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The Assessment of Mentalization

Patrick Luyten, PhD University of Leuven, Belgium University College London, UK

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

Temporary Failure of Mentalisation

Pretend Mode

Psychic Equivalence

Teleological Mode

Pseudo Mentalisation

Concrete Understanding

Misuse of Mentalisation

Unstable Interpersonal Relationships Affective Dysregulation Impulsive Acts of Violence, Suicide, Self-Harm Psychotic Symptoms

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

Psychoanalysis Unit London (UK): Peter Fonagy, Anthony Bateman, Mary Target UPC Kortenberg (Belgi): 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.




Dimensions of mentalization: implicit/automatic vs explicit/controlled

Psychotherapists demand to explore issues that trigger intense emotional reactions involving conscious reflection and explicit mentalization are inconsistent with the patients ability to perform these tasks when arousal is high


Dimensions of mentalization: implicit/automatic vs explicit/controlled

That handkerchief which I so loved and gave thee ThouLateral gavest to Cassio. Amygdala PFC temporal Lateral PFC Medial Ventromedial PFCin's hand. By heaven, I saw my handkerchief




Dimensions of mentalization: internally vs externally focused (mental interiors vs visible clues)

Internal I wonder if he feels his mother loved him? External 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

Youre covering your eyes; you can hardly bear to look at me

Dimensions of mentalization: Cognitive vs affective mentalization


Self affect state propositions

Agent attitude propositions

I thought that Rutten would succeed in forming a proper government

I feel sad about it too Associated with inferior prefrontal gyrus

Associated with several areas of prefrontal cortex

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

Dimensions of mentalization: Cognitive vs affective mentalization

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

Mentalize This!
Mijn vader heeft altijd gezegd dat ik niets kon

Oh nee, wat zal mijn moeder nu zeggen

Ik voel me zo rot

Wij voelen ons allemaal rot

Mentalizing Profile of Prototypical BPD patient

ImplicitAutomatic BPD ExplicitControlled

Mental interior focused


Mental exterior focused

Cognitive agent:attitude propositions BPD Imitative frontoparietal mirror neurone system


Affective self:affect state propositions

Belief-desire MPFC/ACC inhibitory system

Assessment of Mentalization

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

Temporary Failure of Mentalisation

Pretend Mode

Psychic Equivalence

Teleological Mode

Pseudo Mentalisation

Concrete Understanding

Misuse of Mentalisation

Unstable Interpersonal Relationships Affective Dysregulation Impulsive Acts of Violence, Suicide, Self-Harm Psychotic Symptoms

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: selfcorrecting 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 persons 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 didnt 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 peoples 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

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

Youre trying to drive me crazy You hate me I cant 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 others feelings Self-serving empathic understanding A persons feelings are exaggerated or distorted in the service of someone elses agenda

Misuse of Mentalizing(2)

Coercion against or induction of the thoughts of others

Deliberate undermining of a persons capacity to think by humiliation Extreme form is sadistic or psychopathic use of knowledge of others 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

Alien part of self Self representation Externalization

Attachment figure

Self experienced as incoherent

Attachment figure

Self experienced asas coherent incoherent

Through coercive, controlling behavior the individual with disorganized attachment history achieves a measure of coherence within the self representation

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]
cant 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 trustingoverly distrusting) o Through negative feedback: increasing hyperactivation of the ATT system and lowered threshold for decoupling of Mz

Hyperactivation and Maltreatment


Adverse Emotional Experience Exposure to maltreatment

Activation of attachment

Proximity seeking

The hyperactivation of the attachment system

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 hypermentalizationhypomentalization 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 Moderate Strong Weak, but moderate to strong under increasing stress Strong

Recovery of controlled mentalization Fast Slow Relatively fast

Secure Hyperactivating Deactivating

High Low: Hyperresponsivity Relatively high: Hyporesponsive, but failure under increasing stress Incoherent: hyperresponsive, but often frantic attempts to downregulate



Mentalizing Profile of Prototypical BPD patient

ImplicitAutomatic BPD ExplicitControlled

Mental interior focused


Mental exterior focused

Cognitive agent:attitude propositions BPD Imitative frontoparietal mirror neurone system


Affective self:affect state propositions

Belief-desire MPFC/ACC inhibitory system

Very High High

Ordinary/Aver age

Low Very Low

External Legend:




= Typical mentalizing profile for Borderline Personality Disorder = Typical mentalizing profile for Narcissistic Personality Disorder

Treatment vectors in re-establishing mentalizing

ImplicitAutomatic Impression Controlled driven ExplicitControlled

Mental interior focused

Appearance Inference

Mental exterior focused

Cognitive agent:attitude propositions

Certainty emotion Doubt of of cognition

Affective self:affect state propositions

Imitative frontoparietal mirror neurone system

Emotional contagion Autonomy

Belief-desire MPFC/ACC inhibitory system

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)

Time and cost-intensive Mostly uni-dimensional

Score on RF Scale


Full or Exceptional Interviewees answers show exceptional sophistication, are surprising, quite complex or elaborate and consistently manifest reasoning in a causal way using mental states 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 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 Questionable or Low Some evidence of consideration of mental states throughout the interview, albeit at a fairly rudimentary level

Moderate to high RF

Negative to limited RF

Absent but not Repudiated Reflective functioning is totally or almost totally absent Negative Interviewee systematically resists taking a reflective stance throughout the interview


Multi-dimensional assessment with RFscale 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)

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.