#mentalizing

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 “Mentalizing is the ability to flexibly hold and reflect on the affects, cognitions, and mental states of the self and others (Fonagy, Gergely, Jurist, & Target, 2004; Fonagy & Target, 2002). The theory of mentalization is remarkably complex in its conceptualization of both early and ongoing development and the potentially devastating effects of disorganization in early attachment relationships. For this case study, we focus primarily on mentalizing within the therapeutic setting, describing particular aspects of the theory in practice, including issues with what is referred to as psychic equivalence (Allen, Fonagy, & Bateman, 2008). 

As a developmentally based, attachment-oriented theory, the concept of mentalization works well with Bowlby’s idea of internal working models of self and others, with a theoretical foundation based on early experiences with caregivers. Bateman and Fonagy (2006) noted that the child is forced into fragmented states of mind in understanding self and others when the caregiver fails to provide “adaptive affect-reflective interactions” (Fonagy et al., 2004, p. 192) with a child’s internal experiences. That is, children are dependent on their caregivers for accurate reflections of their experience. When the caregiver fails to properly reflect the child’s state of mind, the child internalizes deviant mirroring styles, and these incongruent representations result in disorientation and disorganization within the self. The resulting disorganization within the early attachment relationship will negatively influence developing concepts of self and others, as well as foundational abilities to make sense of and regulate affect. The child’s ability to make sense of his or her own emotional states becomes impaired due to the failure and incongruence of the caregiver’s reflections of the child’s affective states. Based on Lynn’s developmental history, her relationships with her adoptive parents involved repeated, ongoing reflective impairment, including a chronic absence of reflection of Lynn’s mental states due to the neglect she experienced. 

Marked Mirroring and the “Alien Self” 

In an attuned and secure interaction between child and caregiver, the caregiver reflects the mental states of the child such that the reflection is “marked” (Bateman & Fonagy, 2004). That is, the reflected state is exaggerated or altered in a way that makes it clear to the child that the caregiver is specifically reflecting the child’s state of mind and that this mind, although different than the mind of the caregiver, is understood. In contrast, the misattuned and insecure caregiver might respond to the child in a way that is incongruent and frightening. For example, if a young child expresses delight with a particular toy, the attuned caregiver would be expected to provide an exaggerated reflection of that delight, as is often seen with widened eyes, an exaggerated smile, and alteration in tone (usually high in pitch, in a sing-song rhythm). Such a reflection is considered to be marked, referred to specifically as marked mirroring (Bateman & Fonagy, 2006). If an adult, however, responds to a child’s delight by grabbing the toy away, shouting angrily, or ignoring the child, the child will be left disoriented, often with no way of making sense of his or her own emotions, and at the same time, internalizing the caregiver’s response and developing a sense of shame (i.e., “I was treated badly. I caused that response, therefore I am bad”). 

The ongoing disorientation and internalization associated with problematic parental mirroring results in what is known as the alien self (Bateman & Fonagy, 2006), or the child’s assumptions about himself or herself based on the caregiver’s incongruent responses. With Lynn, each time a member of the care team encountered an EP for the first time, the EP would almost immediately present its view of its alien self. An angry child EP would label himself or Lynn as a whole as “bad” and “disgusting;” a lonely, shame-filled child EP would similarly emerge, proclaiming herself “too yucky” for anyone to tolerate, let alone love. This is consistent with research comparing survivors of childhood abuse versus survivors of traumatic experiences in adulthood (Zinzow & Jackson, 2009). Within a mentalizing approach, it is not the therapist’s role to oppose and challenge such beliefs. Instead, it is an opportunity for appropriate marked mirroring, in which the therapist can reflect and “hold” the EP’s feelings of shame or self-loathing while also holding his or her own feelings and reactions toward the EP (e.g., “You’re feeling disgusting and bad and as you talk about that. Those feelings seem like they are really overwhelming for you, yet when I sit here and see you, I feel warmth toward you and I care about what happens to you.”). This interaction models and facilitates mentalizing (see Figure 2), thought of as “holding mind in mind” (Allen et al., 2008), while also helping to contain the client’s overwhelming negative affects related to the alien self.” 

-The Application of Attachment Theory and Mentalization in Complex Tertiary Structural Dissociation: A Case Study. Stewart, Dadson, & Fallding. 

Working With Parents in Therapy: A Mentalization-Based Approach, American Psychological Association, (30 November 2022)

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