Monitoring our own mentalising capacities as therapists
It takes two people to mentalise well and the therapeutic couple is no exception to this. Part of our meta-awareness includes monitoring our own countertransference and this refers to our capacity to mentalise ourselves as therapists. We have described how easy it is for our patients’ mentalising to be affected by their attachment history and emotionally distressing and arousing events. The same holds for therapists. This is partly why it is an essential part of most psychotherapy trainings that prospective therapists undergo their own psychotherapy, with the general rule holding that you would see patients for the same intensity as you have personally experienced in psychotherapy. Thus, someone who has had one or twice weekly psychotherapy would not be equipped to see patients for deeper, more frequent work. If you have had your own difficult attachment history - and many therapists are drawn to this work for this very reason - then it is even more reason to have your own psychotherapy, where you have a chance to form a trusting attachment and make sense of your own difficulties and have ways of taking care of those areas of vulnerability in your own life.
We also are vulnerable to having our mentalising go ‘off-line’ when we are with patients who are not mentalising easily or well. We will elaborate on these ideas further in Chapter 9 when discussing the countertransference, and although these concepts are not routinely or explicitly linked to notions of mentalising, we feel it is helpful to draw out these comparisons here. What are the signs that you as a therapist have stopped mentalising? When you start to feel great certainty that you know exactly what is going on for your patient, or when you feel completely lost and unable to think clearly, you have probably stopped mentalising. Mentalising well often involves grappling with confusion and not-knowing. We need to monitor our own reactions to our patients so that we are always stepping back and observing our own experience in the room and reflecting on it. There are limes when this is more likely to be challenging. You may feel highly identified with what a patient is bringing. Perhaps it has resonance with your own life or someone close to you. You may be subject to attack and criticism by a suspicious, traumatised or angry patient or your patient may make you uncomfortable in other ways by talking about subjects that unsettle you, for example, or when your patient responds to you in a sexualised way. Sometimes we react to these points of discomfort by distancing ourselves from our emotions and becoming experts and scientists.
We run the risk in those moments of no longer relating to our patients as emotional beings but rather objectifying them. We should not be using our patients to fulfil our own needs for reassurance, closeness, admiration and so on. Earlier in this chapter, we described the risks that patients run when they objectify their relationships and as therapists, we are not immune to the same risks. Being an effective therapist involves the capacity to be subjectively affected by your patient while still being able to step back and have an objective perspective. Supervision is a helpful insurance policy against these risks although this requires honesty at sharing your difficulties openly, something that can feel difficult to do when you are also being evaluated by your supervisor. Your personal therapy is another helpful place in which to bring personal difficulties stirred up by your experiences as a therapist.
We hope that this chapter has shown that mentalising is the foundation of psychotherapeutic treatment where we are trying “to apprehend our own and others’ minds as minds” (Fonagy et al., 2011, p. 102). Mentalising bridges different therapist orientations and treatment approaches: “Psychotherapists across modalities necessarily use this capacity, whether or not they conceptualize this explicitly in their theories, and good outcomes may be conceptualized in terms of improvements in mentalizing ability.” (Fonagy et al., 2011, p. 102). There isn’t just one way to improve mentalising capacities and the methods suggested in this chapter are not exhaustive by any means. Indeed, psychodynamic psychotherapy can be seen to facilitate better menta- lising by focusing on the patient’s subjective affective experiences, creating alternate perspectives by responding in flexible, marked and contingent ways to the patient, and attending to interpersonal relationships, including the therapist in the service of creating epistemic trust and safety. Mentalising techniques come into their own with severe mental disorders, such as Borderline Personality Disorder, Obsessive Compulsive Disorder, psychosomatic presentations and eating disorders. They also form part of the therapeutic repertoire employed in brief, Dynamic Interpersonal Therapy when patients are mentalising rigidly in heightened states of depression and anxiety. We hope that this chapter allows you to recognise when to employ these mentalising techniques so as to return to the typical psychodynamic interventions described in this book in order to maximise the value and effectiveness of those interventions.
Box 7.3 Useful resources
There is a very helpful chapter on Mentalising Techniques in Allen, Fonagy and Bateman’s (2008) book, Mentalising in Clinical Practice. This book, together with Bateman and Fonagy’s (2006) Mentalisation-Based Treatment for Borderline Personality Disorder: A Practical Guide contain practical ways of applying mentalising to clinical practice.
There are two important early papers written in 1996 by Peter Fonagy and Mary Target that detail the way mentalising develops in children:
Fonagy, P. and Target, M. (1996). Playing with reality: I. Theory of mind and the normal development of psychic reality. International Journal of Psychoanalysis, 77, 217-233.
Target, M. and Fonagy, P. (1996). Playing with reality: II. The development of psychic reality from a theoretical perspective. International Journal of Psycho-Analysis, 17, 459-479.
The following YouTube clip (https://youtu.be/apzXGEbZhtO) of the Still Face experiment, illustrates the impact of a mother denying her baby attention for a short period of time. Tronick narrates how prolonged lack of attention can move an infant from good socialisation to periods of bad but repairable socialisation, or at their worst, to ‘ugly’ situations, in which the child has no opportunity to return to an experience of the good object, and becomes stuck or damaged irreparably.
The Pixar Movie, Inside Out, offers a Disney explanation of mentalising. The trailer to the movie can be found on YouTube and is worth watching: https:// youtu.be/yRUAzGQ3nSY.
There are some excellent talks and demonstrations of mentalising on YouTube by Anthony Bateman, Peter Fonagy and Jon Allen that are worth watching. We recommend the following:
• https://youtu.be/lzBFIDSnR2jk (Anthony Bateman demonstrating the
stance of empathic validation);
• https://youtu.be/BZI40tQvDDg Anthony Bateman demonstrating the
“not knowing" mentalising stance;
- • https://youtu.be/oeboLKNV3PQ (clip of Anthony Bateman demonstrating how to work with an emotionally aroused patient, particularly using the stop and rewind technique),
- • https://youtu.be/OFIw2QumRPrQ and https://youtu.be/ugyScp3lxDI
- (Peter Fonagy introducing mentalising);
- • https://youtu.be/sSvaXw92W7U (Peter Fonagy talking about mentalis- ing, Borderline Personality Disorder and epistemic trust);
- • https://youtu.be/vYg92Zps1 Dw (a longer clip with Peter Fonagy talking about the links between psychoanalysis and attachment theory);
- • https://youtu.be/KcCYLUn_uG8 and https://youtu.be/NLT7ie03hTk (Jon Allen’s introduction to mentalising);
- • https://youtu.be/QB6oa4Mjplw (Mary Target describing the role for mentalising and attachment within clinical analysis);
- • https://youtu.be/TXjUE7CLs04 (Mary Target discussing affect regulation);
- • https://youtu.be/ZBeEOkwLToM and https://youtu.be/mCqrgQSe2MY (Dickon Bevington describing the importance of mentalising and epistemic trust).