & Fonagy, 200420062012). For example, if they feel mistreated by someone, they assume, in a teleological way, that this person intended to cause them harm. Self-harm and suicide attempts can be understood as efforts to bring about contingent change in the behaviour of others. The pretend mode can be observed in the “non-consequence” assumptions when violent or self-destructive behaviour is decoupled by consequences in reality. In psychic equivalence mode, the client assumes that they know what the therapist is thinking. Their internal view of reality is assumed to be the same as reality.

Part of this framework imagines how the primary caregiver has assisted in the development of mentalizing. The therapist’s task is to provide appropriate mirroring to the client’s internal states. In this way the work of mentalizing has a significant procedural component, as we have seen in the rest of this study aid. Two aspects of affect-mirroring are implicated during infant and child development (Fonagy et al., 2002). “Contingent” affect-mirroring refers to the capacity of the parent to mirror the infant’s mental states accurately in order to promote affect-regulation. If the parent is unable to do this and the child’s anxiety, for example, is responded to as if it is hostility, the child will learn that expressing vulnerability may have destructive consequences on another person later in life. This sets the scene for pretend mode function where the individual’s internal states are not rooted in reality. In contrast, the psychic equivalence mode can be amplified if the parent is unable to offer “marked” affect-mirroring. If as a response to the child’s anxiety the parent becomes anxious, then the child learns that their anxiety is infectious: what is inside appears to materialise outside. Marked affect-mirroring refers to a response that is “marked” for the child’s attention. If the parents responds in a calm, humorous or ironic way (“Aw you hurt your foot and it feels very bad”), the child internalises the parent’s response and is able to develop a “second order representation” (Fonagy et al., 2002) where they become able to represent their emotions rather than only experience them. The therapist is invited to cultivate contingent and marked ways of affect-mirroring the client in order to weaken the hold that pre-mentalistic modes can have on an individual and assist in the development of true representational thinking.