Mentalizing in Interpersonal Psychotherapy

Mentalizing is a cognitive and affective domain encompassing the capacity to understand that mental processes such as thoughts, feelings, and wishes underlie one’s own and other people’s behavior. Bateman and Fonagy (1) describe it as “the process by which we make sense of each other and ourselves, implicitly and explicitly, in terms of subjective states and mental processes.” Mentalizing is a basic human attachment–based capacity and a prerequisite for social interaction (2). Studies show that some forms of psychopathology permanently impair the ability to mentalize, whereas in other disorders, reduced mentalizing capacity may be situational and reflect emotional stress (3). This article addresses whether improved mentalization might be a mechanism of change in interpersonal psychotherapy (IPT) (4), a short-term, manualized treatment originally developed to treat major depression. Many randomized trials have shown IPT’s efficacy (5, 6). Research has shown that IPT also benefits patients with eating disorders, posttraumatic stress disorder (PTSD) (7), and other conditions (4, 6).

Fonagy and colleagues (8, 9) have suggested that improving mentalizing capacity is a key change mechanism across psychological treatments. One study found that pretreatment reflective functioning (RF), an operationalization of explicit mentalizing rated on the Adult Attachment Interview (AAI) (10), influenced IPT improvement trajectories (11). Some trials suggest that improved RF might partly account for symptom reduction in some treatments (12), but others found no significant correlations between change in RF and symptoms, even though RF improved and the number and severity of symptoms decreased (11, 13). Rudden et al. (13) found that panic-specific RF improved during panic-focused psychodynamic psychotherapy (PFPP), but not during applied relaxation therapy, a cognitive-behavioral therapy. Similarly, Ekeblad et al. (11) found that IPT, but not cognitive-behavioral therapy, improved RF rated on attachment history (via the AAI) for patients with depression. Rudden et al. (13) found that symptom-specific RF, a measure of patients’ ability to reflect on and mentalize the emotional meaning of their symptoms, but not standard RF, improved during PFPP. Different treatments, sometimes with different goals, probably change aspects of RF, and to varying degrees. We believe that RF may have particular importance for affect-focused therapies such as psychodynamic psychotherapy and IPT, in contrast with more behavioral approaches, but this theory requires far more research.

Treatment Principles in IPT

IPT was developed as a time-limited (usually 12–16 weekly sessions), diagnosis-focused treatment based on attachment theory (14, 15) and on understanding of how life events and social support interact with mood disorders and other psychiatric disorders. The IPT therapist defines the target diagnosis (e.g., major depression) as a treatable illness that is not the patient’s fault. IPT helps patients to link their feelings and life circumstances. IPT therapists elicit and normalize emotions related to interpersonal encounters and help patients to verbalize them through communication analyses and role play, priming patients to handle social relationships adaptively. This approach strengthens social support, imbues a sense of mastery of the social environment, and has been repeatedly shown to alleviate a range of psychiatric symptoms (5, 6). While facilitating a strong treatment alliance, IPT focuses patients on life circumstances—resolution of an acute, depression-linked crisis, such as a role dispute—rather than on the therapeutic relationship in the office; IPT does not interpret or work within the transference (14). IPT has targeted what DSM-III and DSM-IV termed axis I disorders; excepting pilot work on borderline personality disorder (16), IPT has not been applied to the treatment of personality disorders.

Without focusing on the therapeutic relationship, IPT nonetheless may improve patient mentalizing. IPT focuses on patients’ affects and emphasizes helping patients tolerate, modulate, and understand their emotions in order to address emotional and attachment-related aspects of interpersonal functioning. IPT empathically validates the patient’s narrative, helps to identify and name affects, and provides clarification and exploration.

IPT focuses on the content of patient relationships, organizing treatment around interpersonal themes (e.g., complicated bereavement, role dispute, role transition, or social isolation). This approach contrasts with treatments explicitly focused on improving mentalizing capacity. Mentalizing-based treatments focus on helping patients to improve and stabilize their mentalizing capacity: therapists primarily focus on the process of mentalization and on stimulating patient curiosity about problematic emotional responses. The therapist attempts to enhance the patient’s mentalizing process—that is, to create curiosity about alternative understandings of interactions and to avert the collapse of mentalizing, or “nonmentalizing” modes of experiencing oneself and others. When a patient loses mentalizing capacity, falling into psychic equivalence, pretend mode, or a teleological mode, the therapist works to reinstate mentalization. The therapist adopts an inquisitive stance, acknowledging not knowing what the patient is thinking and curiously questioning the patient about thoughts and feelings (1). Additionally, the IPT therapeutic stance helps the patient find ways to improve social functioning via understanding his or her own feelings in social encounters. Hence, in inviting patients to reflect on their emotional understanding of interpersonal encounters and the role they play in them, IPT, at least implicitly, focuses on mentalizing. A few teaching programs include mentalization as a topic in IPT training.

Purported Change Mechanisms in IPT

Knowledge of potential change mechanisms in IPT remains scarce. IPT’s developers have advocated a multifactorial perspective (1). Although a few empirical studies have reported associations linking change in interpersonal functioning and attachment security with change in depressive symptoms (17–19), they failed to show temporal mediation. Thus, changes in depressive symptoms could cause changes in relational problems or vice versa. Perhaps more probably, such changes could continuously interact during the treatment course.

Lipsitz and Markowitz (20) hypothesized that enhancing capacity for emotional processing, increasing social support, decreasing social stress, and improving social skills might explain symptom improvement in IPT. These mechanisms might all result from improved mentalizing capacity, because mentalizing can be considered a general capacity to understand emotional and relational aspects of human interactions, and part of the IPT process implicitly involves mentalizing.

Background of the Concept of Mentalizing

Mentalizing operationally derives from psychoanalytic theories (21). In 1934, Sterba (22) suggested that the therapeutic action of psychoanalysis lay in the patient’s identification with the therapist’s observing ego. He conceptualized the patient as entrenched in rigid self-conceptions, which analytic interpretations could unlock to permit wider, more constructive self-reflection. This observing stance may be particularly important in the patient’s attempts to understand reactions to the therapist in the transference. Working to improve patient curiosity about how the patient’s mind and the minds of others work can be considered a continuation of Sterba’s speculations about identification with the therapist’s observing and reflecting stances. Mentalizing treatments aim to improve patient mentalization capacity in order to enable more constructive ways of learning from ongoing social interactions outside of therapy.

The Communication Model

Fonagy and colleagues (2, 8) recently presented a new model for therapeutic change based on mentalizing in therapeutic interactions. This model derives from experience in treating patients with borderline personality disorder, but Fonagy et al. suggest the model applies to most psychological treatments. The model describes three “communication systems” that contribute to learning in psychotherapy. The gist is that helping the patient feel mirrored in a marked way activates the patient’s own mentalizing capacity. This emergence of the capacity for mentalizing typically first appears in relation to the therapist as the patient develops greater interest in and curiosity about the therapist’s mind.

The model’s first system involves the patient feeling understood (“mentalized”). An important aspect of this early therapeutic work is that the patient sees the therapist’s suggestions as ostensive cues, leading to a decrease in the patient’s epistemic hypervigilance (i.e., distrust in the particular model or approach the therapist presents), in turn leading to emergence of the patient’s capacity for mentalizing. This process activates a second communication system: the patient’s improved mentalizing capacity generates greater curiosity about the therapist’s ideas about how to understand the patient. This step generates further epistemic trust—that is, the patient’s capacity to accept knowledge that the therapist explicitly or implicitly presents as valid, applicable to the patient, and generalizable to other contexts.

Epistemic trust drives learning that involves a third communication system. Reemergence of epistemic trust and improved mentalizing capacities foster the capacity for social learning, or salutogenesis, the ability to benefit from positive influences in one’s social environment.

In this view, improving mentalizing capacity as such is not the therapeutic goal. Mentalizing is rather a precondition to increase openness to new social experiences. The ultimate goal of psychotherapy is to strengthen the patient’s ability to learn from new experiences.

Mentalizing as a Potential Mechanism of Change in IPT

IPT focuses on helping patients create or renew social contacts and social support. The patient’s ability to understand the motives of significant others—by recognizing and using the affects that arise in difficult situations and relationships, analyzing communication patterns, and then role playing using this understanding—may benefit from and contribute to better mentalizing. Improving mentalizing capacity may thus be key to IPT therapeutic processes and might mediate IPT outcomes. The explicit focus on improving the mentalizing that is central to mentalization-based interventions is not, however, a stated goal in IPT.

IPT focuses on patients’ handling of affects and interpersonal conflicts in defined problems areas and relationships, tasks that require the capacity to mentalize about others. Understanding how interpersonal functioning relates to mood and to distressing life events that may have triggered a depressive episode again requires the capacity to mentalize about oneself. Although not explicitly named in Weissman and colleagues’ IPT manual, mentalization is a crucial facet of IPT communication analysis (4), which aims to determine how the patient understands his or her emotional reactions to an interpersonal encounter outside the office, what that affective response reveals about the situation, the other person’s emotional reaction, and how the patient can use this new understanding to improve social functioning in that relationship. In IPT, the therapist also models mentalization and uses several mentalizing-informed techniques, such as the “contrary move” (23), a shift from a cognitive to an affective focus or from self to other, although with other descriptors.

Communication analyses and role playing, key IPT techniques in preparing for interpersonal encounters, constitute what Bateman and Fonagy (24) term “controlled mentalizing:…a serial and relatively slow process, which is typically verbal and demands reflection, attention, awareness, intention, and effort.” Interest in mentalizing grew while IPT was applied to the treatment of patients with chronic PTSD who, unlike most patients with depression, reported near or complete emotional detachment (25). Before they could engage in the basic IPT strategy of linking affect to situation, they needed affective reattunement in order to regain access to their feelings and to interpret what their feelings meant (e.g., anger generally means one feels unfairly treated). The first half of the 14-week treatment was therefore devoted to building mentalizing capacity, although that term was not used. Once patients could begin to read their own emotions and those of others, IPT could proceed as usual.

The recent Fonagy et al. model of therapeutic change can be considered a common-factors model insofar as it applies to most psychotherapies, irrespective of specific therapeutic interventions (26). Its basic principles are the therapist’s genuine curiosity in comprehending the patient’s understanding of his or her own problems and the therapist’s presentation to the patient, using ostensive cues, a comprehensive, comprehensible model of change. By demonstrating that the therapist has ideas about how the patient can ameliorate his or her situation, the therapist engenders the patient’s epistemic trust. Belief in the therapist evokes trust in the patient’s own capability, gradually increasing the patient’s sense of agency.

The IPT change model arguably fits this schema. A major step in IPT’s initial phase involves helping the patient realize that he or she can actively change his or her situation to resolve a life crisis and reduce symptomatic suffering. The therapist may implicitly improve patient epistemic trust through therapeutic optimism, encouraging the patient and helping him or her explore potential options for change. Diagnosis-derived rigidity in the patient’s conceptions of self and others yield to more flexible understanding of social interaction. Improved epistemic trust associated with better mentalizing capacity opens the patient to new experiences in daily social interactions. Thus, although IPT guidelines and vocabulary do not mention mentalizing, the concept accords with IPT principles.

Case Example

An example helps illustrate how mentalizing in IPT might promote change while indicating aspects of IPT that differ from the communication model.

John is a 24-year-old man with major depressive disorder. In his teens, he entered supportive psychotherapy for several months to treat a depressive episode. His mood improved, but the depression has recurred since. Recently, he moved to a university city distant from his home. Soon after starting a technical program, he felt lonely and wanted to return home. His father, however, insisted that he stay at the university. After a few more weeks, he went home nonetheless. After a harsh conflict with his father, John returned to school but stopped attending lectures and lay in bed for a week. A fellow student found him after he overdosed on painkillers in a suicide attempt. He was briefly admitted to a psychiatric ward. Interviews with the ward psychiatrist indicated that John had friends in his hometown but had become isolated at the university. The only child of two older parents, he had been close to and looked up to his father when young, but during adolescence he had turned to friends, distancing himself from his father. John had had short relationships with a few girls but never established a stable romantic relationship.

After leaving the hospital and again returning home, he contacted a psychiatric service for depression treatment. John was offered a 12-session weekly course of individual IPT. After considering role transition (leaving home and developing an adult identity as a college student) as a problem area, John’s therapist suggested a role dispute with his father as the acute interpersonal problem, because their conflict seemed central to his emotional upheaval. John agreed.

Having validated John’s anger, the therapist helped him to explore options for handling his disagreement with his father more constructively. They then role-played John’s confronting his father, evaluating both the content of what John wanted to say and his tone of voice. The therapist encouraged John to imagine how his father would react to different ways of expressing the anger.

John considered several ways of expressing his anger and realized that none of them would seriously hurt his father. With practice, John was able to tell him, “Dad, I’d really like to have back the relationship we had before I left for college. I know you want the best for me, but you make me really angry when you try to dictate my life. Can we agree to disagree? If I do go into engineering, I want it to be because it’s my choice; and if I don’t, I hope you’ll be proud of me as a poet.” With some bumps, the relationship improved, as did John’s mood.

This IPT case focused on renegotiating John’s filial role dispute in order to improve communication and relieve depressive symptoms. John was aware of his anger toward his father; in other instances, therapists must work harder to elicit patients’ recognition and acceptance of their own feelings (27, 28).

Although the description of John’s treatment is short, it demonstrates how the IPT treatment process may employ the mentalizing perspective when viewed through the lens of the communication systems model. Using this approach, the first goals would be to enhance John’s trust in the therapist’s attempts to understand him and his problem and to present a useful change model. By acknowledging John’s anger and exploring other ways to express it, the therapist may have increased John’s epistemic trust and improved his ability to mentalize his own feelings— although these are not explicit intentions of IPT. The ensuing role play was intended to enhance John’s communication with his father, including his expression of discontent. Implicitly, role play may have given John and the therapist opportunities to reflect on aspects of both sides of John and his father’s interaction. It might thus improve John’s mentalizing about the dispute with his father. So armed, John could later use his newfound mental flexibility to negotiate a better relationship with his father, an interpersonal encounter that may have helped improve his mood and self-confidence (21).

It is important that patients cogently understand a specific treatment’s rationale for why symptoms arise and how to address them. This understanding accords with the aim of the communication systems model that a therapist present clear ideas about the origins and treatments of the patient’s problems while remaining open to the patient’s ideas and experiences. The classical IPT model that focuses on identifying and solving an interpersonal problem has proved highly efficacious for several disorders. Unlike mentalizing treatments, IPT has no explicit intention to augment general mentalizing ability or improve patient social learning in general. Because IPT does not directly target the therapist-patient relationship, altering IPT by focusing explicitly on mentalizing during the therapist’s attempts to understand the patient’s situation might well distract from the therapeutic focus.

This research area has received too little study. Over more than 40 years of clinical trials, IPT researchers have sought measures to capture aspects of how IPT works. The Social Adjustment Scale (29) measures social outcomes; interpersonal circumplex instruments (e.g., Inventory of Interpersonal Problems) (30) assess general interpersonal patterns; other scales measure perceived social support (31). None address the core interpersonal skills implicit in the IPT treatment process and in patient functioning in interpersonal encounters—which surely overlaps with mentalizing.

The Reflective Functioning Scale (32) may answer that need. A few IPT studies have used general RF scores rated on life history (from the AAI), and symptom-specific reflective functioning (SSRF), which measures emotional understanding of one’s psychological symptoms. Because IPT does not target life history issues, measuring current interpersonal problems may have greater relevance. Möller et al. (33) used RF ratings to study prisoners’ mentalizing about their crimes and mothers’ limit-setting with their children (34). We are currently testing change in RF and SSRF as mediators of IPT outcomes in patients with PTSD (35). Further developing RF measures for specific symptoms, problems, and relationships might importantly advance understanding of how IPT attains success.

Conclusions

Although data remain lacking, improving patient mentalization likely plays a key background role as a change mechanism in many psychotherapies, particularly affect-focused psychotherapies, including IPT. Improved mentalizing capacity has greater significance for patients whose mentalizing capacity is low. The communication systems model that focuses on evoking epistemic trust in patients through a therapist’s attempts to present a believable treatment idea that fits the patient’s situation makes sense in IPT. This communication model is best seen as a common-factors model, useful in most therapy methods, particularly those focusing on therapist stance and patient affect. The general significance of common factors, and particularly the mutual collaboration in the treatment alliance, has been shown repeatedly (36, 37).

It is important to distinguish between the therapeutic interventions IPT uses to achieve changes and the idea that improved mentalizing might be an underlying change mechanism. The IPT manual (4) does not describe enhancing the patient’s mentalizing capacity. Therapeutic tools such as role play and affect and communication analysis may enhance patient mentalizing capacity. The general therapeutic stance Fonagy et al. (2, 8) recommend to improve patient epistemic trust in the therapist—and in the patient himself or herself—and to increase curiosity about social relationships accords with IPT principles. Thus, although mentalizing about both oneself and others may improve in IPT, the restoration of social communication, a primary goal in IPT, may—in accordance with the communication systems model—be a more important change mechanism. More research is certainly needed to investigate the roles of mentalizing and social communication more generally in IPT and other types of psychotherapy.

Nonetheless, important nuances between IPT and mentalizing-focused therapy interventions deserve notice. In IPT, therapists openly validate patients’ affective reactions, thereby strengthening their consciousness of (particularly negative) affects. Mentalizing-informed treatments tend rather to emphasize patients’ curiosity about different emotional reactions. Another distinction is between the explicit IPT goal of resolving a particular conflict or problem, and the goal in mentalizing-oriented therapies of improving patients’ general openness to learning from new social situations by better mentalizing. Therapists’ comprehension of different treatment conceptualizations and frameworks may enrich their background understanding of patients and may covertly benefit a course of therapy, but overtly employing multiple and competing frameworks as interventions introduces potential liabilities for the patient by encouraging eclecticism (38). Thus, IPT therapists should appreciate mentalization while continuing to follow the IPT manual guidelines (4).