Abstract: The paper suggests a way of understanding borderline personality disorder in terms of the failure of a secure base. We begin with an account of optimal self-development in a secure attachment context, highlighting the importance of the caregiver's ability to help the small child think about his own and others' minds. This optimal self-development is crucial in developing the child's capacity for mentalization, which can enhance his resilience in the face of later trauma. We discuss the impact of attachment trauma in later development, arguing that the extent of this impact depends on how well early attachment relationships facilitated the capacity for mentalization. We identify some of the consequences for the representations of the internal world of a failure of mentalization that may follow trauma in individuals made vulnerable by genetic predisposition or disorganized early attachment. We link these features to the clinical presentation associated with borderline personality organization. Finally, some...

Abstract: The ability to infer the mental states (beliefs,thoughts and intentions) of others in order topredict and explain their behaviour has beenconceptualized as a mentalizing ability or theoryof mind (1, 2).Frith (3) has proposed thatalterations in theory of mind underlie specificsymptoms of psychosis, notably delusions of per-secution, delusions of reference, delusions of mis-identification, third-person auditory hallucinations,some aspects of thought disorder, and negativesymptoms.According to Frith, theory of mindskills in people with these experiences developnormally, but are impaired during an acute psy-chotic episode.Subsequent studies by Frith and co-workers have indeed found that patients withpersecutory delusions, thought disorder, or negat-ive symptoms had difficulties performing a hintingtask and a false-belief task, two tasks that aresensitive to alterations in theory of mind, whereaspatients who were symptom-free at the time oftesting, performed normally (4, 5).These observa-tions suggest that mentalizing ability is a staterather than a trait variable.However, others foundthat the siblings of individuals with a diagnosis ofschizophrenia performed significantly worser thanthe control participants on theory of mind tests (6).These authors suggested that alterations in theoryof mind in people with psychosis represent at leastin part a trait rather than a state factor.However,their sample was very small and statistical resolu-tion limited.One way to explain findings of alterations intheory of mind in patients and their healthyrelatives is to assume that alterations in theory ofmind are at least in part secondary to neuropsy-chological deficits.Schizophrenia is associated withneuropsychological deficits (7–12), and similar,although reduced, neuropsychological deficitshave also been noted in relatives of patients withschizophrenia (13–18).The relatives may be at riskfor later development of schizophrenia or have anundiagnosed (but genetically related) schizophreniaspectrum personality disorder.Therefore, as agroup, non-schizophrenic relatives will appearless impaired than those with schizophrenia, butpossibly more impaired than unrelated controlsJanssen I, Krabbendam L, Jolles J, van Os J.Alterations in theory ofmind in patients with schizophrenia and non-psychotic relatives.ActaPsychiatrScand2003:108:110–117.aBlackwellMunksgaard2003.Objective: It has been proposed that alterations in theory of mindunderlie specific symptoms of psychosis.The present study examinedwhether alterations in theory of mind reflect a trait that can be detectedin non-psychotic relatives of patients with schizophrenia.Method: Participants were 43 patients with schizophrenia orschizoaffective disorder, 41 first-degree non-psychotic relatives and 43controls from the general population.Theory of mind was assessedusing a hinting task and a false-belief task.Results: There was a significant association between schizophreniarisk and failure on the hinting task (OR linear trend¼ 2.01, 95% CI:1.22–3.31), with relatives having intermediate values between patientsand controls.Adjustment for IQ and neuropsychological factorsreduced the association by small amounts.The association betweenschizophrenia risk and failure on the false-belief tasks was notsignificant.Conclusion: Changes in theory of mind are associated withschizophrenia liability.General cognitive ability and neuropsycholo-gical measures seem to mediate only part of this association.

Abstract: The author describes a particularly perilous frontier on the psychoanalytic landscape‐ namely, the treatment of suicidal patients with serious personality disorders. Using a clinical example of egr...

Abstract: Traditional definitions of insight fail to take into account the cognitive and developmental limitations of young analysands, who lack the capacity to mentalize. It is suggested that insightfulness be redefined as promoting mentalization in young children. Gaining this key psychological function furthers the internal integration and self-regulation necessary to regain developmental momentum. The central importance of promoting such development in child psychoanalysis suggests that the facilitation of a mechanism for self-understanding, not the interpretation of content, is essential. Insightfulness is facilitated by employing a range of interventions beyond the interpretation of resistance and content, rendering meaningless the distinction between interpretive and relational aspects of the analyst's role.

Abstract: The author introduces the concept of mentalization as a central interpretative mechanism of social reality testing. It is argued that developmentally the emergence of this mentalizing capacity to interpret other people's actions in terms of their causal intentional mind states (such as beliefs, desires, intentions, and emotions) is preceded by an earlier, nonmentalistic, teleological action interpretational system that represents others' actions in terms of their concrete and visible outcomes. Then the early psychosocial determinants of the developmental unfolding of our mentalizing capacity are considered from the points of view of attachment theory and developmental psychopathology. It is argued that, in severely dysfunctional (neglecting, abusive, and/or dissociative) caregiving environments, the development of mentalization becomes inhibited and results in a predominantly teleological, nonmentalistic interpretation of intimate attachment relationships that is a core feature of certain developmental psychopathologies such as borderline personality disorder. The normal developmental shift from a teleological to a mentalistic mode of action interpretation is illustrated in terms of recently discovered qualitative changes in imitative and observational learning styles during infancy. It is hypothesized that these changes are related to the infant's developing capacity to interpret the communicative-referential behavioral cues that frame the caregiver's infant-directed actions as signaling a cooperative and benevolent mentalistic attitude toward the baby. In closing, it is proposed that the hypothesized role of severely dysfunctional attachment environments in inhibiting the establishment of mentalization skills could be directly tested in early development in the domain of observational learning. It is predicted that differential patterns of "teleological emulation" versus "mentalistic imitative learning" will be found in infants raised in severely dysfunctional versus congenial and secure caregiving contexts, respectively.

Abstract: The capacity for mentalization emerges from developmental changes in the physical structure of the brain. Although pediatric imaging studies have not directly addressed the process of mentalizing, general principles of brain development may shed light on the neurobiology of mentalization. Increases in white matter, which speeds communication between brain cells, growing complexity of neuronal networks suggested by gray matter changes, and environmentally sensitive plasticity are all essential aspects in a child's ability to mentalize and maintain the adaptive flexibility necessary for healthy transition into adulthood.

Abstract: The author delineates various patterns of psychopathology and impaired relationship capacities in persons referred to the Professionals in Crisis program, patterns that are often associated with failure to respond to prior treatment. He articulates a model of treatment that entails a synergy among three domains of intervention: enhancing mentalizing, strengthening impulse control, and promoting awareness of others' mental states. He addresses the challenges this approach poses for both patients and staff members as they develop attachment relationships that foster mentalizing.

Abstract: In the first part of the overview the author draws on the papers in this issue to support the argument that school violence is but one form of social violence with which modern life confronts us. Without ‘modeling’ from the top down, it is hard to imagine how viable programs for violence prevention in schools can be developed and implemented. Coercion is the rule within most social systems, with the exception of families where secure attachments dominate. In secure organizations social influence is exercised in a framework dominated by an awareness of the mental states, concerns, thoughts, and feelings of individuals within the system—that is, a capacity for mentalization. The creation of a peaceful learning environment requires enhancement of the child's consciousness of his or her own awareness of others' awareness of him/her. In the second part of the overview the author questions whether all violence is understandable in these ways or in any way at all. He suggests for reconsideration the classical psychoanalytic notion of threat as a manifestation of a destructive drive. He speculates that violence may occur in two ways and for two reasons which are often conflated and confused. A psychoanalytic theory of this second type of violence is briefly outlined.

Abstract: The patient, a massive man in his thirties, entered the office. When I saw him, I wondered if he suffered from Down's Syndrome. He sat down and started immediately: \"It was hard to come here. When I was waiting for the traffic light, people were staring and laughing at me. Last week I was in the Social Security office, and the moment I entered, two of those girls, those bitches, started whispering: That's a mongoloid. I could kill them! I would like to bury them 50 feet under the earth, those assholes. \" He continued for another ten minutes, raising his voice, threatening, complaining. In response to a colleague's question about what he would like to change in his situation, the patient's answer was simple: The world around him had to change, all those people who owned houses, cars, money, women-all those who laughed at him. Even after two operations to change the mongoloidposture ofhis eyes, he was still laughed at and scolded. This man, a patient in the outpatient department of the mental hospital where I work, is in treatment because of severe alcohol abuse, threatening and violent behavior, and personality pathology in the paranoid-narcissistic range. He is someone with a nearly complete lack ofmentalization, one of the core concepts in the new book by Peter Fonagy and his colleagues. Affect Regulation, Mentalization, and the Development ofthe Selfis, in my opinion, one of those important books that can influence our

Abstract: The concepts of attachment, mentalization, and theory of mind have significant implications for family treatment. The author explores how these concepts are used to enrich and expand the process of family therapy with the premise that attachment provides a significant conceptual base both for understanding family development and for informing therapeutic interventions. A case example illustrates the use of these concepts in family treatment.

Abstract: The relationship between mentalization and Melanie Klein's concepts of depressive and paranoid-schizoid positions is noted, as well as commonalities between mentalization and narrative coherence. Two case examples are presented to illustrate the vicissitudes of mentalization as a psychotherapeutic tool and to explore the context in which mentalization can flourish.

Abstract: The author traces some of the literature related to such concepts as the development of the therapeutic alliance and collaboration in the inpatient and residential psychiatric treatment of disturbed adolescents. The more recently developed concept of “mentalization” is discussed, especially with its relevance to the psychotherapy of difficult-to-treat adolescent patients. A case presentation highlights the establishment of relatedness and trust with such a patient. The case is described in terms of the mental activities of both therapist and patient that facilitated the psychotherapy process in a number of ways. Mentalization is seen as a useful concept, both in terms of understanding the process of psychotherapy, and as a fundamental attribute of the mental activities of the therapist and, likewise, fostered in the patient.

Abstract: Early maltreatment of children can lead to severe disorders in the regulation of behaviour and affect, alterations in awareness and distorted perception. In development-oriented psychotherapy, therapeutic interventions which are directed to regulating processes, decentration or mentalization, desomatization and symbolization of enacted messages play a central role. The results of early traumatization and of therapeutic interventions are portrayed, examining the multi-dimensional diagnosis and therapy of a dangerously aggressive 12-year-old boy as an example. From this, it becomes clear how, through new experiences with regulating others, he gradually surfaces from a world of annihilation and destruction and learns to survive and to live. Language: de

Abstract: The study aimed at searching for mechanisms of communicative impairments in patients with schizophrenia and their relatives. To evaluate a contribution of attention and memory to communication efficacy and to ability for understanding mental states of others, 100 patients with schizophrenia and schizoaffective psychosis, 150 their healthy relatives and 145 controls have been studied. The results confirmed a presence of communicative deviations in the patients with schizophrenia and their relatives. In these groups, communication deficit was determined by disturbance of 1 out of 4 communication principles--the principle of information quantity. Attention and memory did not exert any significant influence on communication efficacy in the patients and their relatives. Distinct deterioration of fulfilling the tasks demanding mentalizing ability was found only in the patients. However, no correlation was revealed between this deterioration and communication peculiarities.

Abstract: In attributing psychological states, people make personal and interpersonal judgements about desires, beliefs and the like. If the attribution of a mental state, whether to oneself or another, requires characterizing a person’s mental condition as being of one type or another, then psychological attributions involve concepts. How do attributors ordinarily understand or conceptualize the contents of mental states like belief, desire or intention? Three general approaches have been influential among the philosophers of mind and cognitive scientists, who have tackled this question: (1) the theory-theory (TT), (2) the modularity theory (MT) and (3) simulation theory (ST). Before I sketch these approaches and examine how each characterizes the contents of mental state concepts, it is important to discuss two widespread assumptions concerning psychological attribution—the uniformity assumption and the asymmetry assumption. In the course of explaining and anticipating thought and action, we characterize both ourselves and others in psychological or mental terms, e.g. as ‘believing the bus departs at ten’ or ‘wanting tiramisu for dessert’. The ability to characterize oneself and others by means of such predicates is a central feature of the psychological competence of normal adults. It underwrites the self-attribution of beliefs, desires, emotions and other conscious, occurrent ‘mental states’ and subserves the attribution of mental states to others. This ability raises a number of well-known interdisciplinary questions concerning the processes of psychological or mental state attribution, the development or acquisition of such “mentalizing” skills and the contents of psychological concepts. In this talk I want to consider the last question against the background of two common assumptions concerning everyday psychological attributions. The first assumption concerns the notion that the same mental concept is applied both to oneself and to others in mentalistic attributions. Call this the uniformity assumption. On this assumption the concepts expressed by mental predicates are unitary and the mental predicates employed in psychological attributions are not ambiguous between first-person and other-person uses; they are univocal. Everyday mental concepts are taken to be general concepts in that distinguishable individuals fall under them, i.e. they apply to a range of distinguishable individuals. P. F. Strawson points out that non-philosophers have no trouble with the thought that mental predicates mean the same in first-person and other-person uses; he writes, “[D]ictionaries don’t give two sets of meanings for every expression which describes a state of consciousness” (1959: 99). In everyday life the generality of mental concepts is unproblematic. Thus, according to the uniformity assumption, we apply the same mental concepts to ourselves and to others. This assumption is supported by at least two considerations. First, a mental concept is the concept of a state type that can be instantiated in a number of people and in the same person at different times, i.e. it is general. Second, as Ernst

Abstract: The authors report preliminary findings from a longitudinal study on the impact of attachment state of mind and reflective function on therapeutic process and outcome with borderline patients in Transference-Focused Psychotherapy (TFP). TFP is a manualized, psychoanalytically oriented treatment based on an object relations model of understanding patients with severe personality disorders. The attachment theory constructs of internal working models of attachment and mentalization or reflective function provide an important means of both conceptualizing borderline disorders and assessing therapeutic process and change. In the Personality Disorders Institute at New York Presbyterian Hospital-Weill Medical College of Cornell University, the authors have been using the Adult Attachment Interview (AAI) to assess changes in state of mind with respect to attachment and reflective function over the course of 1 year in borderline patients in TFP treatment. As part of the authors' investigations of the impact of patients' attachment status on the therapeutic process, they have adapted the AAI to evaluate states of mind with respect to attachment within the therapeutic relationship through an interview called the Patient-Therapist Adult Attachment Interview (PT-AAI). The AAI is given at 4 months and 1 year, and the PT-AAI is given to patients after 1 year of TFP, and both interviews are scored for attachment classification and reflective function. The authors present preliminary findings on change in both attachment classification and reflective function ratings at 4 months and 1 year for a subsample of 10 patients and therapists. They also present two cases that illustrate how the quality of mentalization or reflective function in the therapeutic dyad may be seen as a bidirectional process in that therapists' and patients' levels of reflective function are mutually and reciprocally influential. In one case, the patient's and therapist's reflective function mirrored each other directly and remained at a low or rudimentary level for the treatment year. Such a pattern of direct imitation does not necessarily promote intrapsychic change. In the second case, the patient moved from a rejecting or bizarre stance toward mentalization on the AAI to some rudimentary consideration of mental states after 1 year of treatment with a therapist who showed a full and nuanced awareness of mental states, but who adjusted his level of mentalization to that of the patient. These findings suggest that optimally the therapist ought to be one step ahead of the patient in the capacity for mentalization.

Abstract: The treatment of borderline personality disorder (BPD) remains controversial. The authors have developed an evidence-based treatment program rooted in attachment theory that integrates research on constitutional factors with environmental influences. BPD is conceived of as a disorder in the self-structure brought about through environmentally induced distortion of psychological functioning, which decouples key mental processes necessary for interpersonal and social function. The primary mental function involved is mentalization, which is enfeebled by an absence of contingent and marked mirroring during development. Treatment strategies target mentalization in order to foster the development of stable internal representations, to aid the formation of a coherent sense of self, and to enable to borderline patient to form more secure relationships in which motivations of self and other are better understood. Destabilization of the self leads to emotional volatility, so treatment also needs to focus on identification and appropriate expression of affect. This article describes some of the techniques used to enhance mentalization within the context of group and individual psychotherapy. Targeting of current symptomatology and behavior is insufficient. Therapists need to retain their own ability to mentalize, maintain mental closeness, focus on current mental states, and avoid excessive use of conflict interpretation and metaphor while paying careful attention to the use of transference and countertransference.

Abstract: OBJECTIVE: Theory of mind (TOM), or “mentalizing,” refers to the ability to attribute mental states to self and others. Inferring what people are thinking and feeling is an important aspect of human social interaction, and it is also an important aspect of both psychiatric diagnosis and treatment. The authors conducted a positron emission tomography (PET) study to examine the neural substrates of TOM, using a task that mimics real-life social interaction. METHOD: Thirteen healthy volunteers underwent [15O]H2O PET while performing an experimental task and a control task. During the experimental task they created a “story” about the mental state of a stranger whom they imagined encountering on a park bench. During the control task, they read aloud a story requiring no mental state attribution. RESULTS: The TOM task activated an extensive neural network that included the medial frontal cortex, the superior frontal cortex, the anterior and retrosplenial cingulate, and the anterior temporal pole; most of these...