the assessment of mentalization

The Assessment of

Mentalization

Patrick Luyten, PhD

University of Leuven, Belgium

University College London, UK

Pretend

Mode

Psychic

Equivalence

Teleological

Mode

Temporary Failure of Mentalisation

Unstable Interpersonal Relationships

Affective Dysregulation

Impulsive Acts of Violence, Suicide, Self-Harm

Psychotic Symptoms

Figure 2.x Understanding BPD in terms of the suppression of mentalization

Pseudo

Mentalisation

Concrete

Understanding

Misuse of

Mentalisation

Why important?

Overview

Theoretical considerations

Clinical assessment of mentalizing:

the mentalizing profile

Structured assessment of mentalizing

Therapeutic implications

Luyten, P., Fonagy, P., Lowyck, B., & Vermote, R. (2012). The assessment

of mentalization. In A. Bateman & P. Fonagy (Eds.), Handbook of

mentalizing in mental health practice (pp. 43-65). Washington, DC:

American Psychiatric Association.

The formula to understand women

Team Psychoanalysis Unit London (UK): Peter

Fonagy, Anthony Bateman, Mary Target

UPC Kortenberg (België): Rudi Vermote, Benedicte Lowyck, Yannic Verhaest, Bart Vandeneede

Yale University (USA): Sidney J. Blatt, Linda Mayes, Helena Rutherford, Michael Crowley

Psychoanalysis Unit Leuven: Nicole Vliegen, Liesbet Nijssens, Naouma Siouta, Tamara Ruijten

University of Durham (UK): Elizabeth Meins

Viersprong & MBT consortium The Netherlands

Some Theory…

What is mentalizing?

Mentalizing is a form of imaginative

mental activity about others or oneself,

namely, perceiving and interpreting

human behaviour in terms of

intentional mental states (e.g. needs,

desires, feelings, beliefs, goals,

purposes, and reasons).

What is mentalization? It is a capacity we use all the time

It is what we need:

To collaborate

To compete

To teach

To learn

To know who we are

To understand each other and ourselves

Is fundamental in our ability to navigate the

social world

Mentalizing is multi-dimensional:

Four polarities

Automatic – controlled

Internal – external

Self – other

Cognitive - affective

Fonagy, P., & Luyten, P. (2009). A developmental, mentalization-based

approach to the understanding and treatment of borderline personality disorder.

Development and Psychopathology, 21(4), 1355-1381.

Dimensions of mentalization: implicit/automatic

vs explicit/controlled

Psychological understanding drops and is

rapidly replaced by confusion about mental

states under high arousal

That handkerchief which I so loved and gave thee

Thou gavest to Cassio.

By heaven, I saw my handkerchief in's hand.

Controlled Automatic

Arousal

Dimensions of mentalization: implicit/automatic

vs explicit/controlled

Arousal

Psychotherapist’s demand to explore issues

that trigger intense emotional reactions

involving conscious reflection and explicit

mentalization are inconsistent with the

patient’s ability to perform these tasks when

arousal is high

That handkerchief which I so loved and gave thee

Thou gavest to Cassio.

By heaven, I saw my handkerchief in's hand.

Dimensions of mentalization: implicit/automatic

vs explicit/controlled

Controlled Automatic

Lateral PFC Medial PFC

Lateral

temporal

cortex

Amygdala Ventromedial PFC

Arousal

Dimensions of mentalization: internally vs externally

focused (mental interiors vs visible clues)

Internal External

I wonder if he feels

his mother loved

him?

He looks tired;

perhaps he slept

badly

With selective loss of sense of mental interiors, external features

are given inappropriate weight and misinterpreted as indicating

dispositional states

You’re covering your eyes; you can hardly bear to look at me

Dimensions of mentalization: Cognitive vs

affective mentalization

Agent attitude

propositions

“I thought that Rutten would

succeed in forming a

proper government”

Associated with several

areas of prefrontal cortex

Cognition Emotion

Self affect state

propositions

“I feel sad about it too”

Associated with inferior

prefrontal gyrus

Mentalize This! Ik denk niet dat het makkelijk

zal worden, maar we komen er

wel!

Maar ja,

zonder

mij zal

het toch

niet

lukken

Ik zal alles

doen om dit

te laten

slagen

With diminution of cognitive mentalization the logic of

emotional mentalization (self-affect state proposition)

comes to be inappropriately extended to cognitions.

“I feel sad, you must have hurt me”

Dimensions of mentalization: Cognitive vs

affective mentalization

Mentalize This! Oh nee, wat

zal mijn

moeder nu

zeggen Mijn vader

heeft altijd

gezegd dat ik

niets kon

Ik voel me zo

rot

Wij voelen

ons allemaal

rot

Implicit-

Automatic

Explicit-

Controlled

Mental

interior

focused

Mental

exterior

focused

Cognitive

agent:attitude

propositions

Affective

self:affect state

propositions

Imitative

frontoparietal

mirror neurone

system

Belief-desire

MPFC/ACC

inhibitory

system

BPD

BPD

BPD

BPD

Mentalizing Profile of Prototypical BPD patient

Assessment of

Mentalization

Pretend

Mode

Psychic

Equivalence

Teleological

Mode

Temporary Failure of Mentalisation

Unstable Interpersonal Relationships

Affective Dysregulation

Impulsive Acts of Violence, Suicide, Self-Harm

Psychotic Symptoms

Figure 2.x Understanding BPD in terms of the suppression of mentalization

Pseudo

Mentalisation

Concrete

Understanding

Misuse of

Mentalisation

Why important?

Clinical Strategy to Assess Mz

2-3 clinical interviews

Essential components:

Demand questions explicitly probing for

mentalization

Exploring mentalizing in specific

relationships and high arousal contexts

Exploring mentalization with regard to

symptoms and complaints

Attention to interpersonal process: self-

correcting tendency of Mz and ability to allow

the clinician to correct mentalizing lapses

General Strategy

Assess general mentalizing abilities

Assess specific mentalizing abilities:

Mentalizing profile based on polarities

Non-mentalizing modes

Individual differences in attachment

Allows to predict what is likely to happen in

treatment

Tailoring of interventions

Demand questions that can reveal

quality of mentalisation

why did your parents behave as they did during your childhood?

do you think your childhood experiences have an influence on who you are today?

did you ever feel rejected as a child?

in relation to losses, abuse or other trauma, how did you feel at the time and how have your feelings changed over time?

have there been changes in your relationship with your parents since childhood?

Elaboration of interpersonal event

Thoughts and feelings in relation to the event

Ideas about the other person’s mental state at turning points in narrative

Elaborate on actual experience

Reflecting on reconstructed past

Understanding own actions (actual past and reflection on past)

Counter-factual follow-up questions

Interpersonal interaction

Last night Rachel and I had an argument

about whether I was doing enough around

the house. She thought I didn’t do as much

as her and I should do more. I said I did as

much as my work obligations allow. Rachel

got angry and we stopped talking to each

other. In the end I agreed to do the

shopping from now on. But I ended up

feeling furious with her

What does non-mentalizing look

like?

Excessive detail to the exclusion of

motivations, feelings or thoughts

Focus on external social factors, such as

the school, the council, the neighbours

Focus on physical or structural labels

(tired, lazy, clever, self-destructive,

depressed, short-fused)

What does non-mentalizing look

like?

Preoccupation with rules, responsibilities,

‘shoulds’ and ‘should nots’

Denial of involvement in problem

Blaming or fault-finding

Expressions of complete certainty about

thoughts or feelings of others (“I just know”)

What does good mentalizing look

like?

In relation to other people’s thoughts and feelings

Acknowledgement of opaqueness

Contemplation and reflection

Perspective taking

Genuine interest

Openness to discovery

Forgiveness

Predictability

What does good mentalizing look

like? Perception of own mental functioning

Appreciation of changeability

Developmental perspective

Realistic scepticism

Acknowledgement of pre-conscious function

Awareness of impact of affect

Self-presentation (e.g. autobiographical continuity vs. identity diffusion)

General values and attitudes (e.g. tentativeness and moderation)

What does extremely poor mentalizing

look like? Anti-reflective

hostility

active evasion

non-verbal reactions

Failure of adequate elaboration

Complete lack of integration

Complete lack of explanation

Inappropriate

Complete non-sequiturs

Gross assumptions about the interviewer

Literal meaning of words

Assessment of mentalization

Distinguish four main types of problems - not

mutually exclusive; more than one may apply to

the same person

Concrete understanding

o Generalised lack of mentalising

Context-specific non-mentalising

o Non-mentalising is variable and occurs in particular contexts

Pseudo-mentalising

o Looks like mentalising but missing essential features

Misuse of mentalising

o Others’ minds understood and thought about, but used to hurt,

manipulate, control or undermine

Concrete understanding

General failure to appreciate feelings of self or others as well as the relationships between thoughts, feelings and actions

General lack of attention to the thoughts, feelings and wishes of others and an interpretation of behaviour (own or others) in terms of the influence of situational or physical constraints rather than feelings and thoughts

May vary markedly in degree

Context Specific - Relational

Dramatic temporary failures of

mentalisation

“You’re trying to drive me crazy”

“You hate me”

‘I can’t think once she starts on me’

Particular problem in family/group therapy!

Pseudo-mentalising subtypes

Intrusive mentalising Opaqueness of mental states not respected

Thoughts and feelings talked about, may be relatively plausible and roughly accurate, but assumed without qualification

Overactive-inaccurate mentalising Lots of effort made, preoccupation with mental states

Off-the-mark and un-inquisitive

Destructively inaccurate Denial of objective reality, highly psychologically

implausible mental states inferred

Misuse of Mentalizing (1)

Understanding of the mental state of the

individual is not directly impaired yet the way

in which it is used is detrimental

May be unconscious but is assumed to be

motivated

Self-serving distortion of the other’s feelings

Self-serving empathic understanding

A person’s feelings are exaggerated or distorted

in the service of someone else’s agenda

Misuse of Mentalizing(2)

Coercion against or induction of the thoughts

of others

Deliberate undermining of a person’s capacity

to think by humiliation

Extreme form is sadistic or psychopathic use of

knowledge of other’s feelings or wishes

Milder form is manipulation for personal gain

o inducing guilt

o engendering unwarranted loyalty

o power games

o Understanding used as ammunition in a battle

Non-mentalizing modes

Teleological mode

Psychic equivalence mode

Extreme pretend mode

Teleological mode Behavior and thought/intentions are

equated

Primacy of the physical/observable

“I only believe you when I see it”

Extra sessions

Need for physical contact

Yawning means you are bored of me

Going on holiday means you want to get rid of

me

Only what you see is real

Doubts about honesty/hypocrisy

Gergely, G., & Csibra, G. (2003). Teleological reasoning in infancy: The

naive theory of rational action. Trends in Cognitive Sciences, 7, 287-292.

Psychic equivalence

What is thought is real

Everything becomes too real (e.g.,

thoughts, feelings, lying on the couch)

Decoupling of Mz or de-symbolization

(concreteness of thought): Rejection

literally hurts (Eisenberger et al., 2003)

Very painful feelings of shame, sadness,

emptiness, badness, which threaten to

disintegrate the self -> evacuation by

means of projection, dissociation, self-harm

Extreme pretend mode Hypermentalization

Mentalization severed from reality (“the

educated neurotic”, “canned language”)

Elaborate, often highly cognitive, or

affective overwhelming, confusing

narratives (e.g., on TAT, Rorschach)

Dissociation/”driving oneself crazy”

May lead to wrong impression of

therapeutic work and progress/indication

for insight-oriented treatment

Creating a Coherent Self-representation by Controlling

and Manipulation – Hyper-activation of Attachment

Attachment

figure

Self experienced

as incoherent

Alien part of self Self representation

Self experienced

as incoherent

Externalization

Through coercive, controlling behavior the individual with

disorganized attachment history achieves a measure of

coherence within the self representation

Attachment

figure

Self experienced

as coherent

Individual Differences

A biobehavioral switch model of the relationship

between stress and controlled versus automatic

mentalization

Attachment - Arousal/Stress

Attachment history determines

Setting of switch

o when controlled Mz switches to automatic Mz

Steepness or slope of change

o how extensive the switch is

Time to recovery from switch

=> Determines affect/stress regulation

Adult Attachment Interview coding system (Main & Goldwyn, 1994)

• Autonomous [secure]

▫ coherent: undefended access to consistent memories and judgments

▫ believable

▫ value attachment and acknowledge impact

• Dismissing [avoidant]

▫ can’t remember / idealise / devalue

• Preoccupied [resistant]

▫ entangled in angry / passive / fearful associations

• Unresolved with respect to trauma [disorganised]

▫ slips, contradictions, gaps, reliving of trauma

Attachment security

High threshold for switching under stress

Fast recovery

Ability for simultaneous activation of ATT

system and Mz system

Associated with effective affect/stress regulation

Leads to so-called “broaden and build” cycles

associated with attachment security

(Frederickson, 2001)

o Security of internal mental exploration, even under

stress

o Ability to ask others for help = relationship-recruiting

Attachment hyperactivation

Lowered threshold for attachment activation

and thus switch

Longer time to recovery

May explain typical pattern of

o Fast attachment to others

o But to unreliable others because of deactivation of

controlled mentalization

o Hypervigilance to emotional states in others

o Hypo-hypermentalization cycles (overly trusting-

overly distrusting)

o Through negative feedback: increasing

hyperactivation of the ATT system and lowered

threshold for decoupling of Mz

Hyperactivation and Maltreatment

DISTRESS/FEAR

Exposure to maltreatment

Proximity seeking

Activation of attachment

The ‘hyperactivation’ of the attachment system

Adverse Emotional Experience

Trauma and Mentalizing

Frightening/frightened states of mind of

caregivers

Lead to defensive inhibition of mentalizing

about caregivers’ mental states

Leads paradoxically to

hypervigilance/hypersensitivity to mental

states in others

But dominated by non-reflective

assumptions about the mind of others

Attachment deactivating strategies

Resembles secure attachment on first

impression

High mentalizing, even under stress

but often hypermentalization =

mentalization “on the loose”

The “educated neurotic” that uses “canned

language”

Collapses under increasing stress

Failure of defense mechanisms

under increasing cognitive load

*Shaver, P. R., & Mikulincer, M. (2005). Attachment theory and research: Resurrection of the

psychodynamic approach to personality. Journal of Research in Personality, 39, 22-45.

Disorganized attachment

Particularly maladaptive mix of

hyperactivating and deactivating strategies

Leading to hypermentalization-

hypomentalization cycles

Relationship-specific nature of

mentalizing!

Mentalizing is interpersonal: can patients

allow co-regulation of mentalizing and affect?

Different profiles/switch points in different

relationships

Immediate therapeutic

implications

Finding optimal balance between ATT

activation and Mz

Tailoring interventions to patients

In hyperactivating patients, failure of Mz

easily ensues: emphasis on insight or deep

interpretations, especially in early phases,

probably counterproductive

In deactivating patients: risk of

pseudomentalization

Threshold for switch Strength of automatic response

Recovery of controlled mentalization

Secure High Moderate Fast

Hyperactivating Low: Hyperresponsivity Strong Slow

Deactivating Relatively high: Hyporesponsive, but

failure under increasing stress

Weak, but moderate to strong under increasing

stress

Relatively fast

Disorganized Incoherent: hyperresponsive, but

often frantic attempts to downregulate

Strong Slow

Implicit-

Automatic

Explicit-

Controlled

Mental

interior

focused

Mental

exterior

focused

Cognitive

agent:attitude

propositions

Affective

self:affect state

propositions

Imitative

frontoparietal

mirror neurone

system

Belief-desire

MPFC/ACC

inhibitory

system

BPD

BPD

BPD

BPD

Mentalizing Profile of Prototypical BPD patient

Ordinary/Average

Low

High

Very Low

Very High

Internal External

Self Other

Cognitive Affective

●

●

●

●

●

● ●

●

●

●

●

●

Legend:

= Typical mentalizing profile for Borderline Personality Disorder

= Typical mentalizing profile for Narcissistic Personality Disorder

Implicit-

Automatic

Explicit-

Controlled

Mental

interior

focused

Mental

exterior

focused

Cognitive

agent:attitude

propositions

Affective

self:affect state

propositions

Imitative

frontoparietal

mirror neurone

system

Belief-desire

MPFC/ACC

inhibitory

system

Impression driven

Appearance

Certainty of emotion

Treatment vectors in re-establishing mentalizing

Controlled

Inference

Doubt of cognition

Emotional contagion Autonomy

Structured assessment

of mentalization

Selective Trust!

Approaches to measure Mz

(Parental) Reflective Functioning is typically

measured based on interviews

Adult Attachment Interview (AAI)

Child Attachment Interview (CAI)

Parent Development Interview (PDI)

Pregnancy Interview (PI)

Working Model of the Child Interview (WMCI)

Limitations:

Time and cost-intensive

Mostly uni-dimensional

Score

on RF

Scale

Description

Moderate to high RF

9

Full or Exceptional

Interviewee’s answers show exceptional

sophistication, are surprising, quite

complex or elaborate and consistently

manifest reasoning in a causal way using

mental states

7

Marked

Numerous statements indicating full RF,

which show awareness of the nature of

mental states, and explicit attempts at

teasing out mental states underlying

behaviour

5

Definite or Ordinary

Interviewee shows a number of instances of

reflective functioning even if prompted by

the interviewer rather than emerging

spontaneously from the interviewee

Negative to limited RF

3

Questionable or Low

Some evidence of consideration of mental

states throughout the interview, albeit at a

fairly rudimentary level

1

Absent but not Repudiated

Reflective functioning is totally or almost

totally absent

-1

Negative

Interviewee systematically resists taking a

reflective stance throughout the interview

Multi-dimensional assessment with RF-

scale is possible:

Specific issues (eg trauma and loss) on the

AAI (Berthelot, Ensink et al., 2012)

Symptoms (e.g. Rudden et al. 2009)

Specific attachment figures (e.g. Diamond et

al. 2003)

Yet:

remains time/cost-intensive

Remains “off-line” measure <---> “on-line”

Assessment of mentalization polarities

Various proxies of mentalizing exist

Different “off-line” and “on-line”

measures can be used an adapted

Multi-dimensional appraoch provides a

guide to measurement selection and

development

Luyten, P., Fonagy, P., Lowyck, B., & Vermote, R. (2012). The assessment of mentalization. In A. Bateman & P. Fonagy

(Eds.), Handbook of mentalizing in mental health practice (pp. 43-65). Washington, DC: American Psychiatric

Association.