Allen

Mentalizing

Mentalizing
Jon G. Allen, PhD

Mentalizing, the process of making sense of mental states in oneself

and other persons, plays a central role in psychopathology and
psychotherapy. The author explicates the concept of mentalizing,
highlights some factors critical to its development, and illustrates its
clinical applications in the domains of trauma and depression.
(Bulletin of the Menninger Clinic, 67 [2], 91-112)

I hope to persuade you that understanding “mentalizing” will sharpen

your clinical thinking and practice. This will be a hard sell because the
general idea is not new. In some terms or other, you have been using the
concept of mentalizing to think about your clinical work all along, not to
mention the fact that you have been a full-fledged mentalizer since your
early childhood. You are mentalizing whenever you are making sense of
what goes on in the mind—your own mind and the mind of another per-
son. Thus you mentalize continually when you conduct psychotherapy.
We mentalize so naturally that we usually take our mentalizing abil-
ity for granted. But our clinical practice sometimes reveals conspicuous
failures in mentalizing. I worked with a young woman who had been
sexually abused in childhood in the most degrading manner—merely
used for gratification. This abuse was worse than humiliating, although
it was certainly that; it was dehumanizing. In her young adulthood,
stressful interactions often rekindled feelings associated with her earlier
trauma. When she felt overwhelmed, she punched the wall, sometimes
so violently she fractured her knuckles. In an early psychotherapy ses-
sion, she told me that she had a powerful sensation in her chest and fore-
arms and, along with the sensation, she had a strong urge to pound her
fist into the wall. She had no idea what she felt emotionally, much less
what had triggered the feelings, and even less what their origin was. Her
experience was raw physical sensation coupled with an impulse to ac-
tion. It made no sense.

Presented at the conference, “Mentalization and Treatment Resistant

Psychopathology: Implications for Clinical Services,” held at The Menninger Clinic,
Topeka, Kansas, January 2003.
Dr. Allen is a senior staff psychologist and Hirschberg Professor in the Child and
Family Center at the Menninger Clinic. Correspondence may be sent to Dr. Allen at
The Menninger Clinic, 2801 Gessner Drive, Houston, TX 77080; e-mail:
jallen@menninger.edu. (Copyright © 2003 The Menninger Foundation)

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Allen

Gradually, we were able to begin labeling some of the emotions the

patient felt in conjunction with her physical sensations and im-
pulses—agitation, fear, and anger. In one session when we were begin-
ning to discuss the origins of these feelings, she casually and
unconsciously put her hands around her throat as if she were going to
strangle herself. This gesture was an unmentalized action, and I drew
her attention to it. Plainly, the gesture could be interpreted as
self-destructive. As we talked about its meaning, however, we associ-
ated the gesture with her inability to allow herself to have a voice. She
could not speak out about the abuse; she had felt unheard persistently
since then; and a recent episode of self-injurious behavior was precipi-
tated by a sense of having no voice in a significant decision in the family
business. More metaphorically, her gesture of strangling herself sug-
gested to me that she could not allow the feelings in her body to go up
into her head, into her mind, to be mentalized. Gradually, we were able
to bring some mental coherence to all this. She was able to identify the
emotional feelings that triggered the impulse to punch the wall, and
then she was able to relate the feelings to the meaning of some episodes
of early abuse. In addition, she was able to understand the contempo-
rary triggers of these feelings. When her feelings became meaningful,
she was able to manage them more effectively, and her urge to injure
herself began to subside.
As just introduced, mentalizing seems simple and commonplace.
Commonplace it is, but simple it is not. This article proceeds in three
stages by (1) explicating the concept of mentalizing, (2) spelling out
some of the conditions that foster or impede its development, and (3) il-
lustrating its clinical applications to the domains of trauma and depres-
sion. This will be a thumbnail sketch; the ideas are elaborated elsewhere
(Allen & Fonagy, 2002; Fonagy, Gergely, Jurist, & Target, 2002).
A word of warning: To get the concept of mentalizing off the ground,
I will say a bit about the nature of mind, which plunges us into some
heady philosophical concepts. The fact that it tangles us up in philoso-
phy of mind makes mentalizing intriguing and vexing. For starters,
mentalizing rests on the distinction between “persons” and “objects,”
and I will begin there. Then I will note briefly how two related technical
concepts, intentionality and mental representation, are essential to un-
derstanding mentalizing. And we also have some technical ground to
cover in developmental psychology, touching upon the ambitious pro-
ject of fathoming how the mind—and mentalizing—comes into being in
infancy. But my ultimate aim remains pragmatic, to show how high-
lighting mentalizing makes a difference in clinical practice. All this will
become plain, I trust, in the section on clinical applications.

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 Mentalizing

Conceptual foundations

We mentalize when we treat others as persons rather than objects. Con-

temporary British philosopher Peter Strawson (1985) made this distinc-
tion with exceptional care and clarity, capturing the gist of mentalizing
in the process: “We simply react to others as to other people. They may
puzzle us at times; but that is part of so reacting” (p. 21). These natural
reactions, Strawson (1982, 1985) contended, are infused with moral at-
titudes and judgments; these reactive attitudes, in turn, are bound up
with our experience of others and ourselves as free agents. Mentalizing
in our inherently personal interactions with others, we are not usually
objective, detached, or indifferent. Our natural interactions have a
moral dimension to the degree that we approve or disapprove of others’
actions; we feel grateful or resentful. These reactions are intrinsic to
mentalizing interactively in all our relationships, those with our pa-
tients included.
Thus we mentalize, and we cannot help it:

Our general proneness to these attitudes and reactions is inextricably

bound up with that involvement in personal and social interrelation-
ships which begins with our lives, which develops and complicates it-
self in a great variety of ways throughout our lives and which is, one
might say, a condition of our humanity. What we have, in our ines-
capable commitment to these attitudes and feelings, is a natural fact,
something as deeply rooted in our natures as our existence as social
beings. (Strawson, 1985, p. 33, emphasis added)

Nonetheless, Strawson (1985) also argued that we can, temporarily and

to some degree, detach ourselves from the mentalizing stance and thus
from our natural reactive attitudes and judgments. We can view each
other as objects, “as natural creatures whose behavior, whose actions
and reactions, we may seek to understand, predict and perhaps control
in just such a sense as that in which we may seek to understand, predict,
and control the behavior of nonpersonal objects in nature” (p. 34). Al-
though Strawson contended that we do not naturally adopt this objec-
tive standpoint, he acknowledged that “perhaps we all edge a little way
toward it from time to time” (pp. 34-35).
Of course, in a nonmentalizing mode, we can treat others as objects
in the most blatant ways. We can be exploitative, merely using others
for our own ends. We can be callous and brutal in such exploitation, at
the extreme committing rape and murder. And although we are prone
to associating mentalizing with compassion, we must keep in mind that
our mentalizing is by no means always benevolent. Psychopaths use

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their mentalizing capacities in the service of manipulation. Sadists

mentalize most perniciously, with their keen awareness of inducing
feelings of humiliation and terror.

Intentionality and mental representations

A definition: Mentalizing entails interpreting the behavior of oneself
and others in terms of intentional mental states, such as desires, feel-
ings, beliefs, and the like. Searle (1998) explained the meaning of “in-
tentional” in this context:

The primary evolutionary role of the mind is to relate us in certain

ways to the environment, and especially to other people. My subjec-
tive states relate me to the rest of the world, and the general name of
that relationship is “intentionality” . . . the general term for all the
various forms by which the mind can be directed at, or be about, or
of, objects and states of affairs in the world. (p. 85)

In short, intentional mental states are about something. Intentionality

thus sharply divides mental beings from physical objects. A rock cannot
be “about” anything; it just is. A mind, on the other hand, actively re-
lates to something outside itself; a mind can think about a rock, another
mind, or even itself.
The intentionality of mind—its “about-ness”—is bound up with its
representational capacity. Mental representations, such as beliefs,
represent something as being a certain way (Perner, 1991): I see her fa-
cial expression as being gleeful. Through this representational capac-
ity, the mind assumes some autonomy in loosening its ties to reality.
For example, our capacity to play is a harbinger of mentalizing (Leslie,
1987). We play with objects, and we play with ideas. To the child, a
block of wood can be a truck. To the psychoanalyst, the whisky bottle
can be a breast. Especially crucial to mentalizing is this ability to repre-
sent the same situation in multiple ways, to think of alternatives, and
to adopt multiple perspectives. Mentalizing, we can imagine various
ways in which others may think and feel, wondering why they do what
they do, striving to make their actions intelligible. We also develop a
capacity for metarepresentation, being able to think about our own
thoughts and feelings. Much of psychotherapy exploits this capacity
for metarepresentation as we engage our patients in reflecting on their
actions and considering them from multiple perspectives.
Thus our mental flexibility is inherent in this representational ca-
pacity. We can be curious about possibilities, playing with reality,
and playing with mental realities. In our best clinical work, we help
our patients become curious about the workings of their mind and

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 Mentalizing

the minds of others. We engage them in the process of exploring vari-

ous possible meanings of their feelings, dreams, and actions. When
they lose this flexible curiosity, they are stuck, for example, in de-
pression: “I failed. I’m no good. That’s the reality, the absolute truth.
Period!”

Different aspects of mentalizing

These brief excursions into the nature of mind are essential to lay the
groundwork for understanding mentalizing, but we cannot equate
“mentalizing” with any and all mental activity. To reiterate, we
mentalize persons, not objects. In theorizing about the structure of ma-
terials, engineers are highly engaged in mental activity, but they are not
mentalizing. And when we treat persons as objects, we cease to
mentalize. Nonetheless, the territory of mentalizing remains vast, and it
is helpful to divide it up.
We will be hopelessly mired in ambiguity if we fail to keep in mind a
fundamental distinction between mentalizing implicitly and
mentalizing explicitly. Mentalizing explicitly, being explicit, is easiest
to grasp. Mentalizing explicitly is a relatively conscious, verbal, delib-
erate, and reflective process—off-line, as it were. We are mentalizing
explicitly when we think about what is going on in another person’s
mind, for example, when we formulate clinical clarifications and in-
terpretations. A simple example: “I wonder if you’re feeling put out
with me right now?” Mentalizing implicitly, which is far more perva-
sive in our interactions, is a relatively nonconscious, nonverbal, proce-
dural, and unreflective process, on-line as it were, akin to riding a
bicycle. We are mentalizing implicitly when we empathize intuitively
and nonverbally, “mirroring” others’ emotional states. We mentalize
implicitly when we respond with a look of interest to what our patient
just said, perhaps leaning forward a bit and raising our brow. We are
barely aware of our implicit mentalizing much of the time, although
we put a fair amount of effort into explicating the implicit, for exam-
ple, drawing our patient’s attention to the meaning of his clenched fist.
And we are mentalizing implicitly whenever we are emotionally en-
gaged in interactions, with all the moral reactive attitudes Strawson
emphasized.
Arguably, the distinction between implicit and explicit mentalizing is a
matter of degree (Karmiloff-Smith, 1992), but this broad distinction is a
place to start, and it is essential that we not equate mentalizing only with
our conscious and reflective thought processes. But two further distinc-
tions are in order. First, the object of our mentalizing varies: We mentalize
the activity of ourselves, other persons, our relationships with other per-
sons, and other persons’ relationships with each other. Second, we

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mentalize in relation to all manner of psychological processes: Desires,

feelings, beliefs, needs, motives, perceptions, attitudes, fantasies, dreams,
hallucinations, delusions—the list is not quite endless, but almost.

The word “mentalizing”

But why should we adopt the neologism “mentalizing”? We already
have in hand a slew of perfectly apt terms: empathy, insight, observing
ego, subjectivity, transitional space, potential space, reflectiveness,
mindfulness, and psychological mindedness. The term mentalizing
joined the fray a few decades ago, when it was introduced into the psy-
choanalytic literature (Brown, 1977; Compton, 1983; De M’Uzan,
1973; Lecours & Bouchard, 1997). Morton and colleagues (Frith,
Morton, & Leslie, 1991; Morton, 1989) then significantly extended its
application when they construed autism as a neurobiologically based
failure of mentalizing. At the same time, Fonagy and Target (Fonagy,
1991, 1995; Fonagy & Target, 1997; Target & Fonagy, 1996) further
expanded its application by articulating how functional deficits in
mentalizing, particularly those stemming from psychological trauma,
illuminated severe character disturbance.
To perseverate, why “mentalizing”? One good reason is grammatical:
We need a verb. We need a way to refer to a mental activity. Hence I pre-
fer “mentalize” and “mentalizing” to “mentalization.” Alternatives like
“psychological mindednessing,” “transitional spacing,” or “observing
egoing” simply will not do. “Empathizing,” although narrower in scope,
captures significant portions of the territory of mentalizing, and contem-
porary theory and research on empathizing has much to teach us about
mentalizing (Preston & de Waal, in press). From the grammatical per-
spective, a good alternative to mentalizing is Bogdan’s (1997, 2000) us-
age of “interpreting” in the context of evolutionary biology. He (1997)
defines the capacity for interpretation as “a competence that allows pri-
mates to make sense spontaneously and effectively of each other in terms
of behavioral dispositions and psychological attributes, such as character
traits, emotions, feelings, and attitudes” (p. 1). Hence interpreting refers
to the same domain as mentalizing. But interpreting has far broader con-
notations. Mentalizing, we interpret quirky actions, dreams, and Ror-
schach Inkblot Test responses. In addition to mentalizing, we interpret
clouds, ancient texts, and tea leaves. Mentalizing is a restricted domain of
interpreting: We just mentalize each other and ourselves (and perhaps
our mammalian pets). Baron-Cohen’s (1995) term, “mindreading,” pin-
points the domain of social deficits in autism and also captures the terri-
tory of mentalizing, but, absent the right context, mindreading falls prey
to parapsychological connotations.

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Developmental foundations

We psychologists want more than philosophical distinctions; we want

to know how mental capacities develop. The move from the “object” to
the “person” is acquired; it is not only a developmental achievement
but also an evolutionary achievement. I advocated adopting
“mentalizing” for a grammatical reason: we need a verb. This justifica-
tion alone is hardly compelling. More substantively, the territory
mentalizing carves out so neatly can be anchored in four domains of
contemporary theory and research: evolutionary biology,
neurobiology, theory of mind, and attachment. The concept of
mentalizing has just the right scope for these connections, and its poten-
tially strong ties to current research can put our venerable concepts of
empathy, insight, psychological mindedness, and the like on far more
solid ground.

Evolution and neurobiology

Phylogeny is the broadest developmental perspective, yet one that is rela-
tively peripheral to our clinical concerns. Nonetheless, the evolutionary
perspective may help us appreciate the sheer complexity of mentalizing.
Neither tool making nor foraging drove the evolution of our en-
ergy-consuming neocortex; rather, the evolutionary arms race was
fought on the battleground of the mind-boggling complexity of our social
reasoning (Bogdan, 1997; Byrne & Whiten, 1988; Humphrey, 1988;
Jolly, 1988). Keeping track of the relationships among 150 persons in the
typical human social network is no small feat (Dunbar, 1996). We need
allies to survive and flourish. We must learn and monitor a multitude of
relationships, all on shifting sands. Who is related to whom and how?
Who are our friends, and who are our enemies? Far more complex still:
Who are each other’s friends and enemies? Researchers are delineating
the “social brain” that evolved to cope with these challenges of daily so-
cial life (Brothers, 1997). This neurobiological endeavor has been bol-
stered by neuroimaging studies that are demonstrating specific patterns
of cortical activity associated with mentalizing (Fletcher et al., 1995;
Gallagher et al., 2000; Goel, Grafman, Sadato, & Hallett, 1995; Happe
et al., 1996; Klin, Schultz, & Cohen, 2000).

Developmental milestones
Given an intact social brain, how does mentalizing develop? Much of
the burgeoning developmental research in this area falls under the ru-
bric of “theory of mind” (Carruthers & Smith, 1996; Gopnik &
Meltzoff, 1997). Although the term theory seems a bit pretentious to
characterize ways we learn to think about ourselves and each other in

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childhood, Gopnick (1996) pointed out that “it is not so much that chil-
dren are little scientists as that scientists are big children” (p. 4). We are
not behaviorists; we learn intuitively to postulate hidden mental causes
to make sense of behavior, and behavior makes no sense otherwise. The
physicist fathoming subatomic particles started out as a psychologist
fathoming the interpersonal world. The developmental research on the-
ory of mind is vast, and I will merely highlight some key steps toward
becoming a full-fledged mentalizer.
Our colleagues George Gergely and his colleagues unearthed a piv-
otal developmental process that hooks infants’ attention into the social
world (Bahrick & Watson, 1985; Gergely & Watson, 1996, 1999;
Watson, 1994). Initially, infants’ attention is captured by perfect re-
sponse-stimulus contingencies, such as watching their limbs move. This
attentional preference enables the infant to differentiate the self from
the world, fostering a sense of bodily agency. In normal development, at
about 3 months of age, a switch occurs, such that infants become more
interested in high, but less than perfect, levels of response-stimulus con-
tingency. They do something, and something related happens just a bit
later. Gergely (2001) aptly dubbed this newfound interest as a prefer-
ence for stimuli that are “nearly, but clearly not, like me.” This clever
gimmick of nature that switches infants’ attentional preferences has a
profound consequence: Infants become attentive to others’ responses to
their actions, and they thereby become ensconced in the social world.
Autistic infants fail to make this switch, remaining fixated on perfect
control over stimulation, failing to get hooked on social responsiveness
(Gergely, 2001).
A perfect example of high but imperfect contingency is dear to the
clinician’s heart: emotional mirroring. Indeed, Gergely and colleagues
(Fonagy et al., 2002; Gergely & Watson, 1996) contend that the first
step toward mentalizing entails mentalizing emotions. Their focus on
emotion at the inception of mind is consistent with Damasio’s (2003)
view that “feelings of pain or pleasure or some quality in between are
the bedrock of our minds” (p. 3). Counterintuitively, taking the
Vygotskian perspective (Vygotsky, 1962; Wertsch, 1998), Gergely and
colleagues propose that infants learn about their emotional states from
the outside in. From our adult standpoint, it seems as if we know our
emotions from the inside through introspection. For us adults, this may
or may not be true—sometimes others may be more aware of our emo-
tions than we are. But infants do not come equipped to diagnose their
emotions on the basis of introspected feelings; they learn to make this
connection via the emotional responsiveness of others.
In fact, what we glibly call emotional “mirroring” is more aptly con-
strued as a process of social biofeedback (Gergely & Watson, 1996):

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 Mentalizing

The caregiver’s emotionally attuned responses to the infant’s states be-

come a source of information to the infant about his or her internal
states. This external feedback is, in effect, hooked up to the infant’s in-
ternal experience (e.g., perceptions of physiological arousal). Through
such social biofeedback, infants obtain their first glimpse of what they
feel. Thus begins a developmental process in which emotions become
meaningful and ultimately can be rerepresented in language.
Csibra, Gergely, and colleagues (Csibra & Gergely, 1998; Csibra,
Gergely, Biro, Koós, & Brockbank, 1999) also pinpointed another
milestone on the infant’s way to full immersion in the world of inten-
tional mental states, what Dennett (1987) famously characterized as the
“intentional stance,” and what we call mentalizing. The precursor to
the intentional stance is the teleological stance, which entails interpret-
ing actions as efficiently achieving goals within the constraints of physi-
cal reality. Gergely and colleagues demonstrated that, by 9 months of
age, infants interpret behavior as rationally directed toward goals, even
when the behaver is a computer-animated ball seen to be “jumping
over” a barrier to make contact with another ball. The infant makes a
quantum leap from the teleological to the intentional stance (Gergely,
2003). This leap entails mentalizing the teleological stance, namely, in-
terpreting rational, goal-directed behavior as guided by unobservable
mental states, such as desires and beliefs. This is the leap from being
able to predict behavior on the basis of observed regularities—as chim-
panzees do and as the behaviorists aspired to do—to being able to com-
prehend behavior in fully human terms.
Language acquisition is another arena that highlights the paramount
developmental significance of mentalizing. Tomasello (1999) also took
an interest in a 9-month turning point, the development of joint atten-
tion. He considered developing the capacity for joint attention as “the
nine-month social-cognitive revolution” (p. 89) and described how
joint attention ultimately fosters self-awareness:

As infants begin to follow into and direct the attention of others to

outside entities at nine to twelve months of age, it happens on occasion
that the other person whose attention an infant is monitoring focuses
on the infant herself. The infant then monitors that person’s attention
to her in a way that was not possible previously . . . . From this point
on the infant’s face-to-face interactions with others . . . are radically
transformed. She now knows she is interacting with another inten-
tional agent who perceives her and intends things toward her. (p. 89)

Communication requires joint attention, and acquiring language is one

of the fruits of learning to relate to others as intentional beings: “Sounds

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become language for young children when and only when they under-
stand that the adult is making that sound with the intention that they at-
tend to something” (Tomasello, 1999, p. 101). Hence mentalizing
implicitly—a sense of interacting with another mental agent—is the
ground on which language develops.

Attachment and arousal

I have highlighted a few markers on the pathway to mentalizing just to
hint at the complexity of the developmental process. Unfortunately, we
cannot take for granted the developmental process of becoming a
mentalizer, a person among persons. As already noted, mentalizing re-
quires an intact social brain. But, as should be obvious by now, becoming
a mentalizer also requires a nurturing relational context. Specifically, as
recent research demonstrates (Fonagy, Redfern, & Charman, 1997;
Meins, 1997; Meins, Fernyhough, Russell, & Clark-Carter, 1998),
mentalizing develops optimally in the context of a secure attachment re-
lationship. As Fonagy et al. (2002) cogently argue, secure attachment is
not only conducive to exploring the outer world but also conducive to ex-
ploring the inner world—the mind of the self and the mind of the other.
More precisely, and just as pertinent to the psychotherapy process as to
early relationships with caregivers, secure attachment is conducive to ex-
ploring your mind in the mind of the other who has your mind in mind.
Just as secure attachment facilitates mentalizing, insecure attach-
ment undermines it. Most glaringly, trauma in attachment relation-
ships, such as abuse and neglect, confers a high risk for disorganized
attachment (Lyons-Ruth & Jacobvitz, 1999; Main & Solomon, 1990;
van IJzendoorn, Schuengel, & Bakermans-Kranenburg, 1999). In the
context of trauma and attachment disorganization, mentalizing be-
comes frightening. Hence, as Fonagy and Target (1997) articulated, at-
tachment trauma promotes a defensive withdrawal from the mental
world. Being aware of the mind of the abuser confronts the child “with
attitudes towards himself which are extremely painful to recognize: ha-
tred, cruelty, indifference” (p. 693). Insofar as mentalizing—making
sense of our experience—is among our core ways of regulating stress
(Fonagy & Target, 2002), attachment trauma and mentalizing deficits
escalate one another: The child avoids mentalizing, and the aversion to
mentalizing undermines the child’s capacity to cope with the frighten-
ing relationship.
In part, secure attachment is conducive to mentalizing by virtue of fa-
cilitating an optimal level of physiological arousal (Field, 1985;
Kraemer, 1999; Panksepp, Nelson, & Bekkedal, 1999). As already
noted, mentalizing is among our most complex cognitive activities. Not
surprisingly, mentalizing depends substantially on optimal prefrontal

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cortical functioning. The prefrontal cortex mediates “executive” func-

tions, which include planning and temporal ordering of responses in the
context of novelty and ambiguity (Goldberg, 2001). Nowhere do we
encounter more novelty and ambiguity unfolding at a fast pace than in
interpersonal interactions. Optimal prefrontal functioning, in turn, de-
pends on optimal arousal. Arnsten (1998) neatly captured the gist of
our vulnerability to being overloaded by arousal in her article, “The Bi-
ology of Being Frazzled.” As Arnsten and her colleagues (Arnsten,
1998; Arnsten, Mathew, Ubriani, Taylor, & Li, 1999; Mayes, 2000)
have delineated, when arousal (mediated by norepinephrine and dopa-
mine) exceeds a certain threshold, it is as if a neurochemical switch is
thrown. This switch shifts us out of the executive mode of flexible re-
sponding into the fight-or-flight mode of habitual responding. The
switch from contemplation to automatic action depends on a switch
from predominantly prefrontal to predominantly posterior-limbic acti-
vation. Those who deliberated in the face of a leaping leopard did not
live to pass on their genes. Those who ran passed on a legacy: when we
become highly aroused, our prefrontal cortex goes off-line.
To put this simply, we all know the experience of being so anxious or
frazzled that we cannot think straight. As an exceptionally complex
cognitive process, mentalizing is quick to collapse in the face of exces-
sive arousal. Moreover, persons with a long history of excessive
arousal, such as would occur in traumatic attachment relationships,
may become sensitized: Their threshold for switching is lowered
(Mayes, 2000). Such traumatized persons are more vulnerable to
arousal, and their mentalizing capacities are more easily lost in the face
of arousal. To mentalize, they need a secure attachment context condu-
cive to optimal arousal.
In applying the concepts of attachment and arousal to clinical work,
I find it helpful to draw a parallel between developmental competence
and current performance. Developing competence in mentalizing re-
quires an intact social brain, a secure-enough attachment history, and a
frequent-enough experience of optimal arousal in relationships. Devel-
opmental competence is attained, to varying degrees, as a function of
thoroughly intertwined psychosocial and neurobiological factors. Yet
competence does not always yield adequate performance. A concert pi-
anist can be paralyzed with stage fright. As it does in childhood,
mentalizing in adulthood will best flourish in the context of a current
secure attachment relationship and an optimal level of arousal. This fa-
cilitating context is just what we endeavor to provide in our clinical en-
counters.

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Clinical applications

We can best apply mentalizing to our clinical practice by shifting our fo-
cus from mental contents to mental processes, less concerned with what
is on our patient’s mind than with the way the patient is using his or her
mind. Focusing on mentalizing, I am now less worried about under-
standing the patient just right in my work as a psychotherapist, al-
though I am not about to give up on that quest. Rather, I am more
content just to be engaging the patient in the process of trying to under-
stand. Thus I am not so much attempting to unearth any particular con-
tent (specific feelings, thoughts, or insights) as I am trying to create a
capacity to mentalize more freely and flexibly—to foster involvement in
personal relationships, as Strawson (1985) put it, and to foster greater
awareness of mental states in self and others.
I will illustrate the process of mentalizing in two clinical domains,
trauma and depression. I will also note how the conditions that foster
mentalizing in our patients apply equally to us clinicians. Finally, I will
contrast the role of scientific psychology and folk psychology in our
clinical practice, returning us to the opening discussion of objectifying
our patients.

Treating trauma
The utility of the concept of mentalizing crystallized for me in the con-
text of treating trauma. Plainly, an interest in mentalizing is consistent
with mainstream trauma treatment, for example, as Edna Foa (1997)
articulated. Foa demonstrated the effectiveness of three essential ingre-
dients in trauma treatment: emotional engagement (i.e., feeling the feel-
ings), constructing a coherent narrative, and altering perniciously
negative views of the self and the world, the latter including inadequacy
(and sheer badness) of the self along with the dangerousness of other
persons. Plainly, all this entails mentalizing as we understand it.
But showing how one set of concepts (mentalizing) maps onto an-
other (Foa’s account) does not show the advantage of adopting the con-
cept of mentalizing. Although I might have come to the realization in
other ways, it was only after Peter Fonagy got me enthralled (indeed,
obsessed) with mentalizing that this idea crystallized in my mind: The
goal of trauma treatment is not to put trauma out of mind but, on the
contrary, to enable the patient to have the trauma in mind—to
mentalize it, to make sense of it, and to bear it without succumbing to
impulsive and self-destructive actions (e.g., drinking, bingeing, cutting,
or trashing a room). This, of course, is the gist of “exposure” treatment,
but the concept of mentalizing put this treatment in a new light (Allen,
2001); the procedure came to make more mental sense.

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Effective as it may be, to me “exposure” therapy—or its cousin

“flooding” (Saigh, 1998)—has connotations of endurance: One learns
to endure pain. No doubt, this idea is apt. Herman (1992), for example,
usefully likened preparation for processing trauma to training for a
marathon. But the concept of mentalizing shifted my emphasis from en-
durance and “desensitization” to mastery. No doubt, much of this
work is grueling, especially for the patient, but also for the therapist.
But it need not always be so. Once patients have become able, in psy-
chotherapy, to have the trauma in mind, I sometimes encourage them to
keep traumatic images in mind, or even bring them to mind, rather than
automatically putting them out of mind. Of course there is no point in
dwelling on these images, except insofar as the patient learns not to be
so frightened of them. Being able to have the traumatic experience in
mind sets the stage for learning voluntarily to put it out of mind.
A young man who had been sexually abused was horrified when im-
ages of committing fellatio occasionally came to mind unbidden when
he encountered men in his daily life. He became panicky and felt faint
when he had these thoughts. We had worked in the psychotherapy to
help him think, feel, and talk about the sexual abuse and then to calm
himself by imagining himself in a safe place in the woods that had been a
refuge in his childhood. He began to feel in control of his mind in the
therapy sessions. Then I suggested that he deliberately bring the
dreaded images of fellatio to mind outside the therapy session for a brief
time and then deliberately put them out of mind. He found that he could
do so without undue distress, and he was no longer so vulnerable to be-
ing blindsided and panicked by these intrusive images. These are not
new techniques, but my understanding of mentalizing shifted the way I
thought about these techniques and my attitude toward them.
And we should not lose sight of the attachment context when we
think about “exposure” and “desensitization” in trauma treatment.
Enabling the patient to have the trauma in mind requires a secure at-
tachment context and the optimal level of arousal (i.e., sense of safety
and security) that such an attachment relationship fosters. Seeing the
treatment in this way hardly changed my approach, but it gave me a
more solid sense of conviction about the process, which has allowed me
to do it with more facility. More easily, I encourage patients to think the
unthinkable and to feel the unfeelable. These mental contents then be-
come more thinkable and feelable, and then patients can achieve more
voluntary control over their mind. Being able to have the trauma in
mind, bearably, allows the patient to put it out of mind as well as to live
in less fear of being blindsided by intolerable mental contents.
From this perspective on mentalizing, the various techniques re-
cently developed for “processing” trauma (Allen, 2001) all rest on an

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ancient foundation—our basic humanity. I imagine the gist of trauma

treatment to be as old as the origin of modern language (Corballis,
2002). Hence a sketch of cutting-edge trauma treatment circa 50,000
years ago:

A: Looks horror-stricken.
B: Asks, “What happened?”
A: Tells the story.
B: Listens compassionately.
A: Mentalizes the trauma.

B’s compassionate listening is therapeutic by virtue of A’s experience

that B has her mind in mind (Fonagy et al., 2002). In Siegal’s (1999) apt
phrase, A “feels felt” (p. 89).

Treating depression
A novel twist in current treatment of depression also illustrates the clini-
cal application of mentalizing, albeit under the rubric of “mindful-
ness.” Teasdale and colleagues (Segal, Williams, & Teasdale, 2002;
Teasdale, Segal, & Williams, 1995; Teasdale et al., 2000) have demon-
strated that combining mindfulness meditation with cogni-
tive-behavior therapy prevents relapse in patients with highly recurrent
depression. Distinguishing two approaches to meditation helps eluci-
date the role of mentalizing in this approach (Goldstein & Kornfield,
1987). Concentration meditation entails focusing the mind,
prototypically, on the process of breathing. Insight meditation, by con-
trast, entails letting the mind wander freely, adopting a nonjudgmental
attitude toward the kaleidoscopic flow of mental contents and states.
Insight meditation also entails turning one’s attention toward rather
than away from distressing thoughts and feelings, then observing natu-
ral changes in these distressing thoughts and feelings. Importantly,
when observed nonjudgmentally, distressing states change for the
better; they wax and wane. Similarly, pleasant mental states change for
the worse; they wax and wane.
The mindfulness meditation aspect of Teasdale and colleagues’ ap-
proach aims not so much to change the content of patients’ thoughts
but rather to change patients’ experience of their mental states. As
Teasdale et al. (1995) stated, patients are taught that “emotional distur-
bance is caused by thoughts and cognitions that are ‘mental events,’ not
‘realities’” (p. 38). Patients might think of “the mental state in which I
view myself as utterly worthless” (p. 31). Segal and colleagues’ (2002)
thesis regarding the impact of their intervention captures the role of
mentalizing as I construe it: “Although the explicit emphasis in cogni-

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tive therapy is on changing thought content, we realized that it was

equally possible that when successful, this treatment led implicitly to
changes in patients’ relationships to their negative thoughts and feel-
ings” (p. 38). Rather than becoming mired in depressive rumination
(Nolen-Hoeksema, 1991, 2000), patients are able to let their depressing
thoughts pass through, to construe them as mental processes rather
than as reflecting absolute truth. They are mentalizing, aware of their
mental states as such. Mentalizing, they can be “bummed out” tempo-
rarily without succumbing to depression. Thus they are demonstrably
less prone to relapse.

In the same boat

Of course, we clinicians must mentalize to foster mentalizing in our pa-
tients. It is through our own mentalizing that we engage our patients in
the process of mentalizing (and, conversely, through their mentalizing
that they engage us in the process). We are in the same boat with our pa-
tients. We, too, must rely on an intact social brain, a secure attachment
history, and an optimal level of arousal. We bring to the session our de-
velopmental competence, and our current state of mind (based on our
feeling of security and level of arousal at the moment) may or may not
be conducive to mentalizing performance. We, too, know the “biology
of being frazzled” as our prefrontal cortical functioning goes off-line,
giving way to our limbic propensities to fight, flight, or freeze re-
sponses. When our patients retreat from mentalizing, for example, by
drawing us into reenacting traumatic attachment relationships, they
provide us with direct experience of the biology of being frazzled. We,
too, may feel threatened and unsafe. Plainly, the process of exploring
the mental world requires a sense of safety and security for both parties,
a sense of mutual trust. It takes two to mentalize therapeutically.

Reflections on folk psychology and scientific psychology

The billiards player relies on “folk physics,” and the mentalizer relies
on “folk psychology”—in Bruner’s (1990) terms, “culture’s account of
what makes human beings tick” (p. 13). Philosophers speculate that sci-
entific psychology, informed by neurobiology, might someday render
folk psychology obsolete (Lycan, 2003). For clinicians, this is a moot
point. We psychotherapists, however well armed with scientific knowl-
edge, must ultimately rely on folk psychology to make any use of it. We
do best when we talk with our patients in plain language. And our im-
plicit mentalizing is beyond language—and far removed from the scien-
tific perspective.
I remember my first foray into conducting psychotherapy as a senior
undergraduate student, with a few graduate courses under my belt, and

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headed for graduate school in clinical psychology. My adviser super-

vised me in conducting systematic desensitization (Wolpe, 1958) with a
man who had a public speaking phobia. I had a scientific procedure:
teaching relaxation, constructing a fear-stimulus hierarchy, and leading
the client through the hierarchy while he maintained a state of relax-
ation—more relaxed than I, no doubt. I was a novice, but I could do
that. After a few sessions, however, it became clear that my client just
wanted to talk about his problems. I had no scientific procedure for
that!
Off to graduate school, I held on to the illusion that there was a sci-
ence to psychotherapy—some sort of algorithm. My mentors obviously
knew it; I just did not yet “get it.” I never did get it, and the reasons are
now clearer to me than ever. But I do not think I have been alone in my
illusions, as the recent quest for manualized, evidence-based treatments
suggests. We want scientific procedures for this daunting clinical prac-
tice: Use your diagnostic decision tree, then prescribe the proper treat-
ment, implementing your manual. Manual in hand (or better, in mind)
you find yourself in the room with your patient. You also may be armed
with a firm grasp of scientific psychology. How much good will the sci-
ence do you? Imagine trying to interact with a patient (or anyone else,
for that matter) on the basis of your knowledge of scientific psychology!
Instantly, you are thrown back on folk psychology—your ability to
mentalize explicitly in ordinary language. And you will forge an attach-
ment relationship largely on the basis of implicit engagement in
mentalizing. Whether explicit knowledge of scientific psychology, psy-
choanalytic theory, or cognitive-behavioral therapy confers any advan-
tage in the domain of what we traditionally call “the relationship” is an
empirical question—perhaps a risky one to pursue. At best, with all our
professional knowledge and skill, our mentalizing capacities are highly
variable, as Diana Diamond and her colleagues (2003) are discovering
in their research on psychotherapy processes.
Yet, while emphasizing our dependence on our natural folk psychol-
ogy and implicit mentalizing abilities, I am not suggesting that we toss
aside all our professional knowledge. To be sure, professional knowl-
edge (including treatment manuals) can be invaluable in providing a
systematic therapeutic strategy, and extensive research attests to the ef-
fectiveness of evidence-based treatment approaches. Although it is a
long way from informing me about what to do with the patient in the in-
teractive moment, I could not imagine conducting psychotherapy with-
out knowledge of psychopathology. And our treatments would quickly
run aground without a solid therapeutic frame (Gutheil & Gabbard,
1993), which is certainly a part of our professional heritage. But it is the
work in the trenches that ultimately counts: the intuitive process of

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emotionally engaging the patient in mentalizing, using our own

mentalizing capacities.
Relying too little on intuitive folk psychology and too much on scien-
tific and professional knowledge always runs the risk of intellectualiz-
ing. Keeping too much science in mind runs the risk of objectifying the
patient, the converse of mentalizing. I introduced mentalizing by con-
trasting persons with objects. And I defined mentalizing as interpreting
the actions of oneself and others in terms of mental states. But this pro-
cess of interpreting, as Strawson (1985) made plain, can be done in a de-
tached manner:

To see human beings and human actions in this [detached, objective]

light is to see them simply as objects and events in nature, natural
objects and natural events, to be described, analyzed, and causally
explained in terms in which moral evaluation has no place; in terms,
roughly speaking, of an observational and theoretical vocabulary rec-
ognized in the natural and social sciences, including psychology. (p.
40)

Our patients are, of course, highly sensitive to excesses of this detached

stance. Overly objectified, they will rightly complain of being analyzed,
scrutinized, or put under a microscope. From this detached stance, we
may formulate intellectualized “interpretations” that do the patient lit-
tle good. Here we have the form but not the spirit of mentalizing. To be
therapeutically effective, the mentalizing intentional stance must be
grounded in emotional engagement.
Plainly, we must meld explicit reasoning and implicit mentalizing in
effective therapeutic interactions. Scientific psychology, and profes-
sional knowledge more generally, will be valuable only to the extent
that we can use this knowledge in the interactive moment to engage the
patient in an attachment relationship that fosters a true meeting of
minds. And there is no escaping it: This is moral engagement, in
Strawson’s sense, with all its sentiments, judgments, and “reactive atti-
tudes”—resentment, gratitude, pain, suffering, satisfaction, frustra-
tion, and joy—sentiments that come naturally with any engaging
human relationship. Without these sentiments, we could do no genuine
“mirroring.” Detaching ourselves through explicit mentalizing (using
our metarepresentational capacities), we construe these sentiments as
“countertransference,” which we aspire to use constructively to inform
our work. But we do not and cannot remain detached. Weaving back
and forth between objectivity and subjectivity, we are engaged in moral
work, continually making emotional judgments (Nussbaum, 2001).

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Allen

Naturally, we must refrain from moralizing in the process (Grayling,

2002).
Of course, we must balance this inescapably natural mentalizing en-
gagement with professional detachment, perhaps more than “edging
away” from emotional involvement a fair amount of the time. Other-
wise, we are liable to become embroiled in counterproductive
countertransference. But edging away into scientific and professional
objectivity, if it helps at all, will help only by informing and enriching
our natural engagement. Psychoanalytic understanding, for example,
can enhance mentalizing by directing our therapeutic attention to as-
pects of our humanity that we are prone to blocking from awareness.
And we can use techniques of cognitive therapy to enhance our patients’
mentalizing by fostering more flexibility in their thinking.
Perhaps we should consider folk psychology and scientific psychol-
ogy as being in continual interplay as we conduct our clinical work.
Maybe this interplay captures the blend of art and science in psycho-
therapy, as we move back and forth between person-to-person emo-
tional engagement and professional-scientific detachment. The latter is
a relatively recent development in the therapeutic use of our humanity.
If we developed the fundamental capacity to do this work at least
50,000 years ago, how much further might we have progressed in the
mere span of the past century?

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