Abstract: ObjectiveThis study evaluated the effect of mentalization-based treatment by partial hospitalization compared to treatment as usual for borderline personality disorder 8 years after entry into a randomized, controlled trial and 5 years after all mentalization-based treatment was complete.MethodInterviewing was by research psychologists blind to original group allocation and structured review of medical notes of 41 patients from the original trial. Multivariate analysis of variance, chi-square, univariate analysis of variance, and nonparametric Mann-Whitney statistics were used to contrast the two groups depending on the distribution of the data.ResultsFive years after discharge from mentalization-based treatment, the mentalization-based treatment by partial hospitalization group continued to show clinical and statistical superiority to treatment as usual on suicidality (23% versus 74%), diagnostic status (13% versus 87%), service use (2 years versus 3.5 years of psychiatric outpatient treatment), use of m...

Abstract: The concept of mentalizing has captured the interest and imagination of an astonishing range of people—from psychoanalysts to neuroscientists, from child development researchers to geneticists, from existential philosophers to phenomenologists—all of whom seem to have found it useful. According to the Thompson Reuter maintained Web of Science, the use of the term in titles and abstracts of scientific papers increased from 10 to 2,750 between 1991 and 2011. Clinicians in particular have enthusiastically embraced the idea, and have put it to innovative use in their practices. Mentalization-based treatment (MBT)—making mentalizing a core focus of therapy—was initially developed for the treatment of borderline personality disorder (BPD) in routine clinical services delivered in group and individual modalities. Therapy with mentalizing as a central component is currently being developed for treatment of numerous groups, including people with antisocial personality disorder, substance abuse, eating disorders, and at-risk mothers with infants and children (A. Bateman & Fonagy, 2011). It is also being used with families and adolescents, in schools, and in managing social groups (Asen & Fonagy, 2011; Fonagy et al., 2009; Twemlow, Fonagy, & Sacco, 2005a, 2005b). In this article, we focus on MBT in the treatment of BPD.

Abstract: This book brings together the latest knowledge from attachment research and neuroscience to provide a new approach to treating trauma for therapists from different professional disciplines and diverse theoretical backgrounds. The field of trauma suffers from fragmentation as brands of therapy proliferate in relation to a multiplicity of psychiatric disorders. This fragmentation calls for a fresh clinical approach to treating trauma. Pinpointing at once the problem and potential solution, the author places the experience of being psychologically alone in unbearable emotional states at the heart of trauma in attachment relationships. This trauma results from a failure of mentalizing, that is, empathic attunement to emotional distress. Psychotherapy offers an opportunity for healing by restoring mentalizing, that is, fostering psychological attunement in the context of secure attachment relationships-in the psychotherapy relationship and in other attachment relationships. The book gives a unique overview of common attachment patterns in childhood and adulthood, setting the stage for understanding attachment trauma, which is most conspicuous in maltreatment but also more subtly evident in early and repeated failures of attunement in attachment relationships.

Abstract: An extensive body of research on the alexithymia construct is reviewed to show how various empirical methodologies can be used to evaluate the validity and increase our understanding of theoretical and clinically derived psychoanalytic concepts. The historical background of alexithymia and the theoretical framework in which the construct was formulated are presented, after which measurement- and experiment-based approaches to construct validation are described. This is followed by a review of empirical investigations that have yielded evidence that alexithymia is a dimensional personality trait associated with several illnesses of interest to psychoanalysts. Empirical research also supports clinical observations and impressions that individuals with high degrees of alexithymia principally employ primitive defenses, have a limited capacity for empathy, exhibit deficits in mentalization, and do not respond well to traditional interpretive psychotherapies. Also reviewed is empirical research that implicates genetic and environmental/developmental factors in the etiology of alexithymia, in particular childhood trauma and insecure attachments, factors generally associated with deficits in affect development and affect regulation. The clinical relevance of the empirical research findings is discussed in the final section.

Abstract: Mentalizing, in particular the successful attribution of complex mental states to others, is crucial for navigating social interactions. This ability is highly influenced by external factors within one's daily life, such as stress. We investigated the impact of stress on the brain basis of mentalization in adults. Using a novel modification of the Reading the Mind in the Eyes Test (RMET-R) we compared the differential effects of two personalized stress induction procedures: a general stress induction (GSI) and an attachment-related stress induction (ASI). Participants performed the RMET-R at baseline and after each of the two inductions. Baseline results replicated and extended previous findings regarding the neural correlates of the RMET-R. Additionally, we identified brain regions associated with making complex age judgments from the same stimuli. Results after stress exposure showed that the ASI condition resulted in reduced mentalization-related activation in the left posterior superior temporal sulcus (STS), left inferior frontal gyrus and left temporoparietal junction (TPJ). Moreover, the left middle frontal gyrus and left anterior insula showed greater functional connectivity to the left posterior STS after the ASI. Our findings indicate that attachment-related stress has a unique effect on the neural correlates of mentalization.

Abstract: Metacognition reflects a spectrum of activities that includes discrete acts in which persons form ideas about specific thoughts and feelings, and synthetic acts in which persons integrate discrete thoughts and feelings into complex representations of themselves and others. This article reviews literature suggesting that persons with schizophrenia and related psychosis experience deficits across the spectrum of metacognitive activities and that these deficits play a key role in dysfunction, often mediating and moderating the impact of symptoms and social adversity on daily life. Treatment approaches including metacognitive training and adaptations of psychotherapy are still in their infancy. Future work is needed to study the etiology of deficits in discrete and synthetic metacognition, as well as their overlap with related constructs such as mentalization and social cognition.

Abstract: Depression is associated with profound impairments in social and interpersonal functioning. However, little research has addressed deficits in mentalizing capacity that may underlie these impairments. The aim of this study was, therefore, to investigate the capacity for mentalization in female inpatients with depression in comparison with healthy controls. We assessed 46 inpatients with major depressive disorder with regard to psychiatric diagnoses, severity of depression, cognitive impairment, and verbal intelligence. In addition, 20 healthy controls matched for sex, age, and education were included. Mentalization was scored on the Adult Attachment Interview using the Reflective Functioning Scale. The female inpatients with depression showed a significantly lower capacity for mentalization compared with the healthy controls. Mentalization deficits were not restricted to depression-specific topics. Moreover, deficits in mentalizing capacity were related to illness duration, number of admissions, and cognitive impairment. The results indicate severe impairment in the ability of the female inpatients with depression to identify and interpret mental states of the self and others. Correlations with illness duration and number of admissions suggest that a chronic course of depression results in further mentalizing impairments. The investigation of mentalization may be of particular importance for the development of targeted psychotherapeutic interventions for depression.

Abstract: , edited by Nick Midgley and Ioanna Vrouva, Hove, Routledge, 2012, 240 pp., £80 (hardback), ISBN: 978-0-41560523-6, £22.99 (paperback), ISBN: 978-0-415-60525-0 In this interesting publication, Midg...

Abstract: The lack of affective responsiveness to others’ mental states – one of the hallmarks of psychopathy – is thought to give rise to increased interpersonal aggression. Recent models of psychopathy highlight deficits in attachment security that may, in turn, impede the development of relating to others in terms of mental states (mentalization). Here, we aimed to assess whether mentalization linked to attachment relationships may serve as a moderator for the relationship between interpersonal aggression and psychopathic traits in an adolescent community sample. Data from 104 males and females with a mean age of 16.4 years were collected on mentalization capacities using the Reflective Functioning Scale on the Adult Attachment Interview (AAI). Psychopathic traits and aggressive behavior were measured via self-report. Deficits in mentalization were significantly associated with both psychopathic traits and proactive aggression. As predicted, mentalization played a moderating role, such that individuals with increased psychopathic tendencies did not display increased proactive aggression when they had higher mentalizing capacities. Effects of mentalization on reactive aggression were fully accounted for by its shared variance with proactive aggression. Psychopathic traits alone only partially explain aggression in adolescence. Mentalization may serve as a protective factor to prevent the emergence of proactive aggression in spite of psychopathic traits and may provide a crucial target for intervention.

Abstract: Antisocial personality disorder (ASPD) is a common condition with major public health implications. Yet effective treatment remains elusive. In this paper the major descriptive symptoms of ASPD are considered using a mentalizing framework. Mentalizing is the implicit or explicit perception or interpretation of the actions of others or oneself as intentional, that is, mediated by mental states or mental processes. It is considered as four intersecting dimensions: automatic/controlled or implicit/explicit; internally/externally based; self/other orientated; and cognitive/affective process. People with ASPD show problems with self/other mentalizing particularly in terms of empathic understanding of others. Their focus is biased toward external mentalizing with little regard for the internal mentalizing of others. The translation of this understanding into a clinical treatment program is discussed. The program is based on the current, evidence-based, mentalization-based treatment (MBT) for borderline personal...

Abstract: Patients with functional somatic disorders (FSD) are markedly heterogeneous with regard to the factors contributing to their illness, their symptoms, and treatment response. In this article, we present a contemporary psychodynamic approach to the conceptualization and treatment of these patients based on attachment and mentalization theory. Extant research is reviewed that suggests a key role for attachment history and mentalization in determining stress and affect regulation, and immune and pain-regulating systems. We focus more specifically on the high interpersonal and metabolic costs associated with the excessive use of insecure secondary attachment strategies in response to stress, and the associated impairments in (embodied) mentalization in patients, both as a cause and consequence of FSD. Finally, a new brief psychodynamic intervention for patients with functional somatic complaints is discussed. (PsycINFO Database Record (c) 2013 APA, all rights reserved)

Abstract: The aim of the study was to examine whether mentalization serves as a protective factor against aggressive behavior in adolescence in the context of early traumatization. We present data from a non-clinical sample of adolescents from Germany (n=97) and calculate a mediation model to test the link between early traumatic experiences and aggressive behavior with mentalizing skills as a mediator. Mentalization was assessed with the Reflective Functioning Scale on the Adult-Attachment-Interview and aggressive behavior was measured with the Reactive-Proactive-Aggression-Questionnaire. Traumatic experience was operationalized as physical and/or sexual abuse as reported in the Childhood Experience of Care and Abuse Questionnaire. Results show a complete mediation for Reflective Functioning on the relationship between early abuse and aggressive behavior. Thus, the findings of the study support an understanding of mentalizing as a protective factor for the relationship between early abusive experience and the development of aggressive behavior. Clinical implications are discussed.

Abstract: Background: ‘Hard to reach’ young people are associated by virtue of their serious, multiple, and complex needs, the difficulty of delivering effective help to them, and their poor long-term outcomes. There is a lack of published evidence relating to the effectiveness of interventions directed at this group. Method: We review these concerns and the options available to service commissioners and clinicians seeking, if not an evidence-based approach then at least an evidence-oriented one. A mentalization-based multimodal intervention (AMBIT) is briefly described, proposing a new kind of specialist practitioner and taking a radically different approach to treatment manualization. Results: A brief description is given of the different settings in which AMBIT is currently being developed, deployed, and evaluated, and of lessons learned. Conclusions: AMBIT offers promise as an evolving ‘open source’ framework supporting development of evidence-based local practice in chaotic complex settings.

Abstract: The human ability to perceive and understand others' suffering is critical to reinforcing and maintaining our social bonds. What is not clear, however, is the extent to which this generalizes to nonhuman entities. Anecdotal evidence indicates that people may engage in empathy-like processes when observing suffering nonhuman entities, but psychological research suggests that we more readily empathize with those to whom we are closer and more similar. In this research, we examined neural responses in participants while they were presented with pictures of human versus dog suffering. We found that viewing human and animal suffering led to large overlapping regions of activation previously implicated in empathic responding to suffering, including the anterior cingulate gyrus and anterior insula. Direct comparisons of viewing human and animal suffering also revealed differences such that human suffering yielded significantly greater medial prefrontal activation, consistent with high-level theory of mind, where...

Abstract: OBJECTIVES Borderline personality disorder (BPD) is frequently encountered in both adult and youth populations. There is a robust literature supporting psychotherapy for adults with BPD, but the literature supporting its use for BPD in youth is more limited. METHODS A literature review was conducted using the keywords "borderline personality disorders" and "adolescence." Relevant articles were reviewed for inclusion. RESULTS Several specialized treatments have been studied with mixed results. Dialectical behaviour therapy has no randomized controlled trials in adolescents, emotion regulation training has not demonstrated superiority of treatment as usual, and cognitive analytic therapy has demonstrated more rapid recovery but little difference at follow-up. Mentalization-based treatment has one study supporting its use in self-harming adolescents. Pharmacotherapy has no evidence supporting its use in this population. CONCLUSIONS Structured therapy may be the most important therapeutic component in this population.

Abstract: Decades of research have displayed a robust relationship between schizophrenia and aggression, with the majority of studies focusing on the role of comorbid Axis I disorders, including drug and alcohol abuse, psychosis, and other sociodemographic and clinical variables. However, only a few studies have examined the role of mentalizing abilities (i.e., the ability to understand mental states) and personality pathology severity, and none have examined the role of attachment representations believed to play a role in aggression. Furthermore, there is a paucity of research that differentiates between premeditated and impulsive aggression in schizophrenia. To this end, we conducted a cross-sectional study of 108 patients with schizophrenia to explore if a specific combination of mentalizing abilities, attachment representations and personality pathology severity pertain to premeditated aggression, while controlling for clinical and sociodemographic variables. Findings reveal that a constellation of diminished ...

Abstract: In recent years, the theory of mentalization has been applied to a number of clinically relevant areas including psychotherapy for patients with borderline personality disorder, therapy with adolescents and children, treatment of self-harm in young people, parent-infant early interventions, and even community outreach (see Midgley & Vrouvam, 2012. Minding the child: Mentalizing interventions with children, young people, and their families. London and New York: Routledge). Extending on this body of work, the present article applies the theory of mentalization to psychotherapies that aim to help first time expecting mothers psychologically adjust to and prepare for motherhood. Theory and research suggest that pregnancy represents an intermediate space in which, under ideal circumstances, the woman comes to represent herself as a mother, her unborn child as a separate and intentional being, and her emotional bond or attachment to the fetus. However, the expecting mother's own conflictual experiences being mothered are likely to influence her ability to mentalize her pregnancy, setting the stage for problems in the mother-infant dyad postpartum. This article explores how mentalizing techniques may be used in psychotherapy to help mothers-to-be to mentalize their emerging identity as a mother, their unborn child, and their developing relationship to the fetus.

Abstract: From a developmental and clinical point of view attachment theory and mentalization are closely connected and have become increasingly important to understand the origins of psychopathological development. However, very little is known about how exactly different inner working models of attachment are related to diverse mentalizing abilities and this is particularly true for adult populations - healthy as well as clinical populations. In the present study we investigated this relation with a sample of inpatients diagnosed with depression and a sample of healthy individuals. In an experimental setting the attachment system was activated using the Adult Attachment Projective Picture System (AAP). Mentalization was assessed during activation and in comparison to a control condition using a modified version of the Reading the Mind in the Eyes Test (RMET). We expected that an activation of the attachment system i) diminishes the capacity to take another’s perspective in individuals with unresolved state of mind, ii) has no impact in individuals with secure attachment representation and iii) is dependent of clinical status in individuals with insecure (but organized) working models of attachment. Overall, these hypotheses were confirmed. However, the impact of clinical status on mentalization in insecure attachment has to be further explored. We summarize that attachment state of mind has a mediating influence on mentalization basically in such situations where the attachment system is activated.

Abstract: Scherzer et al. (2012) offer an important step forward in the literature by exploring the relationship between a range of different measures of Theory of Mind (ToM) with a small sample of patients with schizophrenia experiencing significant symptomatology. Consistent with earlier work (Brune, 2005; Bell et al., 2010), they note that impairments in the ability to make sense of the mental states of others involves multiple components that cannot be reduced to one another. To study this they adopt a wide battery of five tasks ranging from identifying: emotions in photographs of eyes, characters intentions within stories, faux-pas, and intentions on the basis of simple hints. They also use what they define as a real-world task, which is attributing mental states to characters be seen in short movies who are undergoing complex interactions. All the tasks discriminated well between clinical and community participants and were relatively closely related to one another with the expectation of the eyes recognition test. The authors conclude that results support the possibility that ToM involves two dimensions: “first and second order inferences or beliefs, interpretation of intentions, interpretation of affect and on the basis of the social cognitive ToM content: faux pas, interpreting indirect messages, lies, irony etc., and contexts” (p. 9). They point to the importance of future research which considers the role of content and context of social cognition. When trying to make sense of these findings within emerging models of dysfunction, we were struck with five issues which remain to be addressed by future work. The first concerns the nature and onset the social cognitive deficits. Presumably these are deficits which could emerge in different ways and at different times in response to different causal factors. The loss of neurocognitive ability, stigma and the collapse of connections with others, preexisting trauma (Lysaker et al., 2011a) and poverty of early attachment have all been suggested separately to contribute to difficulties recognizing and reasoning about mental states but little work has considered whether social cognitive profiles in schizophrenia can be dissociated on the basis of the causes of and timing of when deficits emerged and not just the manifest nature of those deficits. A second issue concerns the possibility that social cognitive acts also differ from one another in terms of the degree to which they involve making a discrete judgment about phenomenon which are correctly or incorrectly identified (e.g., judging a facial expression) vs. synthesizing information into a larger representation where complexity and coherence are more important than just being right or wrong (e.g., constructing a personal narrative). As we have suggested elsewhere (Lysaker et al., 2013), correctly judging discrete phenomena such as one's performance on a task or the likely intention of someone in a story are certainly relevant, however these acts differ conceptually from metacognitive acts in which persons synthesize a range of information into a complex meta-representation which cannot be said to be right or wrong but which could be to varying degrees rich and flexible and person-specific (Ciaramelli et al., 2013). Discrete and synthetic acts should inform one another and both are necessary for responding effectively to evolving social exchanges. However, different problems would be expected to emerge if one but not the other were more impaired. For instance, to sustain a truly intimate relationship over time it is important to get a decent idea of the specific emotion another is feeling in the moment while also updating a large picture of that person's core identity. A third concern is that test batteries such as those adopted by Scherzer et al. neglect the reality that understanding mental states is of uttermost importance when thinking about personally relevant matters. If one has been abused for example, when encountering another person the main issue is not just identifying a hint about what to buy at a store but deciding whether the other person should be perceived as a potential perpetrator (Lysaker et al., 2011a) or a source of danger (Salvatore et al., 2012). In this example there may be specific mentalizing difficulties when intense affect has been reactivated by memories of abuse which then create a bias for the interpretation of evil intentions, again something that cannot be measured with the traditional ToM tasks. A fourth issue concerns the examination by Scherzer et al. of participants exclusively with moderately severe symptoms. Symptom remission appears to be more the rule than the exception (Silverstein and Bellack, 2008) and hence it is unclear whether the participants here were more treatment resistant, not offered state of the art psychosocial treatment or just in a particularly distressed period of their lives. Symptom remission represents only one domain of recovery and has been suggested by multiple studies to be relatively uncorrelated with more subjective domains of recovery including quality of life. Thus to truly understand the extent to which different social cognitive processes can be dissociated persons in a non-acute phases of illness should be considered. A final issue we would raise concerns the need to study social cognition within treatment. In psychotherapy persons naturally discuss their goals and challenges and are in a position to examine the attributions they make about the mental processes of others (Lysaker et al., 2011b, 2013; Lysaker, in press). We contend that discourse analysis of such interactions will offer unique opportunities to see how persons not only perceive others but then also how they reason about those perceptions. These studies could well assist in the development of such interventions while also deepening our awareness of how mentalistic deficits challenge recovery in real time. In summary we have suggested that for the literature to move forward and better understand deficits in social cognition in schizophrenia, work is needed which consider: the causal factors and emergence of social cognitive deficits, the extent to which discrete vs. synthetic ideas about oneself and others are at issue, the impact of affective states, the phase of illness in which these deficits occur and how these deficits are manifest during and respond to treatment.

Abstract: Background: Theory of mind (ToM) is the natural ability to attribute/infer mental states about ourselves and others. The study of the limits of this capacity in autism-spectrum disorders has been projected more recently to the case of schizophrenia. Method: We review the studies on ToM deficiency in schizophrenia, based on the link observed by Chris Frith between psychotic symptoms and mentalizing anomalies, with particular attention to the implications of ToM in linguistic communication in the field of figurative language comprehension. Results: The data support a connection between ToM deficits and psychotic symptoms. In schizophrenia, the deficit in ToM appears to be specific and not dependent on more general cognitive abilities, and according to the evidence examined, it resembles a trait more than a state condition. The analysis of results shows that anomalies in ToM have projections on pragmatic aspects of language comprehension. Conclusions: ToM deficits showed by schizophrenic patients are especially linked to difficulties in understanding figurative language, beyond the influence of intelligence and executive functions.

Abstract: The International Centre for Arts Psychotherapies Training (ICAPT) was established by CNWL NHS Foundation Trust in London in November 2011. The centre was set up to further research and advance clinical practice within NHS mental health settings. At the la unch of the research arm of ICAPT in July 2012, Professor Peter Fonagy spoke on the subject of the future of research in arts psychotherapies. This paper is a response to Professor Peter Fonagy’s presentation (The ICAPT 2012) on the potential arts psychoth erapies have to enhance the development of the therapeutic relationship. During the presentation Fonagy suggested to a group of arts psychotherapists that: ”˜the future of research is trying to understand what you guys do that actually helps re - establish in our patient a sense of epistemic trust, a sense that human knowledge and human communication, as communicated by fellow human beings can be trusted, can be relied on ... ’ A recording of this presentation is followed by a discussion section in which two art p sychotherapists explore and expand upon the ideas presented by Fonagy. They explore his question about what the processes of making and reflecting on images in a therapeutic context can add to the development of ”˜epistemic trust’ within the therapeutic rel ationship. It is suggested that creative arts have the potential to enhance the development of epistemic trust within the therapeutic relationship by offering opportunities for contingency and joint engagement. Individual, group and dyadic art psychotherap y allow for the creation of an external object which is congruent with the maker's internal world. The art making process and the art object itself can create an additional channel of communication which helps the art psychotherapist to understand the client’s inner world. This greater understanding can support the psychotherapist’s capacity to respond in an attuned way to the client. The authors explore the idea that joint engagement in art making can lead to opportunities for enhanced mentalizing and that with sufficient research and theoretical underpinning, this type of model could help to define clinical practice for arts psychotherapies in mental health. Key Words: Fonagy; mentalization; contingent communication; mechanisms of change; joint engagement.

Abstract: “Mentalizing” is the ability to attribute mental states to other agents. Thelack of online mentalizing, which is required in actual social contexts, may causeserious social disorders such as autism. However, the mechanism of online mental-izing is still unclear. In this study, we found that behavioral entropy (which indicatesthe randomness of decision making) was an efficient behavioral index for onlinementalizing in a human-human competitive game. Further participants played thegame with a humanoid robot; the results indicated that the entropy was significantlyhigher in participants whose gaze followed the robot’s head turn than in those who didnot, although the explicit human-likeness of the robot did not correlate with behavioralentropy. These results implied that mentalizing could be divided into two separateprocesses: an explicit, logical reasoning process and an implicit, intuitive processdriven by perception of the other agent’s gaze. We hypothesize that the latter is a coreprocess for online mentalizing, and we argue that the social problems of autisticpeople are caused by dysfunction of this process.Key words: online mentalizing, matching pennies game, human-robot competitivegame, gaze following behavior.The ability to attribute a mental state toanother agent is called “mentalizing” (Frith F Van Overwalle & Baetens, 2009).Mentalizing is essential for interpersonal inter-action, and many researchers are greatly con-cerned with the process of mentalizing. Thistopic has been investigated in various researchfields,such as comparative psychology,develop-mental psychology, and neuroscience. In par-ticular, clinical disorders (e.g., autism spectrumdisorder) have provided great insight into men-talizing (Castelli, Frith, Happe, & Frith, 2002;White, Hill, Happe, & Frith, 2009). Many previ-ous findings have suggested that dysfunctionassociated with mentalizing causes inappropri-ate social behaviors. However, the concretemechanism behind mentalizing is still unclear.Specifically, there is a paucity of knowledge onhow mentalizing works in actual social situa-tions, for example, interpersonal interaction.Mentalizing has been explained in terms ofdifferent processes, which are called “offline”and “online”; the latter rather than the formerprocess is thought to have a critical role inactual social situations (Frith & Frith, 2010).Offline mentalizing is mental inference made

Abstract: Children and elephants: A study of mentalization, empathy, and attitudes towards conservation in participants of an elephant-based environmental intervention in West Africa.