I am fortunate to have a challenging job that requires flexibility and creativity, but it’s often difficult and sometimes downright exhausting. One time I complained about this effortful experience to our former chief of staff, Richard Munich, and he responded, “That’s why they call it work!” I find Dick’s matter-of-fact attitude toward the difficulty of work to be consoling, and I repeat his words to myself when I struggle to marshal the required effort.

Living requires brain power, and challenging work pushes brain power to the limit. Of all our body organs, the brain uses the most energy. Compared to other animals, the human prefrontal cortex occupies a disproportionate amount of brain territory. This brain region plays a key role in challenging work, and its activity consumes a lot of energy.

Demanding work

I was dumbstruck when I came across a list of specific challenges that tax our prefrontal cortex; I thought immediately, “That’s work!” Here’s the list that grabbed my attention, compiled by Paul Burgess and colleagues at University College London:

1. A number of discrete and different tasks have to be completed.
2. Performance on these tasks needs to be dovetailed in order to be time-effective.
3. Due to either cognitive or physical constraints, only one task can be performed at any one time.
4. The times for return to task are not signaled directly by the situation.
5. There is no moment-by-moment performance feedback … failures are not signaled at the time they occur.
6. Unforeseen interruptions, sometimes of high priority, will occasionally occur, and things will not always go as planned.
7. Tasks usually differ in terms of priority, difficulty and the length of time they will occupy.
8. People decide for themselves what constitutes adequate performance.

Broadly speaking, these challenges call for multitasking. These prefrontal capacities are called “executive” functions, and the list I just quoted would be as familiar to “executives” at work as it was to me. We are all executives. In our increasingly multitasking world, this list is typical of the demands of many persons’ daily lives, going far beyond professional work. Review the list while holding in mind the demands of raising children and running a household.

The prefrontal cortex and mentalizing

Consider also challenging interpersonal situations with this list in mind. A common example is working on a complicated project while trying to forge collaboration among several group members — or family members. Yet much of the list also pertains to difficult negotiations in a relationship, for example, parents coordinating the demands of work, childcare and household responsibilities. As you may have noticed, relating to people can be hard work. Mentalizing — attending to mental states in others and yourself — is part of this interpersonal work. Consistent with the complexity of interpersonal problem solving — and managing our own desires, thoughts, and feelings — the prefrontal cortex plays a key role in mentalizing.

Unfortunately, common psychiatric disorders impair the functioning of the prefrontal cortex, thereby compromising the capacity to engage in complex problem solving — intellectual and interpersonal — that our contemporary multitasking world demands. Thus it is not surprising that psychiatric disorders can be associated with significant disability in occupational and social functioning.

Some appreciation of their neurobiological basis helps us take psychiatric disorders seriously as physical illnesses, which can help combat stigma. Fortunately, treatment of psychiatric disorders — not only with medication but also psychotherapy — normalizes brain function, enabling patients to resume the challenging work of everyday living.

Editor’s note: If you enjoyed Dr. Allen’s post, please check out some of his other recent posts:

• POT: What’s new in plain old therapy?
• Was the Sandy Hook mass shooting “evil?”
• Can’t AND won’t

Reference                 

Burgess, P.W., Gonen-Yaacovi, G., & Volle, E. (2012). Rostral prefrontal cortex: What neuroimaging can learn from human neuropsychology. In B. Levine & F.I.M. Craik (Eds.), Mind and the frontal lobes: Cognition, behavior, and brain imaging, pp. 47-92. New York: Oxford University Press. (The list of challenges is quoted from page 81.)

More than two years ago, I wrote a post on this blog entitled, “Is psychotherapy going to POT?” Tongue in cheek, I was protesting the proliferation of brand-name, evidence-based therapies with all their acronyms: CBT, DBT, ERP, EMDR and the like. There’s no way any therapist can learn to practice 150+ brands, and a half-century of research attests to the difficulty of demonstrating that any one brand is generally superior to any other. Accordingly, I declared myself a practitioner of plain old therapy — relatively unstructured “talk therapy” without any special technical procedures. And I liked the acronym.

This post led to an interchange on the blog with my colleague, Tom Ellis, an expert therapist and research-minded psychologist who expressed some reservations. In his post, “Make my psychotherapy plain, but with a twist,” he took issue with the implication that there is nothing new happening in the field of therapy and pointed out the benefits of recently developed specialized procedures and treatments for certain disorders, such as panic and obsessive-compulsive disorder.

POT vs. BEER?

In conversation, Tom expressed concern that I might be communicating to therapists that whatever they’ve been doing all along is perfectly fine and they don’t need to learn anything new. I responded with another post, “Can we grow more potent POT?” In so doing, I acknowledged the need to continue refining psychotherapy on the basis of new knowledge, which I had aspired to do in homing in on mentalizing in the context of attachment relationships as a common therapeutic factor that cuts across different brand-name therapies. “Mentalizing” refers to being aware of mental states such as desires, feelings and thoughts in oneself and others, and “attachment” refers to relationships with strong emotional bonds, such as parent-child relationships, romantic partnerships and patient-therapist relationships. Tom responded with a second rejoinder, “Psychotherapy: Bring on the POT, but don’t forget the BEER,” a new acronym for “But Empirical Evidence Required.” In other words, Show me the data!

Therapists like POT

There was a playful quality to this blog-post interchange, but Tom and I are equally serious about current debates in psychotherapy, often pitting two broad camps against one another, that is, the clinicians versus the researchers. Tom and I share allegiance with both camps. After this initial foray in the blogosphere, I started to take the idea of plain old therapy more seriously, and for the past two years I’ve been talking about it in presentations and workshops locally, nationally and internationally. As intended, “POT” elicits amusement, but I’ve been surprised at therapists’ sheer enthusiasm for it. I went public in print, responding to an invitation to write for the “From the Expert” column in Psychiatric News with an editorial, “Reviving Plain Old Therapy.”¹ Ultimately, I took it so seriously that I wrote a book about it, entitled Restoring Mentalizing in Attachment Relationships: Treating Trauma with Plain Old Therapy.²

Why POT?

I have a few ideas about the basis of therapists’ enthusiasm:

1. Like me, many therapists are put off by the implication that they should learn a whole bunch of different therapies.
2. Many of the brand-name therapies were developed to treat specific psychiatric disorders and, like me, many therapists are generalists who work with patients with diverse problems, many of whom struggle with multiple disorders at the same time. We generalist therapists are the counterparts to general practitioners in medicine. Such physicians, too, must refer patients to specialists when indicated.
3. My emphasis on plain old therapy is consistent with the well-demonstrated contribution of the therapeutic relationship to the treatment outcome³ as well as a current humanistic counter-reaction to increasingly technological approaches to psychiatry, now abetted by enthrallment with neuroscience.⁴
4. I use the “old” in plain old therapy with some irony, because I find a substantial evidence base supporting the effectiveness of plain old therapy in contemporary attachment theory and research, including the recent work in mentalizing.⁵ When I discuss this work on attachment with patients and clinicians, many find it intriguing and eye-opening. Hence I was pleased when my colleague, psychiatrist Robert Fischer, who is executive director of the Optimum Performance Institute commented in an article that plain old therapy “actually is the most novel approach I have heard in the past 15 years!”⁶

Notwithstanding my confidence in the value of reviving plain old therapy, we therapists have no reason to be complacent about our work. The fact that a half-century of horseraces comparing different brand-name therapies has failed to reveal champions and that their commonalities are therapeutically significant does not mean that all are equivalent for a given individual.⁷

In the face of disagreement among proponents of different approaches as well as between clinicians and researchers, there is considerable consensus on one point: We are far from understanding the specific psychological and interpersonal processes that render psychotherapy effective.^{8, 9} I think mentalizing in the context of attachment relationships points us in the right direction, and new research supports this path.¹⁰ Indeed, we always desire more empirical evidence but, meanwhile, I think plain old therapists stand on solid ground.

Editor’s note: If you enjoyed this post from Dr. Allen, please check out some of his other recent posts:

• Was the Sandy Hook mass shooting evil?
• Can’t AND won’t
• Can’t OR won’t?

References 

1.       Allen JG. Reviving plain old therapy. Psychiatric News. 2012;47(10):3.

2.       Allen JG. Restoring mentalizing in attachment relationships: Treating trauma with plain old therapy. Washington, DC: American Psychiatric Publishing; 2013.

3.       Norcross JC, ed Psychotherapy relationships that work: Evidence-based responsiveness. Second ed. New York: Oxford University Press; 2011.

4.       Bracken P, Thomas P, Timimi S, et al. Psychiatry beyond the current paradigm. British Journal of Psychiatry. 2012;201:430-434

5.       Allen JG. Mentalizing in the development and treatment of attachment trauma. London: Karnac; 2013.

6.       Fischer R. Reflections on “Reviving plain old therapy”—A recent article featured in psychiatric news. Optimal Performance Institute. 2012;June 7.

7.       Budd R, Hughes I. The Dodo bird verdict—controversial, inevitable and important: A commentary on 30 years of meta-analyses. Clinical Psychology and Psychotherapy. 2009;16:510-522.

8.       Kazdin AE. Mediators and mechanisms of change in psychotherapy research. Annual Review of Clinical Psychology. 2007;3:1-27.

9.       Mansell W. Core processes of psychopathology and recovery: “Does the Dodo bird effect have wings?” Clinical Psychology Review. 2011;31:189-192.

10.     Rossouw TI, Fonagy P. Mentalization-Based Treatment for self-harm in adolescents: A randomized controlled trial. Journal of the American Academy of Child and Adolescent Psychiatry. 2012;51:1304-1313.

If a distinguished Princeton philosopher can write a (small) treatise on it, I think we clinicians are entitled to use the word “bullshit” as a technical term rather than relegating it to the bin of vulgarities. Harry Frankfurt’s book, On Bullshit, is a gem. We can understand bullshitting best by contrasting it with lying. Lying requires a keen concern for the truth; to pull off a lie, you must be aware of the other person’s factual knowledge and tailor your lie accordingly. Bullshitting is marked by a lack of concern with truth—spinning a yarn for the sake of spinning a yarn, without concern about concealing or revealing anything real.

What does bullshitting have to do with psychotherapy?

Here’s what grabbed my attention. Frankfurt pointed out that politicians often are at risk for bullshitting, because they are asked a wide range of questions to which they could not possibly have all the answers. I immediately realized that the same is true for psychotherapists:

“How long will it take me to pull out of this depression?”

“Should I go through with the divorce?”

“Should I give up on reconciling with my mother?”

“Do these images that keep coming to mind mean that I was really sexually abused, even though I can’t remember it?”

Therapists who strive to answer such questions with any sense of certainty put themselves at risk for bullshitting.

But patients as well as therapists are liable to bullshit in psychotherapy—to their own detriment. For example, avoiding painful experiences and conflicts, patients may talk in elaborate detail about relatively minor or peripheral concerns. Or they may gloss over serious problems such as self-destructive behavior with flippant remarks. More rarely, patients may strive to entertain therapists with their exploits.

Making strides with mentalizing

Here we need to bring in the concept of mentalizing, that is, being aware of mental states such as thoughts, feelings, and desires in yourself and others—and interpreting behavior accordingly. If you were sitting with a friend at a coffee shop and she suddenly bolted out of her chair, you couldn’t help mentalizing because you’d immediately start trying to figure out what’s going on in her mind.

Mentalizing involves empathy, not only for others but also for oneself. And what makes mentalizing “real” is emotional authenticity, a feeling of conviction, anchored in reality. Our colleague, British psychoanalyst and attachment researcher Peter Fonagy, PhD, pioneered our understanding of mentalizing. He distinguishes the “mentalizing mode” of functioning from the “pretend mode,” where ideas are no longer grounded in reality—reality doesn’t matter. After reading Frankfurt’s little book, it occurred to me that “bullshitting” is plainer language for the pretend mode as it pertains to psychotherapy. For this reason, we put a section on bullshitting in our book, Mentalizing in Clinical Practice, which I am reiterating here for a more general audience.

Psychobabble

Here’s my worry about psychotherapy: we can engage in bullshitting without being aware of it. All of us, patients and therapists, can engage in “psychobabble,” that is, using jargon and well-worn clichés. We have psychology texts and self-help books filling shelf after shelf, and we can easily parrot concepts and lines from these. “I have a self-esteem problem.” “My inner child is feeling abandoned.” And we can use diagnostic terms in the same way: “What else would you expect me to do in that situation? Don’t you know I’m borderline?!”

Blatant psychobabble isn’t a major problem, because it’s easy to detect. A more significant problem is bullshitting and not knowing that you’re doing it. Detecting bullshitting, in oneself or another person, requires mentalizing: Is what we’re talking about sincere, real, significant, authentic? Most important, will this conversation make any difference? Bullshitting in psychotherapy in any form risks wasting time and money, where the patient and the therapist have the illusion of doing real work and yet nothing changes.

Frankfurt makes a final point about bullshitting that is worthy of a Zen master. We call mentalizing a not-knowing stance. That is, we can never know with any certainty what’s in another person’s mind. Moreover, we cannot know with certainty what’s in our own mind. Our conscious experience is a mere glimpse of the working of our mind—often enough, we speculate about the reasons for our actions. Thus I leave you to ponder Frankfurt’s paradox and its implication for detecting bullshitting: to quote him, “Sincerity itself is bullshit.”

The field of psychotherapy suffers from acronymania: a proliferating plague of acronyms. Your psychotherapy brand will not be taken seriously if you don’t have a good acronym for it, preferably three letters, although you can get by with four or two. A short list: CBT, DBT, TFP, DIT, CPP, TPP, SIT, ERP, IPT, PCT, CFP, EFT, MBT, RLX, EMDR, ADEP and PE. Ideally, your therapy will qualify as an EBT or EST (evidence-based or empirically-supported treatment), that is, a treatment of experimentally-proven effectiveness that comes with a manual instructing the therapist on how it’s to be conducted.

More acronyms, please

Of course, we also have acronyms for psychiatric conditions: MDD, OCD, PTSD, BPD and so on. The crowning glory is having an EST for a particular condition: CBT for MDD, ERP for OCD, PE for PTSD and MBT for BPD (translation: cognitive-behavior therapy for major depressive disorder, exposure and response prevention for obsessive-compulsive disorder, prolonged exposure for posttraumatic stress disorder and mentalization-based treatment for borderline personality disorder, respectively).

We are truly blessed that clinician-researchers have developed all these ESTs for various psychiatric disorders. We need these specialized treatments for specific disorders and symptoms. Yet there are two problems with this state of affairs. First, to be fully competent in treating a range of psychiatric disorders, the therapist would need to learn 150+ treatment manuals—a daunting task. Second, many patients who seek treatment have a number of different disorders and problems at the same time (e.g., depression, anxiety, alcohol abuse, an eating disorder and personality disturbance).

Do we send such patients to several psychotherapists, as we might send patients to several medical specialists? Does the same psychotherapist administer several treatments sequentially, one after the other, or even concurrently?

Common factors

The problem I am addressing is not unique to psychiatry or even general medicine. We live in a world of increasing specialization such that individuals can hardly even keep up with the knowledge in their own field of endeavor. In the field of psychotherapy, there has been, in response to ever-increasing specialization, a countervailing movement for decades: the emphasis on “common factors” that account for the effectiveness of the therapy, regardless of the therapist’s specific technique or the brand name of the therapy. There is solid research support for this focus on common factors: it is extremely difficult to demonstrate that any good type of therapy is more effective than any other.

For example, we know that a positive therapeutic alliance—a trusting relationship in which the patient and therapist are working together toward common goals—is a major contributor to the effectiveness of therapy. Another important common factor is the therapist’s empathy. Recently, we have been advocating another common factor based on attachment theory and research: mentalizing, that is, an open-minded or mindful attentiveness to mental states such as thoughts, feelings and needs in oneself and others. It is a truism that psychotherapy requires interest in what is going on in the mind—and a meeting of minds. We use our colleague, Peter Fonagy’s, phrase for this process: holding mind in mind. We describe the ubiquitous role of mentalizing in relationships—including psychotherapy relationships—in our book, Mentalizing in Clinical Practice.

New psychotherapy brand

I am more concerned with common factors than specific techniques; I aspire to mentalize and help my patients to do so with me; and, not denying my competitive response to social pressure, I feel a need for a catchy acronym.

Hence, after more than four decades of practicing psychotherapy, I have decided on my own brand of psychotherapy: POT, Plain Old Therapy.

A patient once asked me at the beginning of our first session, “What kind of therapy do you practice? Talk Therapy?” I replied, “Yes, Talk Therapy, that’s what I do.” But I like POT better than TT.

To the extent that psychotherapists are returning to a common core of effective elements, the psychotherapy field might be going to POT. For many patients whose symptoms are multifaceted and rooted in problems with self and others, POT is in order. I acknowledge that POT is not optimal for treating patients with specific disorders for which effective specialized treatments are available. But even these specialized treatments, well delivered, must be laced with POT.

In his popular book, A Secure Base, John Bowlby, the psychiatrist and psychoanalyst who pioneered attachment theory, stated that the psychotherapist’s role is

“to provide the patient with a secure base from which he can explore the various unhappy and painful aspects of his life, past and present, many of which he finds it difficult or perhaps impossible to think about and reconsider without a trusted companion to provide support, encouragement, sympathy, and, on occasion, guidance.”

In a trauma education group, I once remarked, “the mind can be a scary place.” A young woman in the group spontaneously replied, “Yes—and you wouldn’t want to go in there alone!” She thus epitomized Bowlby, and I have never heard such a trenchant characterization of psychotherapy since. This is POT, as I endeavor to practice it.

Dr. Allen is a co-author of this book on mentalizing.

I introduced the technical term “excrementalizing” in our book, Mentalizing in Clinical Practice. We start with the slightly less technical term “mentalizing,” which refers to the natural human ability to interpret behavior in relation to mental states: desires, emotions, beliefs and the like. If you were sitting and talking with a friend, and your friend suddenly leapt out of the chair and ran out of the room, you couldn’t help mentalizing: you’d try to figure out why your friend behaved in such an unexpected way. Panic attack? Forgot something vital and urgent? Had to go to the bathroom?

In short, mentalizing involves paying attention to thoughts and feelings in yourself and others. Mentalizing includes empathy, namely, awareness of others’ mental states. But mentalizing also includes awareness of your own mental states, in effect, empathy for yourself. We use some handy shorthand phrases for mentalizing: holding mind in mind, or being mindful of mind.

Mentalizing and attachment

We learn to mentalize in the first years of life, and we learn best in the context of secure attachment relationships, through which we can express feelings and desires with confidence that they will be well received and understood by those who care for us. Intuitively, infants will seek comfort from caregivers whom they sense have their mind (feelings) in mind.

Throughout life, mentalizing fosters secure attachments, that is, emotionally close relationships that provide a feeling of safety and security. Plainly, mentalizing makes for good communication in relationships. We advocate a mindful, “mentalizing stance,” namely, an inquisitive, curious, and open-minded interest in the experience of others and oneself. Mentalizing in this mindful way makes for a good relationship with oneself as well as with others.

When mentalizing breaks down

Mentalizing can go awry in three basic ways:

1. We can fail to do it, for example, ignoring the impact of our actions on others or acting without self-awareness in the midst of an emotionally aroused state—drinking without thinking;
2. We can misuse mentalizing to exploit, torment or mislead others; and
3. Finally, we have excrementalizing, our technical term for distorted mentalizing. Here’s a definition: mentalizing but doing a crappy job of it.

Mentalizing at the movies

Sideways, starring Paul Giamatti

Now to the back story. My wife and I took our daughter, Yvonne, to see the movie Sideways. Yvonne is a speech and language pathologist who works with children with autism, and she has been privy to mentalizing for many years. We were captivated by a scene in Sideways in which a main character, Miles (Paul Giamatti) was lamenting his fate: his agent could not find a publisher for his book and gave up on him.

Sitting under a bridge and looking out toward the water with his cohort, he proclaimed, “Half my life is over and I have nothing to show for it—Nothing!” Then he talked about his insignificance: “I’m a thumbprint on the window of a skyscraper.” Here’s the line that grabbed us:

“I’m a smudge of excrement on a tissue surging out to sea with a million tons of raw sewage!”

Reflecting on this line on our drive home, Yvonne exclaimed: “He was excrementalizing!”

Such self-deprecating depressive rumination is a common example of excrementalizing. Paranoid interpretation of others’ behavior is another. But excrementalizing isn’t a sign of disturbance; we all are inclined to misinterpret or misconstrue our own and others’ behavior sometimes, if not much of the time. We need to check out our perceptions with others and talk through our thoughts and feelings to mentalize with some reasonable degree of accuracy. Excrementalizing is a handy concept that can promote self-awareness: being alert to the possibility that you are excrementalizing is, in fact, good mentalizing. Ironic, isn’t it?

1974 Immanuel Kant stamp

I am partial to big ideas, general concepts that keep us properly oriented. And I’m more concerned with what’s important than what’s new. So I was captivated by a chapter entitled “Love and Respect” in New Zealand philosopher Christine Swanton’s book Virtue Ethics. Swanton draws from the eighteenth-century German philosopher Immanuel Kant, who declared that love and respect are the two “great moral forces.” What could be more important than great moral forces?

Love and respect

Kant made an intriguing contrast:  love entails coming close, whereas respect entails keeping one’s distance. Consistent with our ordinary sense of the word, Swanton elaborates loving as involving concern for the welfare of the beloved, desire to be together, expression of affection, sharing of experience and compassion. She also includes novelist and philosopher Iris Murdoch’s view of love as requiring attentiveness to the reality of the other person, undistorted by one’s own needs and emotions.

At first, I found equating respect with keeping distance to be somewhat jarring but, as Kant saw clearly, respect is an essential counterpart to love.

Kant framed love and respect as opposing forces that keep one another in check; Swanton asserted that love and respect maintain equilibrium in relationships.

Respect entails keeping distance in the sense of appreciating separateness, giving the other person space and granting autonomy. We should not lose sight of Swanton’s claim that the moral force of respect encompasses self-respect, which is consistent with setting limits and maintaining boundaries in relationships. Failures of respect include wounding and controlling others, which are intrusive and thereby violate respect.

Love, respect and attachment

These two moral themes of love and respect are pervasive in the psychological literature, for example, in the recognition that development entails striking a balance between connection and separateness, or relatedness and autonomy. Attachment theory, as developed by psychoanalyst John Bowlby and psychologist Mary Ainsworth, elegantly frames this balance in terms of two pillars of security:  a safe haven and secure base. Think of the toddler with his mother on the playground:  with her enthusiastic encouragement, he explores confidently, as long as he sees she is still there when he checks back periodically. If he falls down or sees a frightening dog, he wants to make contact with his emotionally responsive mother. Having made contact, then feeling safe and reassured, he can return with her encouragement to exploration and play, confident that she will be there when needed.

In sum, parents of the securely attached child encourage closeness in offering a safe haven in the face of danger, and they support distance in providing a secure base for exploration. A failure to provide a balance of safe haven and secure base experience contributes to insecure attachment, which takes the forms of needing to stay too close (anxious attachment) or maintaining too much distance (avoidant attachment).

Bowlby and Ainsworth were emphatic about our lifelong need for secure attachment:  all of us, toddlers at heart, need a safe haven and secure base “from the cradle to the grave,” as they put it.

We move back and forth between closeness and distance and, ideally, as attachment figures—parents, romantic partners, caregivers—we balance love with respect in moving back and forth between providing comfort and encouraging autonomous exploration and the self-confidence that goes with it. As our colleague, psychoanalyst Peter Fonagy, has taught, we maintain this equilibrium in attachment relationships by means of our natural human capacity to mentalize, that is, to be aware of thoughts and feelings in others and ourselves. On the one hand, mentalizing enables us to feel connected through empathy; on the other hand, mentalizing enables us to be aware of the separateness of our mind from the mind of others, that is, to recognize the uniqueness of each person’s perspective.

Love, respect and stigma

Pertinent to the general theme of this blog, we should note that love and respect are antithetical to stigma, which is a manifestation of contempt. As Swanton states, contempt shows a failure to come close insofar as it maintains a barrier, for example, in cold indifference. Yet she also points out that contempt entails a failure of respect in being a form of psychological wounding. In this respect, contempt shows failure to keep distance; it can be intrusive, for example, in taunting, bullying or talking down to the person held in contempt.

As mental health professionals, as attachment figures, as humans, we navigate in a moral space, balancing love and respect. To navigate this space adroitly requires judgment, common sense, wisdom and—technically speaking—mentalizing. We have much philosophy and psychological science to guide us, but navigating this elastic space between closeness and distance on a moment-to-moment basis is an art and, like any other art, we will not always find it easy to do well.

You read countless news stories about human deeds, ranging from horrific—snipers, arsonists, suicide bombers—to heroic—rescues of all sorts, an airline pilot landing safely on a river. Quite often, you can’t help wondering:  What were they thinking and feeling? You speculate. You’re an armchair psychologist. We all are, professional psychologists included.

Even Lucy's an armchair psychologist.

What makes it possible

To use a technical term—unfamiliar but in the English lexicon for two centuries—you are mentalizing:  interpreting behavior as based on mental states such as beliefs, motives and emotions. You could not make sense of news stories, novels, movies or daily observations of your fellow humans without mentalizing. Like using language, mentalizing is a natural human capacity that we all develop (barring autism, of course, which is distinguished by impaired mentalizing, an inability to relate based on an intuitive sense of others as persons with a mind). Empathy is a major part of mentalizing, but mentalizing includes understanding the workings of your own mind as well as others’ minds. Thus mentalizing includes empathy for yourself.

A mentalizing test

We are not born speaking, and we are not born mentalizing. Over the course of our lifetime, we use language more or less well, and we mentalize more or less well. One way developmental psychologists measure children’s mentalizing capacity is through the false-belief test. The child to be tested watches a scenario in which another child sees his mother put chocolate in a green cupboard, after which the child goes out to play. While the child is out, the mother uses the chocolate and puts it back into a blue cupboard. The child comes back from playing and looks for the chocolate. The test question:  Will the child look in the green cupboard or the blue cupboard? A mentalizing child will answer “green,” realizing that the child in the scenario would act on the basis of a false belief. The non-mentalizing child will answer “blue,” not taking into account the observed child’s mental state but rather answering on the basis of what the tested child knows to be current reality.

The importance of attachment

Barring autism, children normally pass the false belief test around three to four years of age. Interestingly, children who are securely attached to their parents, as indicated by confidently reaching out to a parent for comfort when emotionally distressed, are likely to learn to mentalize earlier and more skillfully than those who are insecurely attached. Moreover, parents who are securely attached to their own parents are more likely to have children who are securely attached to them. What determines security of attachment, that is, confidence in the emotional availability of the caregiver? One important factor is mentalizing. Over the generations, mentalizing begets mentalizing. Parents who engage in mentalizing interactions with their children are fostering secure attachment. Such parents, for example, are attentive to their children’s emotional states and, when their children can use language, they help them understand what is on their mind by talking with them about their thoughts and feelings. The connection between such mentalizing is commonsensical:  Why would a child turn to a parent for comfort if the child could not anticipate that the parent would mentalize? In short, as our colleague Peter Fonagy aptly puts it, securely attached children have the sense that their parents hold their mind in mind. Just as we learn language by engaging in linguistic interactions (which, by the way, require mentalizing), we learn mentalizing by engaging in mentalizing interactions.

As it is in childhood, it remains throughout life. Trusting, stable, secure attachment relationships are based on mentalizing. Indeed, all cooperative (and competitive) relationships are based on mentalizing. And, to mentalize in interactions with others, we must mentalize in relation to ourselves; you must know your own mind to make your mind known to others. How do we encourage others to mentalize? Mentalize. This is how securely attached parents encourage their children to mentalize. We advocate a curious, inquisitive, open-minded mentalizing stance.  When feeling put out or let down, inquire:  I’m wondering what you were thinking and feeling? When puzzled about your own behavior:  What was I thinking and feeling?

Parenting, friendships, love relationships, and psychotherapy all rest on mentalizing. All of us do it, and all of us always could do it better.