Mentalizing in Clinical Practice

Mentalizing in Clinical Practice

by Jon G. Allen, PhD; Peter Fonagy, PhD; and Anthony W. Bateman, MA. American Psychiatric Publishing, Inc, Arlington, Virginia, 2008, 403 pages, $62.00.

Daniel Gilbert, PhD, in his fascinating book, Stumbling on Happiness, puts forth a tongue-in-cheek supposition: "Few people realize that psychologists’ ¦take a vow, promising that at some point in their professional lives they will publish a book, a chapter, or at least an article that contains this sentence: ‘ The human being is the only animal that…" We are allowed to finish the sentence any way we like, of course, but it has to start with those 8 words."

Jon G. Allen, Peter Fonagy, and Anthony W. Bateman, it appears, have taken their vows as well. With the publication of Mentalizing in Clinical Practice, the eminent and experienced psychologists have reached the point of declaration, and it goes something like this: "The human being is the only animal that can think about how it thinks and feels."

With this assertion, the authors take on the enormously challenging task of deconstructing our current conceptualization of emotional ailments and their treatments. They are quite methodical in undertaking the task; their book is diligently referenced, very well structured, and full of helpful tables, engaging case studies, end-of-chapter summaries, and even an appendix that can be copied and given to patients.

The authors’ main supposition is that one’s ability to understand his or her behavior, and the behavior of others, hinges on the capacity to comprehend what it is that one thinks and feels. The process by which we cogitate about our own mental processes is called "mentalizing." Self-aware individuals who can tune into their own emotions, and who are capable of empathizing with others’ mental states, are inclined to function healthily. Conversely, much of psychiatric pathology can be explained by impairments in mentalizing.

The authors attest that much of their knowledge and clinical experience in mentalizing grows from their treatment of individuals with borderline personality disorder. Yet, they apply their theory to many disorders including trauma treatment, parent-child therapy, impulse-control disorders, and other nonpsychotic conditions.

The book opens with an engaging and provocative foreword by Stuart C. Yudofsky, MD, followed by a helpful introduction, then the body of the book in 2 parts, and finally a brief epilogue, in which its author, John Oldham, MD, admits, "The authors themselves leave little room for additional comment."

Part I, "Understanding Mentalizing," proposes the concept of mentalizing and discusses its foundations in developmental research and social-cognitive neuroscience. The review of developmental theories is extremely helpful; the authors adroitly interweave physical and emotional developmental milestones with mentalization theory. For example, the authors note that receiving good caregiving provides a positive external world, which can then be internalized. The development of a stronger self through mirroring, joint attention, and pedagogical interactions cannot take place unless a person has the ability to form a mental picture of these events; a secure attachment is essential for mentalizing to take place.

When writing the chapter on neurobiology, the authors perhaps didn’ t sufficiently mentalize the psychiatrist’s needs: They state, "[We] recogniz[e] that many clinicians are less interested in neuroanatomy than in the psychology of mentalizing…" (p. 118). For me, it was quite the opposite; the discussion of mirror neurons and brain anatomy involved in mentalizing was extremely interesting.

Part II, "Practicing Mentalizing," presents the principles of psychotherapeutic interventions that promote mentalizing in a range of current clinical applications. The take-home message was this: Patients with unstable interpersonal interactions often act thoughtlessly: they do things "without thinking," "put things out of their mind," or "lose their minds" when they engage in destructive (or self-destructive) behavior. If patients are educated about this phenomenon, and provided with a safe environment (in therapy) in which they recognize their own emotions and thoughts, they can develop mental representations of these events and use those mental processes to grow and heal.

The authors of this book don’ t think that mentalizing is just a helpful heuristic tool; they make strong assertions that it is elemental to understanding and treating mental illness. If you are concerned about finding a better way to conceptualize pathology and improving treatment of patients with an approach that integrates psychodynamic and attachment theory, this book may make a big difference in your practice.

Scott D. Haltzman, MD

[email protected]

Author affiliation: Warren Alpert Medical School of Brown University, Providence, Rhode Island. Financial disclosure: None reported.

doi:10.4088/JCP.09bk05202

© Copyright 2009 Physicians Postgraduate Press, Inc.