1. health and fitness
2. disorders
3. mental disorder
4. panic and anxiety

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
Pseudo
Mentalisation
Psychic
Equivalence
Teleological
Mode
Concrete
Understanding
Misuse of
Mentalisation
Unstable Interpersonal Relationships
Affective Dysregulation
Impulsive Acts of Violence, Suicide, Self-Harm
Psychotic Symptoms
Overview
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
Team
Psychoanalysis Unit London (UK): Peter
Fonagy, Anthony Bateman, Mary Target
 UPC Kortenberg (België): 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.
Controlled
Automatic
Arousal
Dimensions of mentalization: implicit/automatic
vs explicit/controlled
Psychotherapist’s demand to explore issues
that trigger intense emotional reactions
involving conscious reflection and explicit
mentalization are inconsistent with the
patient’s ability to perform these tasks when
arousal is high
Arousal
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
PFCmy
Medial Ventromedial
PFCin's hand.
By heaven,
I saw
handkerchief
cortex
Controlled
Automatic
Arousal
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
You’re covering your eyes; you can hardly bear to look at me
Dimensions of mentalization: Cognitive vs
affective mentalization
Cognition

Agent attitude
propositions
“I thought that Rutten would
succeed in forming a
proper government”
Associated with several
areas of prefrontal cortex
Emotion
Self affect state
propositions

“I feel sad about it too”
Associated with inferior
prefrontal gyrus
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”
Oh nee, wat
zal mijn
moeder nu
zeggen
Mentalize This!
Ik voel me zo
rot
Mijn vader
heeft altijd
gezegd dat ik
niets kon
Wij voelen
ons allemaal
rot
Mentalizing Profile of Prototypical BPD patient
ImplicitAutomatic
BPD
Mental
interior
focused
Cognitive
agent:attitude
propositions
ExplicitControlled
BPD
Mental
exterior
focused
BPD
Affective
self:affect state
propositions
BPD
Imitative
frontoparietal
mirror neurone
system
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
Pseudo
Mentalisation
Psychic
Equivalence
Teleological
Mode
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 person’s 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 didn’t 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 people’s 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
 Pseudo-mentalising
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
“You’re trying to drive me crazy”
“You hate me”
‘I can’t 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 other’s feelings
Self-serving empathic understanding
A person’s feelings are exaggerated or distorted
in the service of someone else’s agenda
Misuse of Mentalizing(2)

Coercion against or induction of the thoughts
of others
Deliberate undermining of a person’s capacity
to think by humiliation
Extreme form is sadistic or psychopathic use of
knowledge of other’s 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
asascoherent
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]
▫ can’t 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
DISTRESS/FEAR
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
Recovery of controlled
mentalization
High
Moderate
Fast
Hyperactivating
Low: Hyperresponsivity
Strong
Slow
Deactivating
Relatively high:
Hyporesponsive, but
failure under increasing
stress
Weak, but moderate to
strong under increasing
stress
Relatively fast
Disorganized
Incoherent:
hyperresponsive, but
often frantic attempts to
downregulate
Strong
Slow
Secure
Mentalizing Profile of Prototypical BPD patient
ImplicitAutomatic
BPD
Mental
interior
focused
Cognitive
agent:attitude
propositions
ExplicitControlled
BPD
Mental
exterior
focused
BPD
Affective
self:affect state
propositions
BPD
Imitative
frontoparietal
mirror neurone
system
Belief-desire
MPFC/ACC
inhibitory
system
Very High
●
●
High
●
●
●
Ordinary/Aver
age
Low
●
●
●
●
Internal
●
Self
External
Very Low
●
Cognitive
Other
Legend:
= Typical mentalizing profile for Borderline Personality Disorder
= Typical mentalizing profile for Narcissistic Personality Disorder
●
Affective
Treatment vectors in re-establishing mentalizing
ImplicitAutomatic
Impression
Controlled
driven
Appearance
Inference
Mental
interior
focused
Certainty
emotion
Doubt of of
cognition
Cognitive
agent:attitude
propositions
Imitative
frontoparietal
mirror neurone
system
ExplicitControlled
Emotional
contagion
Autonomy
Mental
exterior
focused
Affective
self:affect state
propositions
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)

Limitations:
Time and cost-intensive
Mostly uni-dimensional
Score
on RF
Scale
9
7
5
3
Description
Full or Exceptional
Interviewee’s answers show exceptional
sophistication, are surprising, quite
complex or elaborate and consistently
manifest reasoning in a causal way using
mental states
Moderate to high RF
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
1
Absent but not Repudiated
Reflective functioning is totally or almost
totally absent
-1
Negative
Interviewee systematically resists taking a
reflective stance throughout the interview
Negative to limited RF

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)

Yet:
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.