Introduction

How does a person come to intuitively know that a certain look from their partner means they have had a tough day at work? How can best friends have entire dialogues with each other without completing a single sentence? For millennia, philosophers have thought about how the mind works, and twentieth-century playwrights, novelists, singers, and poets have told stories about what it is like to be inside someone else’s mind. More recently, psychologists have used experimental methods to deepen our understanding of how our minds work. But in our everyday life we are all philosophers of the mind—almost all of us devote substantial amounts of our “headspace” to wondering what is going on in other people’s heads, and tracking our own thoughts or feelings. There are several terms that have been used to cover this territory of thinking about thoughts—mental-state inference, Theory of Mind, intentional stance, reflective functioning, and mentalizing—all of which signify the ability to represent something beyond, behind, or simply different from physical objects, moving bodies, and expressive faces. We have increasingly come to realize that such “mind-wondering” is pretty central to social interaction, culture, and morality—and, while we are at it, to politics, religion, and technology. In the world of mentalization-based treatment (MBT) we have focused on the concept as a way of making sense of mental health difficulties, and used it to shape a new form of psychotherapeutic treatment.

We all know what mental states are—they encompass intentions, beliefs, pretense, irony, and knowledge; the German philosopher Franz Brentano identified that what they have in common is being about something [Reference Brentano1]. The other thing about such mental states is that they require qualification, such as “I believe that… .” They need this note of caution because thoughts lack physical substance and are invisible to others—but, of course, despite being intangible, they can have very real consequences through their power to direct action. Human beliefs are determinants of behavior with massive observable consequences; for that reason, they are of far greater significance than the physical world from which they emerge and with which they have only a loose relationship. To give an example, the last European victim to be burned at the stake for witchcraft was a woman in the Polish city of Reszel, in 1810. Three years earlier, there had been a fire in the city for which no cause could be found. A woman—who for years had been suspected of witchcraft—was accused and tortured, and although she did not admit to the offense, she was declared guilty and sentenced to be burned at the stake. The case went through every level of the Prussian court, even reaching the king, but the sentence was upheld and the execution was carried out. There are many more dramatic examples of the horrendous impact that false beliefs can have, and human history stands as testament to the gravity of the consequences of mentalizing when it goes wrong. This book describes how MBT seeks to harness what we know about the human mind’s sometimes troubled fascination with the content of other human minds, in order to help to improve the treatment of mental health disorders. We shall start in Part I (this chapter and Chapter 2) by giving some background on mentalizing, the ideas that are behind it, and the evidence base to support it. The bulk of the rest of this book is quite practical—we aim to give a concise overview of MBT and how it is applied in different situations and with different groups of patients. But first we shall give a theoretical overview.

“Theory of Mind” was a term first used half a century ago to refer to the capacity of people to anticipate the actions of a protagonist acting on a false belief (looking for an object that was, unknown to them, displaced). As the Theory of Mind industry took off, a wide range of experimental designs and philosophical conceptualizations began to be squeezed into this shallow suitcase of “having a Theory of Mind” (e.g., Daniel Dennett’s concept of “taking an intentional stance”) [Reference Dennett2]. Because Theory of Mind mixed the concept with an experimental design, and risked reifying such a multifaceted and abstract activity, another term—mentalizing—was independently proposed by two psychologists from dramatically different traditions. Uta Frith introduced the term in presenting a cognitive account of autism [Reference Frith3]. Peter Fonagy launched it from a psychoanalytic perspective when thinking about the interpersonal difficulties experienced by patients with a diagnosis of borderline personality disorder (BPD)—in particular, the clinical experience of working with someone for whom thinking about the content of other people’s minds was so aversive and frightening that in certain situations it became impossible [Reference Fonagy4].

In the meantime, Anthony Bateman and Peter Fonagy—as peers and colleagues in clinical training and practice—found themselves increasingly aware of and concerned by the ineffectiveness of help that was currently available to individuals with a diagnosis of BPD within the UK’s National Health Service. Reviews of treatments in the 1990s, at the time when MBT was developed, indicated that 97% of patients with BPD who presented for treatment in the USA received outpatient care from an average of six therapists. An analysis of outcomes measured 2 to 3 years after treatment suggested that this treatment was at best only marginally effective (see [Reference Lieb, Zanarini and Schmahl5]), and that most patients failed to improve or even deteriorated—suggesting that the psychosocial treatments being provided actually impeded patients’ capacity to recover. In Michael Stone’s classic follow-up of patients, a recovery rate of 66% was only achieved after 20 years [Reference Stone6]. A rethink about treatment approaches was required, and MBT was developed for the treatment of BPD in the 1990s to meet some of this need. Perhaps because MBT emerged as a response to this gap in the clinical options available, it has always been an unashamedly pragmatic approach. Although its origins are in psychodynamic psychotherapy, it quite openly cherry-picks whatever techniques are available from other models that enhance robust mentalizing, and it studiously avoids interventions that have the potential to undermine mentalizing, in order to minimize potential harmful effects of therapy.

MBT is primarily informed by the idea that mentalizing is a complicated task that we all wrestle with quite a lot of the time and which, as with most complex skills, it is easy to do badly, often regardless of how hard we try. Some feelings are complex and hard to pin down—for example, who can say that they completely understand love? Talking of which, intense emotions often disrupt mentalizing (for more on this, see Chapter 2), even though understanding feelings is one of the primary tasks of mentalizing. Mentalizing is made even more difficult by the fact that people often do not want to reveal their mental state, and so the evidence that we have about what they are really thinking may be very much less than what we need. Often we make assumptions—sometimes wild ones—about what people are thinking. We sometimes presume mental states as potential explanations of behavior, and use this theory as an explanation for others’ reaction to us (e.g., “I have heard them explaining their work far better in the past; they must have been quite anxious—you know, perhaps they were feeling intimidated by having to explain what they’re doing to us”). This kind of reasoning can be quite simple, but as situations become more complex and more players are involved, these lines of thinking become more elaborate (e.g., what does A think I think about B, and how does B understand A’s relationship with C?). We offer these examples of how easy it is to mentalize inaccurately to suggest that humility in relation to mind reading has to be the order of the day. In fact, perhaps the clearest indicator of poor mentalizing is excessive certainty when faced with such complexities.

Concluding Remarks

In summary, it seems that we are saying something quite contradictory—that mentalizing is quite an ordinary and everyday process (we all do it, all of the time, and we all know that we do it even if we have never thought of ourselves as “mentalizers” before), and yet it is also multifaceted, liable to go awry, and sometimes needs careful attention. This is part of the paradox of human consciousness—its nature and complexities form one of the great unsolved mysteries of philosophy and science, but most of the time we use it to plan ahead or mull over why our neighbor is being so annoying as we try to navigate within our social world. In Chapter 2 we shall explain more about what mentalizing is and why thinking about it can be so helpful for understanding psychopathology, beginning with the different facets—or dimensions—of mentalizing, and how we tend to act and think when mentalizing goes “offline.”