Abstract: Objective We examined whether mentalization-based treatment for adolescents (MBT-A) is more effective than treatment as usual (TAU) for adolescents who self-harm. Method A total of 80 adolescents (85% female) consecutively presenting to mental health services with self-harm and comorbid depression were randomly allocated to either MBT-A or TAU. Adolescents were assessed for self-harm, risk-taking and mood at baseline and at 3-monthly intervals until 12 months. Their attachment style, mentalization ability and borderline personality disorder (BPD) features were also assessed at baseline and at the end of the 12-month treatment. Results MBT-A was more effective than TAU in reducing self-harm and depression. This superiority was explained by improved mentalization and reduced attachment avoidance and reflected improvement in emergent BPD symptoms and traits. Conclusions MBT-A may be an effective intervention to reduce self-harm in adolescents. Clinical trial registration information —The emergence of personality disorder traits in adolescents who deliberately self harm and the potential for using a mentalisation based treatment approach as an early intervention for such individuals: a randomised controlled trial; http://www.controlled-trials.com; ISRCTN95266816.

Abstract: Religious believers intuitively conceptualize deities as intentional agents with mental states who anticipate and respond to human beliefs, desires and concerns. It follows that mentalizing deficits, associated with the autistic spectrum and also commonly found in men more than in women, may undermine this intuitive support and reduce belief in a personal God. Autistic adolescents expressed less belief in God than did matched neuro-typical controls (Study 1). In a Canadian student sample (Study 2), and two American national samples that controlled for demographic characteristics and other correlates of autism and religiosity (Study 3 and 4), the autism spectrum predicted reduced belief in God, and mentalizing mediated this relationship. Systemizing (Studies 2 and 3) and two personality dimensions related to religious belief, Conscientiousness and Agreeableness (Study 3), failed as mediators. Mentalizing also explained the robust and well-known, but theoretically debated, gender gap in religious belief wherein men show reduced religious belief (Studies 2–4).

Abstract: The purpose of this study was to develop and validate a self-rating scale for a differentiated assessment of mentalization. A pool of 40 items was developed and evaluated on n=434 inpatients with mental disorders at three time points. Symptom severity, self-injuring behavior, suicidal tendency and attachment style were also assessed. A varimax-rotated factor analysis supported the extraction of four factors. The model fit was checked by confirmatory factor analysis. Internal consistency of the mentalization questionnaire (MZQ) was .81. The relation between symptom severity and MZQ scores was found to be significant, and significant group differences were found between patients displaying self-injuring behavior and those who did not as well as between patients with and without suicide attempts. The MZQ can be considered as a practicable self-rated instrument with acceptable reliability and sufficient validity to assess at least aspects of mentalization in patients with mental disorders.

Abstract: This article attempts to bridge two seemingly different and yet related worlds, the intra-psychic and the interpersonal, by viewing systemic practice(s) through a mentalization-based lens. It is argued that in therapy there needs to be a deliberate, conscious and consistent focus on mentalizing. The emerging mentalization-based therapy for families is an innovative approach and a distinctive model which is systemic in essence, deriving its ideas and practices from a variety of diverse systemic approaches, yet enriching family work by adding mentalizing ingredients.

Abstract: Patients with functional somatic disorders (FSD) represent a sizeable group in our health care system. FSD are associated with high health care use and considerable personal and economic costs. Evidence-based treatments for FSD are only modestly effective in a large subgroup of patients, particularly in the long run, which emphasizes the need to develop more effective treatments rooted in extant knowledge about the nature of FSD. This paper presents a contemporary psychodynamic perspective on the conceptualization and treatment of patients with FSD rooted in attachment and mentalization theory. First, we review animal and human research demonstrating the close relationships among attachment, stress regulation, and immune and pain-regulating systems. We highlight research findings concerning the high interpersonal and metabolic costs associated with the use of insecure secondary attachment strategies (i.e. attachment deactivating and hyperactivating strategies) leading to increased vulnerability for stress...

Abstract: In this review, the history of the theory of mind (ToM) theory of autistic spectrum disorder (ASD) is outlined (in which ToM is indexed by success on false belief tasks), and the explanatory power and psychological causes of impaired ToM in ASD are critically discussed. It is concluded that impaired ToM by itself has only limited explanatory power, but that explorations of the psychological precursors of impaired ToM have been fruitful in increasing understanding of mindreading impairments in ASD (where 'mindreading' refers those abilities that underlie triadic interaction as well as ToM). It is argued that early explanations of impaired mindreading are untenable for various reasons, but that impairments of dyadic interaction in ASD that could lead to impaired ability to represent others' mental states may be the critical psychological cause, or causes, of impaired ToM. The complexity of causal routes to impaired ToM is emphasized.

Abstract: When we mentalize we are engaged in a form of (mostly preconscious) imaginative mental activity that enables us to perceive and interpret human behavior in terms of intentional mental states (e.g., needs, desires, feelings, beliefs, goals, purposes, and reasons) (Allen, Fonagy, & Bateman, 2008). Mentalizing must be imaginative because we have to imagine what other people might be thinking or feeling. We can never know for sure what is in someone else’s mind (Fonagy, Steele, Steele, & Target, 1997). Moreover, perhaps counterintuitively, we suggest that a similar kind of imaginative leap is required to understand our own mental experience, particularly in relation to emotionally charged issues. We shall see that the ability to mentalize is vital for self-organization and affect regulation. The ability to infer and represent other people’s mental states may be uniquely human. It seems to have evolved to enable humans to predict and interpret others’ actions quickly and efficiently in a large variety of competitive and cooperative situations. However, the extent to which each of us is able to master this vital capacity is crucially influenced by our early experiences as well as our genetic inheritance. In this chapter, we discuss the evolutionary function of attachment relationships, arguing that their major evolutionary advantage is the opportunity that they give infants to develop social intelligence, as well to acquire the capacity for affect regulation and attentional control. We outline the neurobiological substrates that may link secure attachment and mentalization or social cognition, and describe how secure attachment facilitates both the release of hormones enhancing social sensitivity in mothers and the activation of reward processing regions of the brain in mothers’ interactions with their infants, even when the infant is upset. We review evidence from the developmental literature on the social influences on attachment and mentalization. We then describe how our understanding of ourselves and others as mental agents grows out of interpersonal experience, particularly the child-caregiver relationship (Fonagy, Gergely, Jurist, & Target, 2002), and how the development of the ability to mentalize may be compromised in children who have not benefited from the opportunity to be understood and thought about in this way by a sensitive caregiver. Such individuals are then at greater risk of developing personality pathology, particularly if early neglect is compounded by trauma. Finally we offer some reflections on the challenges of mentalizing in family interactions.

Abstract: Metacognitive theory, amongst other theories, gives an important role to beliefs about mental states, including beliefs about emotions, in the maintenance of distress. Mentalization theory as well as the dialectical behaviour therapy and emotion-focused therapy literature specifies particular beliefs thought to be related to emotion dysregulation and therefore to a label of borderline personality disorder. The current study aimed to develop a questionnaire to measure the beliefs about emotions as specified by this literature and to test the relationship of this new measure to various aspects of emotion regulation in a non-clinical sample of 289 participants. A factor analysis extracted six factors, which described beliefs about emotions as (a) overwhelming and uncontrollable; (b) shameful and irrational; (c) invalid and meaningless; (d) useless; (e) damaging; and (f) contagious. The final measure showed some promising psychometric properties. All of the questionnaire subscales were related to aspects of emotion dysregulation including distress, borderline personality disorder symptoms and behaviours associated with dysregulation of emotion, suggesting that beliefs about emotions could be an important metacognitive construct involved in the ability to regulate emotions. Beliefs about emotions may be a useful direct or indirect target for treatment of difficulties regulating emotions, and this could be achieved through the use of various therapeutic modalities.

Abstract: mental health services for inner city children and their caretakers. Community Ment Health J. 1996;32:353–361. 37. McKay MM, Lynn CJ, Bannon WM. Understanding inner city child mental health need and trauma exposure: implications for preparing urban service providers. Am J Orthopsychiatry. 2005;75:201–210. 38. Valleley RJ, Kosse S, Schemm A, et al. Integrated primary care for children in rural communities: an examination of patient attendance at collaborative behavioral health services. Fam Syst Health. 2007;25:323–332. 39. Macharia WM, Leon G, Rowe BH, et al. An overview of interventions to improve compliance with appointment keeping for medical services. JAMA. 1992;267:1813–1817. 40. Sices L, Egbert L, Mercer MB. Sugar-coaters and straight talkers: communicating about developmental delays in primary care. Pediatrics. 2009;124:e705–e713.

Abstract: This article evaluates a pilot mentalization-based treatment programme for borderline personality disorder (BPD), which had an art therapy group as one of its three components. Evaluation involved a range of standardised measures and showed the programme had positive results with increases in distress tolerance, lowered service use and at least two participants no longer meeting criteria for the BPD diagnosis. The question was asked about what art therapy might contribute to mentalization in this context. A qualitative research strategy was undertaken to explore one of the author's experience of art therapy as one of the programme's service users. Repeated rounds of audio-recorded interviews resulted in eight themes which describe what helped and what should be avoided in art therapy treatment of BPD. The service user view was that art therapy was an essential ingredient in helping to develop greater mentalization. The study suggests that in anchoring mental content in an externalised form, art t...

Abstract: Clinicians in the fields of mental health, neuroscientists, and social psychologists have been increasingly interested in how persons with psychiatric conditions experience a range of difficulties related to how they think about themselves and others. These difficulties include problems forming and retrieving the specific autobiographical memories (AM) that ground a sense of personal identity (McAdams, 2001). They have also involved diminishments in the capacity to engage in acts of mentalization or metacognition which allow for the understanding of mental states. Both of these forms of dysfunction are of increasing relevance given that each has been commonly observed across different psychiatric conditions, appears relatively independently from symptoms, and is uniquely linked to functional impairment (Dimaggio and Lysaker, 2010; Liu et al., in press). To date deficits in AM and metacognition have mostly been analyzed separately. Psychopathology research has tended to explore either one or the other, thus neglecting the larger issue of how metacognition and AM are produced by systems which are likely closely related and likely feed and support one another (Markowitsch and Staniloiu, 2011). In development, AM and Theory of Mind (ToM) tend be influenced by common factors (Nelson and Fivush, 2004). Persons who present with overgeneralized AM also experience mentalizing problems including reduced affect awareness and poorer ToM (Palmieri et al., 2012). Psychotherapy research and general neuroscience have begun to examine how these functions support one another and how disruptions in either AM or metacognition might lead to decrements in the other. To explore this issue we review psychopathology research concerned separately with problems in AM and metacognition in two forms of mental illness: schizophrenia and personality disorders (PD). We then discuss the advances from psychotherapy research and neuroscience for understanding how these two phenomena are related and comment on opportunities offered by these insights for scientific and clinical work.

Abstract: Despite being a contested and imprecise notion, the term ‘highly resistant families’ has grown in usage over the past few years. It refers, at one end of a spectrum, to parents who have been falsely accused of maltreating a child and to violent, even dangerous individuals, at the other. To complicate matters, the notion of false or ‘disguised’ compliance describes some family members who may confuse practitioners by appearing to co-operate while merely going through the motions. Excluding parents who have been falsely accused, resistant or reluctant family members are likely to find considerable difficultly ‘mentalizing’– a concept similar to empathy, derived from contemporary applications of attachment-based research – which we discuss in this paper. From an innovative study by Forrester et al., we note en passant that empathy was rarely observed when social workers were asked to enact a child protection referral in vignettes conducted by actors playing the role of parent. We summarize key neurobiological research underpinning pioneering new insights into empathy and mentalization, along with their implications for child protection social workers. We conclude by briefly outlining a promising mentalization-based intervention already proving to be effective with reluctant or resistant parents.

Abstract: This paper discusses practical ways that school psychologists can influence schools to be effective holding environments for students and faculty members. A holding environment is one that fosters the natural maturation and development of the full potential of each child. In such an environment security is bolstered and learning is optimized. The concept of a holding environment emerged from and has been expanded upon by psychodynamically oriented writers and clinicians. Donald Winnicott's work on holding and Peter Fonagy's writings on mentalization are central to the themes presented. An emphasis is placed on translating these concepts into mentalization-based classroom interventions that can foster children to be more aware of the emotions of others while they also develop greater self-awareness and self-regulation skills. Case material and examples of mentalization inspired interventions are given. When a holding mindset is introduced into the school community by the school psychologist, there is an op...

Abstract: The phenomena of self-awareness and self-observation are thought by many to be uniquely human qualities, and questions about how they develop have engaged philosophers and spiritual thinkers throug ...

Abstract: The editors of Handbook of Mentalizing in Mental Health Practice have authored two previous books aimed at establishing mentalizing as a developmental and clinical concept.

Abstract: This study examined the underlying factor structure of the DSM-IV criteria to determine whether the diagnosis could be classified into subtypes. It also sought to enhance the clinical interpretation of any identified subtypes by examining their relation to comorbid axis I and II disorders. In 95 treatment-seeking adults (82 women, 13 men), attending a psychiatric outpatient clinic principle components analysis yielded support for three subtypes: ‘affect dysregulation’, ‘rejection sensitivity’ and ‘mentalization failure’. Results of logistic regression analyses indicated that the affect dysregulation subtype was associated with the comorbid diagnosis of generalized anxiety and panic disorder and other cluster B and C personality disorders. The mentalization failure subtype was found to be predictive of posttraumatic stress disorder and other cluster B personality disorders. With further research, confirmation of these subtypes may inform diagnostic revisions and appropriate treatment regimes that are individually designed to target the patients' core symptoms. Copyright © 2012 John Wiley & Sons, Ltd.

Abstract: This study describes the mentalization-based child therapy of a boy who suffered from early abuse and neglect, who was living in a shelter in southern Brazil. This single case study aimed at assessing whether this kind of psychotherapy contributes to reducing depressive symptoms and developing a greater capacity for reflection on the mental states of self and other, as part of developing a more coherent sense of self. Structured assessments were conducted before therapy and after six months of treatment, and the audio-recorded treatment sessions were analyzed using content analysis, in order to identify key themes in the treatment itself. The results suggested a significant improvement in depressive symptoms and some changes in mentalization with the beginnings of a movement toward a more cohesive and integrated self. We argue that mentalization-based child therapy could be a promising therapeutic approach for children who have experienced severe disruptions of emotional bonds, due to the way it focuses o...

Abstract: Objective: To examine the role of mentalizing in the relationship between psychopathy and aggression in a sample of 75 male adolescents. Method: The participants were drawn from two other studies comparing mentalizing abilities of offenders with healthy community samples. Data was collected on mentalization capacities using the Adult-Attachment-Interview. Psychopathic traits and aggressive behavior were measured via self-report. Results: A mediator-analysis revealed that mentalization partially explains the relationship between psychopathic traits and proactive aggressive behavior. Furthermore, mentalization has a moderating effect indicating that only individuals low on mentalization behave aggressively when high on psychopathic traits. Conclusions: Psychopathic traits alone do not explain aggressive behavior and therefore further research is needed to understand other mediating factors.

Abstract: To have empathy with another is to experience the psychological life of that person by projecting one’s self into another to understand what they are thinking or feeling. The term “empathy” has definitions marked by ambiguity and discrepancy among philosophers, behavioral, social, and medical scholars. Despite this, the professional responsibilities of teachers to be empathic are defined in the graduate standards. Relatively little research examining teacher empathy on teacher-student relationships exists. This paper seeks to develop a definition of empathy that can be used to catalogue teachers’ observation of, and interactions with, students. Firstly, a systematic review of the literature reveals considerable disagreement about what constitutes empathy. Secondly, examining empathy in primary school teachers provides connections with mentalization (Fonagy, 1991). Defining empathy in terms of mentalization provides important insights for primary educators about how to create positive and productive classrooms built on strong teacher-student relationships.

Abstract: Most interventions for depression have shown small or no effects. ‘Third wave‘ cognitive therapy and mentalization-based therapy have both gained some ground as treatments of psychological problems. No randomised trial has compared the effects of these two interventions for patients with major depression. We plan a randomised, parallel group, assessor-blinded superiority clinical trial. During two years we will include 84 consecutive adult participants diagnosed with major depressive disorder. The participants will be randomised to either ‘third wave‘ cognitive therapy versus mentalization-based therapy. The primary outcome will be the Hamilton Rating Scale for Depression at cessation of treatment at 18 weeks. Secondary outcomes will be the proportion of patients with remission, Symptom Checklist 90 Revised, Beck’s Depression Inventory, and The World Health Organisation-Five Well-being Index 1999. Interventions for depression have until now shown relatively small effects. Our trial results will provide knowledge about the effects of two modern psychotherapeutic interventions. ClinicalTrials: NCT01070134

Abstract: The analyst's self-analysis—originally fashioned on Freud's solo foray into his own unconscious mind—continues to play an important psychoanalytic role. A summary of relevant literature is presented that includes recent relational psychoanalytic and neuroscientific data. Three major findings emerge: First, analysts' achievement of self-awareness in the analytic setting is clearly limited, more limited than we might like to admit, especially when we act alone; second, analysts reaching clinical self-awareness is a mutual, interactive process that, in addition to psychological processes, can be understood on the basis of operations uncovered by neuroscience, especially the mirror neuron system; third, accordingly, a form of “mutual” analysis is seen as an indispensable element of the analytic process. Analysts' achievement of self-awareness is discussed with a particular focus on our intrinsic relationality, and on mentalization, self-reflexivity, new relational experience, and therapeutic action. Illustrat...

Abstract: The present article first theoretically defines the term “resilience” from the clinical psychoanalytic standpoint, in view of differentiating normal development from pathological development following trauma. It then formalize two essential processes underlying resilience: mentalization and the ability to identify a developmental tutor . We studied two Romanian 12-year-old twin girls who exhibit opposing adaptations following multiple, cumulative traumas (premature birth, early severe deficiencies, parental maltreatment, parental abdication and abandonment). The study is a projective clinical study that uses a pluridimensional methodology (interviews, storytelling test, Rorschach test, and house-drawing test). The clinical data obtained clearly demonstrate the importance of two major axes in accounting for resilience or maladjustment in the face of trauma.

Abstract: The editors of Handbook of Mentalizing in Mental Health Practice have authored two previous books aimed at establishing mentalizing as a developmental and clinical concept.

Abstract: In the light of current UK national guidelines, this paper considers how outpatient art therapy groups can reverse the development of the pervasive effect of negative symptoms of schizophrenia. Five therapeutic aspects are identified that lead to improvement in the mental health and quality of life for group members. Theoretical understanding based on clinical experience from the 1980s and 1990s is revisited and presented again to reflect current research, understanding and scientific evidence from the neurosciences, in particular through the concept of mentalization. Key words: Schizophrenia, outpatient, mentalization, neuroscience, attachment theory

Abstract: Empathy and interpersonal skills are components of mentalizing and competencies that social work students are expected to acquire during training. Yet limited scientific data exists on factors that influence their attainment. This study was conducted to examine how social work training and individual attachment style are associated with two aspects of mentalization: reading non-verbal communication and reflective thinking. Using a cross-sectional design, 63 social work students participated in this internet-based study. Results showed that regardless of the amount of exposure to social work training, students with an insecure style of attachment had significant deficits in their ability to accurately identify non-verbal expression of thoughts and emotions. Additional results showed that social work training significantly influenced the use of higher order reflective thinking. These findings suggest that students bring an internal relational template with them that is associated with one's capacity for mentalization, specifically accurately interpreting interpersonal communication. Copyright © 2011 John Wiley & Sons, Ltd.