How therapy works - mentalisation

The idea for this article came from listening to the psychoanalyst and clinical psychologist Peter Fonagy speaking on Radio 4's The Life Scientific (Jan 2020). Along with colleagues, Fonagy developed a therapeutic approach called mentalisation, or mentalisation-based treatment (MBT), to help patients who were more difficult to treat. Realising that his analytic techniques were not working for all of his patients, he decided to research how they could be more effective. He concluded that some patients needed help simply understanding what was going on in their minds and those of others.

This type of basic emotional and cognitive understanding, which the majority of us have mastered to some degree, helps people control impulsive behaviours and sustain better relationships. According to Fonagy, all successful therapies contain an element of mentalisation, helping us develop our internal narrative and improving our emotional literacy.

How does therapy work?

Many people come to therapy looking for relief from painful feelings or due to difficulties in personal relationships. These two issues may appear to be distinct but are closely linked. We are all social beings in a fundamental sense, meaning that we are born into, and exist within, a network of relationships with others. These may be close family relationships, friendships, collegiate relationships at work, or those forged through shared interests.

Patterns of relating start very early in life. A parent or carers' ability to translate their feelings into thoughts and words enables them to teach their infants how to do this as well. They 'teach' this in two ways, by modelling such behaviour themselves, and by talking to their baby or child about their feelings and helping to soothe them. For example, a child who cannot have the toy she desperately wants in a shop may be sad, but also frustrated. A parent who can tolerate an outburst of crying or shouting and name the child's feelings is demonstrating that emotions can be thought about and understood.

People who have not had the experience of having their feelings regularly understood and spoken about tend to struggle to find words to describe their emotions, and this leads them to either burying those feelings or acting impulsively on them, rather than being able to communicate them to others in a helpful way. An example would be reaching for a few drinks when you feel sad rather than speaking to someone close to you.

If this has been your experience, you may unconsciously seek out partners and friends who remind you of your family and who are similarly not able to meet your emotional needs. After repeated experiences of feeling let down and alone, you may have given up trying to get your needs met and turned to other methods of coping instead, such as overeating, being a workaholic, excessive exercise regimes, drugs, or alcohol. However, none of these behaviours is ultimately satisfying for more than a brief period. They are temporary fixes which need to be repeated again and again when their effect wears off. They do not address the underlying issue and do not lead to change.

If a parent can help a child interpret their emotional experience, they equip them well for their adult lives. Therapy can provide a similar experience in adult life, especially where it was lacking at an earlier stage, or when adverse experiences have knocked someone emotionally off-balance.

People who can understand their feelings well and communicate these to others verbally are more likely to get their emotional needs met. Repeated experiences of being listened to and understood can lead to increased self-esteem, closer relationships with others, and a sense of greater overall emotional satisfaction.

Historically, there has been a lack of empirical research into how therapy works, especially psychoanalytic therapies which focus on unconscious processes and the effects of our past on our present. Fonagy is aiming to change this. His research demonstrates that one of the key things therapy does is help us to mentalise and that mentalising is at the core of our ability to function effectively as human beings.

References

Al-Khalili, J. (Host). (2020, Jan 28). Peter Fonagy on a revolution in mental healthcare [radio programme]. In Anna Buckley (Producer), The Life Scientific. BBC London: BBC R4