Mind to Mind; Infant Research, Neuroscience, and Psychoanalysis

Excerpted from
Mind to Mind; Infant Research, Neuroscience, and Psychoanalysis
By Sharone Berger, PH.D.

Early in 2004, we began to plan a conference aimed at examining the impact of Peter Fonagy and Mary Target's notions of mentalization and reflective functioning upon current and future psychoanalytic theory and practice. The main purpose or the conference was to consider how (and whether) these constructs inform or have changed the ways psychoanalysts think about internalization, representation, and other central contemporary psychoanalytic ideas. We asked: How are the concepts of mentalization and reflective functioning related to psychoanalytic constructs? How are they distinct? What do these constructs add to questions of theory and technique? How do they change the ways we work with patients? Have these constructs changed the landscape of psychoanalysis in meaningful ways?

The conference opened lively discussion and even debate about the meaning, utility, and limits of the concepts of mentalization and reflective functioning, issues that are both far from settled and full of promise.

Although this volume is based on the papers presented at that conference, it is not simply a volume of conference proceedings, because we invited the contributors to expand upon and elaborate their presentations. In addition, new papers were added to those in the original conference by two of the editors, Arietta Slade and Elliot Jurist, rounding out the volume. The result is a broad and diverse array of reflections on the constructs of mentalization and reflective functioning as these relate to the current status of key psychoanalytic ideas and to the future of psychoanalysis.

The concept of mentalization has its roots in a range of disciplines. It was originally introduced to psychoanalysis by French psychoanalysts writing about so-called psychosomatic patients, who displayed a lack of symbolization of mental states. It is also derived from the theory of mind literature, which itself spans philosophy, cognitive psychology, and developmental psychology. Over the past twenty years, Peter Fonagy and his colleagues (notably Mary Target) have expanded upon these ideas in ways that have brought the construct of mentalization to the forefront of psychoanalytic theory and practice. They have defined mentalization as the process of interpreting (the behavior of) oneself and others in terms of mental states. In their view, to adopt a mentalizing stance is to conceive of one's self and of others as having a mind and acting in relation to feelings, beliefs, desires, and intentions. Thus, mentalization is a skill, capacity, or process that requires cognition; however, as several chapters in this volume emphasize, it is deeply shaped by the affective dimensions of experience, specifically the earliest affective and affect regulating attachment relationship between infant and caregiver. The construct of reflective functioning - which is essentially an operationalization of mentalization - was introduced by Fonagy, Target, and attachment researchers Miriam and Howard Steele.

The terms mentalization and reflective functioning refer to a crucial human capacity that develops out of the child's earliest attachment relationships, specifically the mother's capacity to represent the child's mind, and the child's internalization of this representation of himself as a mentalizing being. The mother's willingness and readiness to understand people (and specifically her baby) in terms of mental states (i.e. her own capacities for reflectiveness) set the stage for the development of reflective functioning in her baby.

Tracing the development and current status of the concept of mentalization is an exercise in interdisciplinary thinking and cross-methodological dialogue. Fonagy and his colleagues' current conceptualizations of mentalization combine insights and ideas derived from (a) neuroscientific research about the brain and the link between brain and mind, as well as about the way early relationships affect development, (b) attachment theory and research about the properties of early (and potentially also later therapeutic) relationships that promote, or hinder, the capacity for mentalization, and (c) theory of mind studies in developmental psychology and in philosophy. It thus provides a unique arena for fertile, mutually enriching collaboration between psychoanalysis and its neighboring disciplines.

The constructs of mentalization and reflective functioning promote a focus on the mind. In reflecting on the future direction of psychoanalysis, it is interesting to consider whether such a focus on the mind augurs a paradigm shift within psychoanalysis, echoing prior conceptual shifts in the field. Ego psychology's focus on the ego and superego, for instance, deepened our understanding of character and of the importance of defenses. At the same time, however, it produced a more normalizing version of psychoanalysis that threatened to soft-pedal the power of the unconscious. Likewise, the turn to a focus to the self, brought by object relations theory and sell psychology, provided a richer account of subjective experience and directed attention to the affective bond between the self and both its internal and external objects; at the same time, it ushered in less specificity about defenses and a downgrading of the role of the superego. The current turn to the mind directs psychoanalysis to find a common language with other disciplines and to seek a comprehensive approach to mental functioning that does not minimize cognition or the interaction between cognition and affect.

Of course, the mind is not a new concept in psychoanalysis; terms like "mind" and "mental" have always been around. It is no betrayal of any psychoanalytic orientation to seek to understand the mind as a whole, without dwelling exclusively on various elemental features at the expense of others. Still, there remains something problematic and unresolved about the psychoanalytic conception of the mind. The classical view of the structural model of id, ego, and superego no longer guides even Freudians in the way it once did. The relational movement, despite its contributions to technique, has conspicuously lacked a model of the mind. The growing interest in the mind within psychoanalytic circles augurs, in our view, the possibility of a fruitful engagement with the world beyond psychoanalysis, paving the way toward a lively and less isolated future.

The chapters in this volume attest to the value of dialogue and collaboration between psychoanalysis and related fields. Although we have divided the book into parts, many of these contributions synthesize ideas and findings from overlapping domains in describing the development, psycho-pathology, and treatment of the mentalizing self. Considerations of the limits of mentalization theory for psychoanalytic thinking as well as variations of its clinical applications are also here, reflecting a collective effort to push and prod ideas and collaboration along. We think this is most fitting for a volume on mentalization and psychoanalysis, as it captures the spirit of the work of fathoming the minds of others and embracing the process of reflection in the context of otherness.

The chapters in Part I of the book, Mentalization and Attachment, address the concept of mentalization in relation to attachment in two ways. First, these chapters consider the construct of mentalization itself, placing it in the context of attachment theory and research and articulating ways in which it links psychoanalysis, as well as other domains, with attachment theory. In this sense, these chapters help us to map the construct of mentalization against the backdrop of a number of fields - primarily, though not only attachment theory - and to understand how it contributes to the evolution of ideas germane to psychoanalysis. Second, these chapters address the development and vicissitudes of the skill or function of mentalization within a relational, or attachment-based context. In this sense, they help us understand how and why the development of the mentalizing self is facilitated, as well as how the mentalizing function and the object relational world interrelate.

Peter Fonagy and Mary Target's opening chapter sets the stage by deftly weaving together psychoanalytic theory, attachment theory, and neuro-science research. These multiple perspectives provide a backdrop for discussing the concept of mentalization and its relation to the pathologies of trauma. The authors begin and end with clinical material, opening with two disturbing examples of the devastation caused by trauma, and culminating with a touching illustration of how to work productively and successfully with a traumatized patient. Their main claim is that trauma impairs mentalization: victims have difficulty in understanding others and themselves, and especially have difficulty in discerning the boundary between external and internal reality (the psychic equivalence mode) and in making sense of others beyond motivation that has to do with physical constraints and observable goals (the ideological mode). The authors underscore the enormous psychic cost of trauma to the normal functioning of the mind and self. They pay special attention to the relation between attachment and mentalization: on the one hand, mentalization is seen as growing out of secure attachment; on the other, the systems are recognized as distinct. Attachment is about security and relies on trust, whereas mentalization has its evolutionary source in competition and social survival. Trauma patients lack both the benefit of being able to rely on attachment (thereby allowing mentalization to be off-line) and to access mentalization when it is needed.

Gergely and Unoka's chapter opens up crucial questions about mentalization. The main focus is a discussion of the relation between attachment and mentalization in humans. On the basis of recent research suggesting that mentalization begins as early as 1 year of age (rather than 4 or 5, as had previously been outlined in the developmental literature), Gergely and Unoka argue that the notion that mentalization flourishes as a result of secure attachment must be revised. Along these lines, they urge us to be cautious and indeed skeptical in our interpretations of studies that link attachment and mentalization. Their perspective suggests that mentalization contributes to affective development by facilitating secondary (cognitive) appraisals that in turn foster affect regulation. Along the way, Gergely and Unoka review their previous work on affect mirroring, contingency detection, and affect regulation, and introduce a fascinating new idea: natural pedagogy, the parental stance that initiates infants into the realm of culture.

Jurist's chapter explores the concept of mentalization in terms of its various meanings, seeking to clarify but also address problematic areas and thus to push the concept along toward greater articulation and specificity. He focuses on the complex relation between attachment and mentalization, and turns to the theory of mind literature in philosophy to introduce a key distinction between low and high levels of mentalization. Jurist suggests that the psychoanalytic concept of mentalization is unique in its particular emphasis on development. Mentalization is about self-understanding as well as the understanding of others; it involves emotions and emotional styles in a fundamental way; and it is not, by definition, accurate. Jurist's chapter culminates with a discussion of his concept of "mentalized affectivity," the process of reevaluating the meaning of emotions that occurs in psychoanalytic psychotherapy. This chapter directly addresses and seeks to begin to resolve an issue raised by a number of our contributors, namely, the place of affect in mentalization theory.

Steele, Kaniuk, Hodges, Henderson, Hillman, and Steele's chapter addresses mentalization across a variety of contexts - childhood and parenting, attachment research and clinical insights, narrative, and observation. The authors describe their longitudinal study of intergenerational patterns of attachment in adoptive parents and their late-placed, previously maltreated adopted children. They explore the links between the adoptive mothers' reflective functioning in the pre-adoption Adult Attachment Interview, which taps representations of childhood, and these mothers' representations of the evolving relationship with the child, as assessed by the Parent Development Interview administered after the adoption. The authors identity Specific dimensions of the mothers' representations of the adopted child and the experience of parenting - including the capacity for acknowledging difficulty - that correlate most strongly with mothers' capacity to reflect on their own childhoods. Their findings shed light on the aspects of parental reflective functioning that allow for robust adaptation even in the exceedingly challenging context of late adoption of a maltreated child, and offer insights that are useful for identifying appropriate adoptive parents and developing supports for such parents and the children they adopt.

Part II of this book, Mentalization in Clinical and Neuroscience Research, brings together a variety of research methodologies and domains in order to consider the development of mentalization, the processes and factors that hinder such development, and the pathology that results and is entrenched by defects in mentalization, as well as treatment approaches that aim to target such deficits.

In the chapter that opens this part, Fonagy and Bateman discuss their treatment program for borderline personality disorder, Mentalization-Based Treatment (MBT). In their view, deficits in mentalization are at the heart of the affective, interpersonal, and regulatory disturbances that characterize borderline personality disorder. In line with this thinking, Fonagy and Bateman have developed an approach to working with borderline patients that is aimed specifically at developing or enhancing disrupted and disabled mentalizing capacities. Many of the accepted psychodynamically oriented approaches to working with borderline patients may actually induce instability and severe regression, they argue, as these require patients to think about mental states and about the mental states of the therapist in ways that they are not able to do.

Such approaches also activate the attachment system without providing the patient with the requisite mentalizing skills to make use of and internalize that attachment. Only the development of mentalizing capacities within the framework of the treatment itself, and within the framework of the transference, will allow the patient to be able ultimately to tolerate and make sense of his mental experience, and decrease his reliance on pathological modes or relatedness and defense. Fonagy and Bateman describe the findings of a randomized clinical trial that compared MBT with Dialectical Behavior Therapy (DBT) and treatment as usual; it showed significant and enduring changes in mood states and interpersonal functioning after an 18-month treatment.

Kemberg, Diamond, Yeomans, Clarkin, and Levy examine Transference Focused Psychotherapy (TFP), their own manualized psychodynamic treatment for borderline personality disorder, and compare it to the other central psychodynamic manualized approach for such patients, Fonagy and Bateman's Mentalization-Based Treatment (MBT). The authors discuss TFP's interpretive approach in detail, and use research data on the efficacy of their treatment model along with detailed case material from one of their studies to explain their finding that TFP is associated with improvements in the capacity for mentalization in borderline patients, as well as with attachment status and symptomatology changes, including a reduction in aggression.

The interpretive process that is unique to TFP is based upon Keniberg's object relations model, and the particular theoretical formulations regarding the etiology and structure of borderline pathology that are derived from it. Through their explication of features that are central to their understanding of such pathology, as well as of those features of their treatment approach that are unique and mutative, the authors highlight both their common ground and disagreement with Fonagy s approach, including points related to the centrality of affect and to the structure of the borderline patient's object-relational world. The chapter also offers a critique of the concept of mentalization as it is used in MBT, and puts forth a view of the process of mentalization as a multistaged one involving transformations in both cognitive and affective ego and superego structures.

Gabbard, Miller, and Martinez identify various neurobiological correlates of borderline object relations and internalized object representations. In particular, they suggest that the relationship between amygdalar abnormalities on the one hand, and decreased activity in the prefrontal cortex on the other, create a challenge to mentalization as well as to the articulation of coherent and integrated self-states. Also implicated in the phenomenology of borderline syndromes, particularly in patients who have suffered early abuse and neglect, are hippocampal abnormalities that have an impact on working and other crucial forms of memory that are involved in forming new relationships. The authors use such neurobiological underpinnings to explain the tenacity with which borderline individuals cling to destructive patterns of relatedness, and suggest that it is only through sustained effort in long-term psychotherapy that problematic links in activated networks can be deactivated, and newer circuits be created to override old ones. They emphasize the complex point that while brain dysfunction from neglect and abuse should not be underestimated, internalized object relations continue to influence brain function; thus, altering internalized object relations within the context of treatment is the central challenge in treating borderline patients.

In their chapter, Blatt, Auerbach, and Behrends address the relationship between representation, internalization, and mentalization. For the past 30 years, representation and internalization have been viewed by psychoanalysts as key to crucial developments in the self, in relationships, and in affect regulation, and have been at the heart of much of contemporary developmental psychoanalysis. Blatt and his colleagues, who have long been at the forefront of study in this area, consider the relationship of mentalization to these key processes. They suggest that mentalization is intrinsically linked to representation and internalization, and depends - as those functions do - upon crucial relationship experiences for its development.

They suggest that two core aspects of a mutative relationship are gratifying involvement, which promotes intimacy, and experienced incompatibility, which promotes separation and autonomy. Both are crucial to the development of these three processes, and occur within the context of early development as well as the psychotherapeutic relationship. Using narrative data from the longitudinal study of patients in long-term, psychoanalytically oriented inpatient treatment, the authors examine the development of mentalization, representation, and internalization over the course of a lengthy hospitalization. Shifts in these processes, which are presumed to result from the gratifying involvement and experienced incompatibility with the therapist, are reflected across descriptions of a number of key relationships.

In their chapter, Swain, Thomas, Leckman, and Mayes consider a number of the complex psychological, neurological, and biological aspects of parenting. The importance of adequate parenting is obviously implicated in the development of mentalization, and thus seems a particularly crucial area of investigation. Swain and his colleagues discuss recent advances in understanding the genetic, epigenetic, and neurobiological substrates of maternal behavioral in model mammalian species, and explore the relevance of these findings for understanding risk and resiliency. They suggest, for instance, that maternal preoccupation may be correlated with the release of the hormone oxytocin, itself linked to parturition and nurture, and which triggers a range of care giving behaviors. Other studies reviewed suggest that aspects of maternal behavior are nongenomically transmitted from one generation to the next and that the nature of the maternal care received in infancy may "program" aspects of infants' responses to stress later in life and have enduring consequences affecting their approach to the world. They argue that the increasing evidence for the intergenerational transmission of parenting, both at the behavioral and the neural level, underscores the importance of early intervention programs, and provides a model for understanding vulnerability and resilience.

In the third and final part of this volume, Mentalization in Practice, we consider the applicability of mentalization theory to work in the consulting room and the world at large. While many of the chapters in the other parts synthesize findings from clinical work with research-based insights, the chapters in this last part focus in greater detail on some of the ways mentalization theory enriches applied psychoanalysis as well as individual clinical work.

In her chapter, Slade considers the development of a mentalizing stance in work with parents. She describes the parent work that is central to many child therapies in light of mentalization theory, and suggests that often parents whose children come for psychotherapy are themselves struggling to make sense of and reflect upon their children's emotional lives. The therapist's work with a child's parents invariably involves helping them to mentalize aspects of their child's experience that they have been unable to recognize or regulate. She emphasizes the notion that the capacity to imagine another - in this case the child - from a different point of view is essential to resolving conflict and promoting development.