Mentalization is the ability to understand our own and others’ mental states. It is a fundamental skill that allows us to navigate the complex world of human relationships and regulate our emotions.
Why is mentalization so important? Research shows that deficits in this ability underlie many mental problems – from personality disorders to difficulties regulating emotions. When mentalization is impaired, we lose the ability to understand ourselves and others, leading to conflict, impulsive reactions and feelings of confusion.
Learn what mentalization is, how it manifests itself, and the important role of schema therapy in developing mentalization skills.
What is mentalization ?
Mentalization is the ability to understand one’s own mental states and the mental states of others. It has been defined by Peter Fonagy as “the ability to interpret one’s own and others’ behavior in terms of underlying thoughts, feelings, needs and desires.” Mentalization goes beyond mere empathy or social understanding to include the ability to think about thinking, both in relation to oneself and others.
Contemporary understanding of mentalization emphasizes its dynamic nature, where mentalizing abilities can change depending on context, emotional state and interpersonal relationships. This means that mentalization is not a fixed personality trait, but rather a flexible skill that can be developed through appropriate therapeutic interventions. This approach opens up new possibilities for clinical practice, suggesting that even people with severe mentalization disorders can benefit from targeted interventions.
Dimensions of mentalization
Automatic vs. controlled – is the process conscious or unconscious? Refers to the level of awareness of the mentalization process. Automatic mentalization occurs spontaneously and unconsciously, often in familiar social situations, while controlled mentalization requires conscious effort and reflection, especially in complex or stressful situations- Self-directed vs. others-do we focus on our own or others’ mental states?Self-directed mentalization is concerned with understanding one’s own mental states, motivations and emotional reactions, while others-directed mentalization focuses on interpreting others’ thoughts, feelings and intentions.
- Internal vs. external – are we based on internal sensations or external observations? Refers to the sources of information used in the mentalization process, whether we rely on internal sensations and intuitions or external observations of behavior and expression.
- Cognitive vs. affective – do we focus on thoughts or emotions? Cognitive mentalization focuses on thoughts, beliefs and reasoning processes, while affective mentalization deals with emotions, moods and emotional reactions.
Balanced functioning in all four dimensions characterizes healthy mentalization, while disorders in individual dimensions can lead to various mental problems.
Examples of mentalization in everyday life
Developed mentalization skills may look like the following:
Situation: partner returns late from work without prior warning
- Mentalization regarding self: “I feel angry and anxious. Maybe I’m tired today, or maybe I’m anxious because I don’t know what’s going on.”
- Mentalization regarding the partner: “Maybe he had a difficult day at work, or got stuck in traffic, or just forgot to write. He probably isn’t doing it on purpose to upset me.”
- Balanced response: Conversation: “I was worried when you didn’t come back at the usual time. What happened?”
Difficulty with mentalization can lead to:
- Hyper-mentalization: “He’s definitely having an affair. He thinks I’m stupid and won’t figure it out. He’s probably planning how to leave me.”
- Hypo-mentalization: “It’s late. I’m angry. That’s all” (no reflection on own feelings or partner’s motives)
- Reactions: Attack, withdrawal or accusations without checking the facts.
The neurobiological basis of mentalization
Neuroimaging studies reveal that mentalization engages distributed brain networks, including the medial prefrontal cortex (mPFC), temporoparietal junction (TPJ) and posterior cingulate cortex. Recent research from 2024 also shows a direct role for dopamine in mentalizing abilities and the effect of oxytocin on mentalizing in attachment relationships.
Development of mentalization
Mentalization develops gradually from early childhood.
The first years of life: the child learns to recognize basic emotions in himself and caregivers, which lays the foundation for later, more complex mentalization skills. This process is closely linked to the quality of the relationship with caregivers, who, through their reactions and interpretations, help the child understand his own mental states.
Preschool age: develops an understanding that others may have different thoughts and feelings, a phenomenon known as theory of mind. This is a watershed moment in the development of mentalization, which enables the child to predict the behavior of others and adapt his own behavior to the social context.
School age: the ability to understand complex emotional states and intentions, which allows for more complex social interactions.
Adolescence represents a special period in the development of mentalization, characterized by a temporary deterioration of mentalizing abilities due to intense hormonal and neurological changes. There may be difficulties with peer relationships, increased impulsivity or problems with emotional regulation.
Adulthood: in adulthood, with normal development, full capacity for flexible mentalization is achieved. This means the ability to adapt mentalization processes to different contexts and situations, maintain perspective in stressful situations, and effectively use mentalization in interpersonal relationships.
Factors that interfere with the development of mentalization:
- Childhood trauma.
- Insecure attachment patterns.
- Emotional neglect.
- Chronic family stress.
- Mental illnesses of caregivers.
Characteristic signs of mentalization disorders
In interpersonal relationships:
- Rapid shift from idealization to devaluation of others.
- Difficulty understanding other people’s intentions.
- Reactivity to implicit rejection.
- Problems maintaining stable relationships.
In emotional regulation:
- Intense, rapidly changing emotions.
- Difficulty identifying one’s own feelings.
- Feelings of “emptiness” or detachment.
- Impulsive behavior in response to stress.
In thinking about oneself:
- An unstable self-image.
- Alternating thoughts of one’s uniqueness and then worthlessness.
- Difficulty integrating positive and negative aspects of self.
Jeffrey Young’s schema therapy
Schema therapy, developed by Jeffrey Young, focuses on identifying and modifying deep cognitive and emotional patterns called early maladaptive schemas. These schemas are formed in childhood and affect the way we view ourselves, others and the world.
Healthy Adult Mode as a function of mentalization
In the schema therapy model, the Healthy Adult Mode has a mentalization function. In this mode, the patient has the ability to mentalize and the ability to stop and think about his or her own experiences..The Healthy Adult Mode develops during the therapy process and is one of the primary goals of working in schema therapy. When the patient functions in the Healthy Adult Mode he can:
- Regulate emotions effectively.
- Understand the perspectives of others.
- Make informed decisions.
- Maintain stable interpersonal relationships.
Mentalization breakdown
The activation of maladaptive patterns is associated with a temporary breakdown in mentalization abilities. For example, an active feeling pattern in a particular situation, affects a low level of mentalization processes.
Example: Abandonment schema
Maria (32) has a pattern of abandonment developed in childhood by unstable relationships with her parents.
Trigger situation: Her partner doesn’t write back messages for several hours.
Activation of the pattern and breakdown of mentalization:
- Thoughts: “I’m sure he doesn’t love me anymore,” “He’s looking for someone better,” “Everyone always leaves me.”
- Emotions: Intense anxiety, panic, anger.
- Behaviors: Sending multiple messages, checking partner’s social media, imagining worst-case scenarios.
- Disturbed mentalization: Inability to consider other explanations (work, meeting, dead battery).
Return to Healthy Adult Mode:
- Recognition: “I’m starting to panic – this could be my pattern of abandonment.”
- Reflection: “What do I actually know? My partner hasn’t written back for 3 hours. This could have many causes.”
- Mentalization regarding the partner: “Maybe he has a lot at work or a meeting. He usually writes back, so he’s probably busy.”
- Emotional regulation: Deep breathing, recalling positive experiences with your partner.
- Constructive action: Writing one quiet message or waiting until the evening.
Mentalizing – examples of change in the Healthy Adult Mode
Situation 1: Conflict at work
Event: A supervisor criticizes a project in the presence of the team
Mentalization troubles (activation of defect pattern):
- Thoughts: “I suck. Everyone thinks I’m incompatible. I should never get into this.”
- Emotions: Shame, anger, helplessness.
- Behavior: Withdrawal, defensiveness or aggression.
Mentalization (Healthy Adult Mode):
- Mentalization of self: “I feel shame and anger. It’s probably my defect pattern reacting to criticism.”
- Mentalization of the supervisor: “Maybe he’s having a bad day or is under deadline pressure. He probably wants the project to be better, and he doesn’t want to hurt me.”
- Response: “I understand your comments. Can you give specific suggestions on how I can improve it?”
Situation 2: The partner is tired and not very talkative
Trouble with mentalization (activation of the pattern of abandonment):
- Thoughts: “He doesn’t love me anymore. He’s planning how to leave me. I’m doing something wrong.”
- Emotions: Anxiety, panic, anger.
- Behavior: Demanding attention, accusations, “checking” partner’s feelings.
Mentalization (Healthy Adult Mode)
- Mentalization of self: “I’m getting anxious because the partner is quiet. This could be my pattern of abandonment.”
- Mentalization of partner: “He looks tired. Maybe he’s had a rough day or is stressed. Not everything is about our relationship.”
- Response: “You look tired. Do you need some time to yourself, or can I help with something?”
Research
A meta-analysis by Hajek Gross and colleagues (2024) on self-injury included 14 studies with 612 participants and found significant reductions in self-injurious behavior in patients treated with mentalization-based therapy (MBT).
Luyten and colleagues’ (2024) systematic review of 33 papers based on 29 studies with a total of 3,124 participants provides solid evidence that mentalization acts as both a mediator and moderator of treatment outcomes in various forms of psychotherapy.
For borderline personality disorder, multiple randomized controlled trials demonstrate superiority or equal efficacy of mentalization-based therapy compared to standard treatment, with recovery rates of 45-52% compared to 24-29% for comparative therapies.
Assessment of mentalization ability – questionnaires
Reflective Functioning Questionnaire (RFQ)
This is a short, 8-item self-report instrument with two subscales:
- Confidence (RFQ-C) – measures overconfidence in understanding mental states
- Uncertainty (RFQ-U) – assesses anxiety and confusion related to mentalizing
Sample questions:
- “I always know why I do what I do” (Certainty)
- “Sometimes I don’t understand why I am so angry/angry” (Uncertainty)
The tool is freely available and can be used in both clinical practice and research. Link: https://www.ucl.ac.uk/psychoanalysis/research/reflective-functioning-questionnaire-rfq
Reflective Functioning Scale (RFS)
Considered the gold standard for measuring mentalization, the RFS uses an 11-point scale (-1 to 9) and requires analysis of interview material. Scores of 5 and higher indicate higher mentalization ability.
Indications for therapy
Schema therapy is particularly indicated for patients with:
- Personality disorders – especially borderline personality, narcissistic personality and avoidant personality
- Emotional dysregulation – difficulties in recognizing and regulating emotions.
- Interpersonal problems – repeated difficulties in relationships.
- Developmental trauma – early experiences of neglect or abuse.
- Self-injurious behavior – as an alternative to emotional regulation.
Psychotherapy – practical benefits for patients
Patients who develop mentalization skills. They experience many benefits in many areas of life.
Improvement in interpersonal relationships
- Before therapy: “Everyone eventually leaves me. Can’t trust anyone.”
- After therapy: “Sometimes I have a fear of rejection because of my childhood experiences, but I can see if my fears are justified.”
Improved emotional regulation
- Before therapy: Intense emotional crises that last for hours or days.
- After therapy: Ability to recognize early warning signs and apply calming techniques.
Increased self-awareness
- Before therapy: “I don’t know why I’m acting this way. I’m just angry/angry.”
- After therapy: “I recognize that my pattern of distrust was activated by this situation. I can stop and think about it.”
Symptom reduction
- Reduction in the severity of depressive, anxiety or impulsive symptoms.
- Reduction in self-injurious behavior.
- Improved quality of sleep and daily functioning.
Summary
Difficulties with mentalization are now understood to be a key mechanism in the development of many mental problems, especially in personality disorders and emotional dysregulation.
Schema therapy offers an effective working model to help change deep maladaptive patterns of functioning, and supports the way we understand ourselves and others. Are you considering this form of therapy? Feel free to contact us – schema therapy
Bibliography:
- Hajek Gross, C., Oehlke, S. M., Prillinger, K., Goreis, A., Plener, P. L., & Kothgassner, O. D. (2024). Efficacy of mentalization-based therapy in treating self-harm: A systematic review and meta-analysis. Suicide and Life-Threatening Behavior, 54(2), 317-337. https://doi.org/10.1111/sltb.13044
- Luyten, P., Campbell, C., Moser, M., & Fonagy, P. (2024). The role of mentalizing in psychological interventions in adults: Systematic review and recommendations for future research. Clinical Psychology Review, 108, 102380. https://doi.org/10.1016/j.cpr.2024.102380
- Fonagy, P., Gergely, G., Jurist, E., & Target, M. (2018). Affect regulation, mentalization, and the development of the self. Routledge.
- Bateman, A., & Fonagy, P. (2016). Mentalization-based treatment for personality disorders: A practical guide. Oxford University Press.
- Young, J. E., Klosko, J. S., & Weishaar, M. E. (2003). Schema therapy: A practitioner’s guide. Guilford Press.