The Assessment of Mentalization: Measures for the Patient, the Therapist and the Interaction

Abstract

Purpose: Mentalization has been clearly defined in the literature as a relational concept and yet in surveys and transcript-based measures it is almost universally treated as an individual capacity. That approach has value but may not capture the emergent nature of mentalization, as it is jointly constructed within a relational context. Methods: We report here on a critical evaluation of measurement approaches commonly used to conceptualize and assess mentalization and argue for the value of conversation analysis (CA) as an alternative approach. Results: A variety of approaches have been shown to have utility in assessing mentalization as an individual capacity. We illustrate how conversation analysis allows for an in-depth-analysis of mentalization as it is co-created across different contexts in real-life therapy sessions. This method of analysis shifts the focus from content to process. Conclusion: Conversation analysis is a potentially valuable tool to support training, to assess treatment integrity, and to improve outcomes with mentalization-based interventions.

Mentalization in CALM psychotherapy sessions: Helping patients engage with alternative perspectives at the end of life

“…[1] Mentalization has received a great deal of recent attention, although published research has overwhelmingly focused on measuring the capacity to mentalize, rather than on the process by which it occurs in conversation. [7] Conversation analytic studies have more recently begun to examine mentalization from an interactional perspective, viewing it as an enactment in conversation. [8,9] Davidsen and Fosgerau (2015) and Keselman et al, (2016) used conversation analysis to study implicit mentalization in particular, which refers to an unconscious and automatic process that is evident in the tailoring of talk to be responsive to a conversational participant.…”

A Critical Evaluation of the Reflective Functioning Questionnaire

“…introduced the Reflective Functioning Questionnaire (RFQ-8), which is intended to assess an individual's capacity to adequately interpret mental states of both the self and others (i.e., reflective functioning or mentalizing) via self-report. This measure as well as its translated versions have been positively evaluated in several validation studies (Badoud et al, 2015;Fonagy et al, 2016;Morandotti et al, 2018;Park & Song, 2018), leading to the consensual conclusion that the RFQ-8 is able to capture deficits in reflective functioning (e.g., Shaw et al, 2020). The theoretical spectrum of reflective functioning includes hypo-and hypermentalizing (i.e., too little or too much certainty about one's interpretation of mental states), and genuine mentalizing (the optimal trait level, i.e., acknowledging the opaqueness of mental states).…”

Metacognition, social cognition, and mentalizing in psychosis: are these distinct constructs when it comes to subjective experience or are we just splitting hairs?

“…Mentalizing can be defined as the “ability to understand actions by both other people and oneself in terms of thoughts, feelings, wishes, and desires” [ 89 ] (p3). First introduced as a higher-order mental process through which individuals engage in representation and symbolization, the term mentalization was used to characterize the process by which individuals make meaning of human behavior within a context of understanding the mental activities of oneself and other people [ 90 , 91 ]. Fonagy and colleagues [ 92 ] then progressively outlined an attachment-based approach to the development of mentalizing on the basis of observed, early parent-child interactions in borderline personality disorder [ 93 ] and other severe mental disorders [ 94 ] in which there is a failure to understand oneself because of a lack of access to or a negative regard for others [ 95 ].…”

“…In addition to assessing the patient’s capacity for mentalizing, instruments have been created to assess the therapist’s capacity to mentalize. Such measures include the Therapist Mental Activities Scale, Therapist Relationship Interview, and Mentalization-Based Treatment (MBT) adherence and competence scale, which assess the therapist’s own ability to mentalize as well as their ability to promote the mentalizing process within therapy [ 91 ]. A final approach to measuring mentalizing, the interactional approach, derives from the assumption that mentalizing occurs in relationships with others, or within intersubjective contexts [ 91 ].…”

“…Such measures include the Therapist Mental Activities Scale, Therapist Relationship Interview, and Mentalization-Based Treatment (MBT) adherence and competence scale, which assess the therapist’s own ability to mentalize as well as their ability to promote the mentalizing process within therapy [ 91 ]. A final approach to measuring mentalizing, the interactional approach, derives from the assumption that mentalizing occurs in relationships with others, or within intersubjective contexts [ 91 ]. An example of this is Conversational Analysis [ 102 ], a qualitative method that examines the structure and process of social interactions, such as a therapy session.…”