Damian Sendler: It appears that mentalization processes play an important role in social learning and in all types of therapy. It’s still unclear what mentalization processes have to do with psychotherapy. The purpose of this systematic review is to determine if mentalization has a moderating, mediating, or predictive role in the therapeutic outcome.
Damian Jacob Sendler: Mentalization’s role in therapy usually necessitates highly detailed study designs. Mentalization appears to be depicted in a variety of ways in various treatment modalities. While the patient’s mentalizing capacity appears to be relevant to the psychotherapy process, it should be noted. Consequently, psychotherapies should be reworked.
Dr. Sendler; Recent years have seen a rise in the popularity of MBT (Mentalization Based Psychotherapy) in psychodynamic psychotherapy and research. By “mentalizing,” we mean being capable of gaining insight into the thoughts, feelings, beliefs, and intentions of others while also taking into account one’s own. Fonagy, Steele, and Steele [6] developed the mentalizing approach as part of the London Parent–Child project. They found that a secure attachment is not just a result of the mother’s attachment security, but rather the mother’s insight into her early childhood relationship with the parents [8]. Seventy-nine per cent of the mothers with secure attachment styles had children who had similarly secure attachments, as compared to just 28 per cent of the mothers who had insecure attachment styles. Because of their high level of reflexive competence, it is possible to confirm the hypothesis that mothers who reported more negative childhood memories were able to provide coherent statements and coping strategies [8].
Early attachment experiences [8], self-representation, and affect regulation are all linked, according to Fonagy et alfindings, .’s even in patients with severe personality disorders [4]. It’s been found that people with severe personality disorders have a lower capacity for mentalizing than the rest of the population. Other mental illnesses such as depression [14,15,16,17,18] and eating disorders [16] have also been shown to benefit from this treatment.
According to neuropsychological research, the four dimensions of mentalization can be found [19,20]. There are two types of mentalizing: automatic and deliberate. It is a sequential and slow process that is usually expressed verbally and requires a lot of self-reflection to control one’s thoughts. In contrast, automatic mentalization requires only a small amount of attention, intention, awareness, and effort. Problems with mentalization arise in this dimension when people rely solely on automatic assumptions about their own and others’ mental states. In situations where it’s difficult for someone to apply these automatic assumptions correctly, problems can arise. As part of the second dimension, the ability to mentalize oneself and others is included (self- versus other-mentalizing). This refers to the ability to comprehend one’s own and other people’s thoughts, feelings, and desires. Drawing conclusions based on external cues can also be referred to as mentalization (e.g., facial expressions and gestures). However, it can also refer to a person’s internal experience based on what they know about the person and the situation they are in (internal versus external mentalizing). Mental states can be classified in two ways, cognitively and emotionally, using the fourth dimension (cognitive versus affective mentalizing). Affective mentalization entails being able to name, perceive, and deduce the causes of one’s own inner states, while cognitive mentalization focuses on the ability to do so [21]. It is possible for mentalization to take place in any one of the dimensions listed here. There are mentalization difficulties if a dimension (e.g., cognitive mentalization) has too much emphasis on one side of the spectrum [21].
Borderline patients were the original target of MBT, which was developed by Bateman and Fonagy. For patients with severe personality disorders, MBT’s primary goal is to increase their mentalization capacity in all dimensions. According to Allen, Fonagy and Bateman [22], mentalization is a feature in all psychotherapies and that the facilitation of mentalization makes psychotherapies effective [23]. Fonagy et al. [24] have recently expanded the hypothesis from an evolutionary and developmental point of view, indicating that improvement in mentalization is needed to maximize the benefits of social experiences to better get along in the social world. Only in a therapeutic relationship that is seen as safe is this possible. Fonagy et al. [24] argue that therapeutic change can only occur in the context of an epistemic trusting therapeutic relationship. Epistemic trust is the willingness to accept social messages and therapeutic messages that are relevant and helpful to the patient [24]. The foundation of social learning is based on trust in one’s own knowledge and the ability to benefit from one’s social environment. People with mental disorders are thought to have epistemic mistrust, which prevents them from benefiting from social interactions and conversations. Individuals who are unable to update their own expectations and beliefs and adapt to changing circumstances are affected. Epistemic trust enables individuals to adapt their social imaginations to the prevailing social reality through mentalization [24]. Mentalization, on the other hand, is more likely to serve as a buffer. In the absence of epistemic trust, a patient with mentalization difficulties is likely to misinterpret the apparent cues [24]. Therefore, any evidence-based psychotherapy should emphasize mentalization processes [25].
Interviews, questionnaires, or visual tests can be used to assess mentalization or reflective functioning, which is the operationalization of mentalization. As of now, a wide range of instruments are available for assessing various aspects of mental capacity (e.g., the cognitive-affective dimension, [26]). The Reflective Functioning Scale (RFS) [26], based on adult attachment interviews (AAI) [26], is the most widely used expert assessment method. The mental states of the subjects are evaluated on a scale ranging from 1 (rejected reflective functioning) to 9 (maximum reflective functioning) (very high reflective functioning). A valid and reliable instrument, the RFS necessitates specialized training for raters in order to administer. Parental Reflective Functioning Coding System (PRF-CS) was created by Slade and Slade et al. by combining the RFS with the Parent Development Interview (PDI). In order to measure the reflective functioning of parents in relation to their children, their parenthood, and the perceptions of their children, the RFS based on the PDI is a reliable and valid method. An increasing number of studies are attempting to measure reflectivity in specific mental disorders without undergoing the time-consuming AAI procedure. Depression-specific Reflective Functioning Interview (DSRF) [26] is one of these instruments that has shown excellent results in initial reliability and validity studies [26]. Rudden et al. [27] developed a specific interview, the Brief Reflective Functioning Interview, because the AAI has an average interview time of 1 to 2 hours [26]. (BRFI; [27]). The BRFI’s questions are based on the AAI and are meant to elicit answers about one’s own attachment experiences. As with the AAI, the BRFI uses an average value for all ten questions to assess reflective functioning. As a result, the BRFI is a practical, cost-effective, dependable, and valid way to assess reflective functioning.
Fonagy et alReflective .’s Functioning Questionnaire (RFQ) is a recently developed self-assessment instrument. [28] Reflective functioning is assessed with 12 items on two subscales that measure a person’s sense of security or insecurity. Using clinical samples, three studies have shown both reliability and validity, but results from a non-clinical sample show that the level of uncertainty is still too high [26]. The Parental Reflective Functioning Questionnaire (PRFQ; [29]) was created in the same way as the Parental Dilemma Inventory (PDI). Parents’ ability to reflect on their child’s mental health is assessed using the PRFQ, which includes three subscales: pre-mentalizing modes, certainty, and interest. Reliability and validity were confirmed in the first study [30]. We’ve seen all of the methods so far based on Fonagy’s AAI and RF scale [28]. Luyten et al. [4] provides additional methods for measuring reflective functioning, mainly focusing on emotional perception.
In recent years, the importance of psychotherapy based on mental imagery has grown. Aside from social learning, it appears that mentalization processes play a significant role in all psychotherapies. Mentalization processes may play a role in psychotherapy, but no one knows for sure. In spite of research on psychotherapy mentalization processes (e.g. [31,32]), this remains the case. However, the existing evidence has not yet been synthesized in this regard To better understand mentalizing processes in relation to psychotherapy outcomes, a review of studies looking at the relationship between mentalizing processes and other relevant processes is warranted. Mentalization may be moderating, mediating, or even predicating treatment outcome, which is why the current systematic review seeks to find out.
There are a number of ways in which variables can be linked to the success of psychotherapy.
It is a statistical baseline variable that has an interdependent effect on the outcome of research. Subgroups of participants may have different relationships between an independent and a dependent variable, according to the moderator’s recommendations. Consequently, a third variable modifies the impact of an independent variable on a dependent outcome variable [33, 34, 35].
Damian Jacob Markiewicz Sendler: Interfering with the relationship between the dependent variable (outcome) and the independent variable, a mediator is defined as a statistical variable (treatment). As a result of this, both the independent and proposed mediator variables are directly linked to the outcome. Thus, after controlling for the mediator effect, the relationship between treatment and outcome is reduced. mediators alone cannot explain exactly how change occurs, but they can point to possible mechanisms without necessarily being involved in the process [33].
(Not mediator or moderator) A statistical baseline variable is a predictor [35] when it comes to predicting outcomes independent of subgroups.
There must be evidence that the treatment is changing the outcome before any further research can be done on the association between a variable and psychotherapy outcome [35]. Furthermore, without a control group, it is impossible to distinguish between predictors and moderators or mediators of treatment effects. [35].
The following research questions were examined in this systematic review based on these concepts: Are there any links between mentalization and the outcome of psychotherapeutic treatment? When it comes to psychotherapy, does mentalizing play a role as a moderator, mediator or predictor?
Psychotherapy outcomes may be predicted by mentalization, according to five studies. The improvement of outcome variables (with the GSI for symptom distress) was not predicted by linear mixed modeling (LMM) analyses with RFS and time parameters in the study by Antonsen et al. [39]. The results of the six-year follow-up study were consistent with those of Gullestad et al. [40], who examined the same sample after three years of follow-up. HAM-D improvement was significantly predicted by the baseline RFS score ( = 0.75, p = 0.025) in a study by Bressi et al. [45], which accounts for 13.8% of the variance in the HAM-D change. In Ekeblad et al. [46], they found a medium-sized effect of = 0.35 on BDI-II improvement over 14 sessions, which was significant (standardized regression coefficient). Also significant in a three-month inpatient psychotherapy, the RFS also predicted overall improvement (r = 0.37 (p = 0.05) for RFS and the GSI at termination, partialling out the effect of both the overall structural level according to the operationalized psychodynamic diagnostics (OPD), as studied by Müller et al. [53]. Taubner et al. [54] found contradictory results. After 36 months, Taubner et al. [54] discovered that the RFS score at baseline (r = 0.48, P = 0.05) predicted an improvement in the depression index (BDI) by 23.04 percent, while the initial RFS score had no significant effect on the GSI change (r = 0.316, P = 0.17) [54]. There were no significant effects of RFS scores on BDI/GSI scores and changes after 8 months and 15 months of treatment in previous studies [17,18].
Mentalization was measured in two separate studies to see if it could serve as a predictor. Ekeblad et al. [46] used the DSRF in addition to the RFS [26,46]. After 14 sessions, they found that there was a BDI-II improvement prediction ( = 0.41). Using the CRF, Boldrini et al. [44] examined therapy sessions and found that CRF significantly predicted the final personality health index (PHI; [57]) and GAF scores [44]. As a result, Boldrini et al[44] .’s findings do not represent a true predictor analysis because they combined initial scores with those obtained after one month of treatment.
Damian Sendler
No state-of-the-art mediator analysis was conducted in any of the included studies that examined an overall treatment effect (outcome change) with a control condition that also examined the treatment effect on mentalization (change), and if applicable, the effect of the change in mentalization capacity on outcome change. Half of the studies included in this review looked at how mentalization changes during treatment and how they affected outcomes, but the mediating role of mentalization in the therapeutic process was not examined.
Two treatment arms were studied by Fischer-Kern et al. [47] to see how mentalization changed (transference-focused psychotherapy, TCP, and treatment by experienced community therapists, ECP). After one year of TFP, they found significant improvements in mentalization, but no significant improvement in ECP. Mentalization improvement could also be linked with higher outcomes, but the researchers did not investigate the directional causation of mentalization change.
Using the RFS and PSRF, Barber et al. [42] studied early mentalization change in two comprehensive psychotherapy approaches (CBT and Panic-Focused Psychodynamic Psychotherapy; PFPP). They studied the relationship between mentalization change from the beginning of treatment to the end of treatment and the subsequent change in panic severity. Barber et al. [42] found no improvement in RFS for either condition. Both treatments failed to show a significant correlation between early RFS change and change in outcome (PDSS). Different outcomes were obtained by utilizing the panic-specific mentalization tool PSRF. In PFPP, the early PSRF change was significant, but not in CBT. Early PSRF change was associated with a greater change in outcome (PDSS) in both interventions, but was (not significantly) stronger for CBT in the early stages of treatment. The absence of a control condition makes it difficult to determine whether the shift in symptom-specific mentalization was brought on by the treatment itself or something else. Barber et al. [42] found that the magnitude of an early mentalization change has a greater impact on outcome change than the mean probability that a mentalization change will occur, in addition to the fact that there is no early change in RFS (without a significant effect on outcome change).
The RFS change examination is only reported for the therapy condition in the study by Taubner et al. [54] and not for the control condition (baseline RFS scores were reported for both conditions in Taubner et al. [18]). This change in RFS could be a result of the psychotherapeutic treatment, but there is no control group. From the first to the second assessment, the RFS improved significantly (with a medium effect of d = 0.61, p = 0.039), as found by Taubner et al. [54]. Additional research was conducted by Taubner et al. [54] to examine whether there was a correlation between changes in RFS and changes in symptoms between baseline and the 36-month assessment. BDI change was not correlated with changes in RFS nor with changes in GSI change, according to the researchers. Non-significant correlations may or may not be explained by the treatment effect. As a result, the study’s findings can only be interpreted in a very limited way.
Damien Sendler: From session 4 to session 12, Karlsson and Kermott [50] found a significant decrease in RFS (measured on sessions’ transcripts) for IPT, but no significant change in RFS for CBT. There were significant correlations between high versus low RFS and PQS items in a post-hoc analysis. There was a correlation between good outcome scores and PQS items with high RFS and those with low RFS, according to a follow-up analysis of the relevant PQS items and the results. The post hoc analysis did not include a comparison of the interventions. For this reason, it is difficult to determine how mentalization change affects treatment outcomes, given that there is no direct correlation between mentalization change and outcomes.
An analogous BPDT treatment was examined in a second Karlsson and Kermott [50] study (sessions 1, 5, and 14). After treatment, the researchers found no significant change in RFS. In a follow-up study, the researchers used the same post-hoc analysis they used in their initial investigation and discovered links between higher RFS and better or worse outcomes. In spite of this, many correlations failed to be statistically significant, as reported by Karlsson and Kermott [50]. The results are interpreted in a similar way to their first study, which is a limitation.
Damian Jacob Sendler
When discussing mentalization’s predictive role in CRF scores, we mentioned that Boldrini et al. [44] looked at predicting an early period CRF score (which was a mean accumulation of the first four treatments and four treatments after one month of treatment) rather than an initial CRF score. According to Boldrini et al [44], there was no significant change in CRF during the three treatment phases studied (early, middle, late). Analysis of CRF course impact on outcomes was not provided.
Mentalization’s role in longitudinal effects is not clear; Antonsen et al. [39] appear to rule it out while Taubner et al. [18,54] suggest a longitudinal effect, and the results of Boldrini et al. [44] are not comparable due to the different design of data-analysis in the two studies. It appears to be more consistent in shorter studies [45,46,53], all of which support a positive prediction of psychotherapy outcome by the initial capacity for mentalization.
A single study [39] focused on mentalization’s role as a moderator. According to the findings, patients with varying degrees of mentalization may require a variety of treatment modalities.
Psychotherapy can alter one’s mentalization capacity, but this is not always the case. RFS increased significantly in two studies [47,54], one found a significant increase in PSRF (while RFS did not change significantly in the same study), one examined a significant RFS change in the follow-up assessment (while RFS did not change significantly in the same study), and one found a significant decrease in RFS (study 1). Two studies found no significant change in mentalization (study 2) [44,50], and three studies found no change in mentalization (studies 39,46,53) or did not examine it. The results show that the change in mentalization during psychotherapy is not consistent. ‘ A number of studies have shown that mentalization change is affected by at least two treatment conditions (for RFS: [47,50]; for PSRF: [42]). This question remains unanswered in regard to the link between mentalization change and outcome change. However, Fischer-Kern et al. [47] and Barber et al. [42] did find a correlation between RFS changes and outcome changes, while Taubner et al. [54] did not.
Rather than making a clear distinction, the findings suggest that mentalization may play multiple roles in the course of psychotherapy. The concept of mentalization may provide a possible explanation. Self-other and cognitive-affective, internal-external, automatic-controlled [19,20] dimensions may but do not have to emerge and (differently) affect the psychotherapy process at the same time.
Psychotherapy research is still in its early stages when it comes to examining and understanding mentalization’s impact on therapy outcomes, as can be seen from a review of the current state of the field. Mentalization has been linked to psychotherapy outcomes in a small number of studies, but the design of these studies and statistical analyses indicate that at best, the systematic summary of results can only provide indications of the possible role that mentalization plays in psychotherapy…
The lack of data makes it impossible for more than one person to report findings from the systematic review of the included studies. This is one of the findings that emerged from the one-year-long studies: mental changes were observed. It is possible that mental changes will occur during treatment, but only at a certain point in time. Predictive effects are based on studies that show mentalization’s capacity at an early stage should be considered. However, because of the absence of control conditions, these significant findings cannot definitively pinpoint the precise role of mentalization.
According to Allen et al. [22], mentalization is present in all forms of psychotherapy and makes them effective by facilitating mentalization [22]. However, the studies included in this review cannot directly support this assertion. Even though it is still unclear whether or not psychotherapy improves mentalization, different treatment approaches seem to represent mentalization in different ways. There was a surprising absence of MBT in any of the studies. Thus, the role of mentalization in this mentalization-specific treatment has not been established.
Mentalization’s mediating role has yet to be empirically supported in any way, shape, or form. Complex and comprehensive study designs are needed in the future to account for the true effects of mediation. In order to track mentalization during psychotherapy, a more efficient operationalization of mentalization is needed. A timeline of change for the proposed mediator variable must be demonstrated before any changes in the outcome can be shown [34]. Therefor self-report measures and text analysis on computers are appropriate tools. In the meantime, the time-consuming rating measures will have to be used to implement these measures. The comparability of different instruments should also be repeatedly verified despite the existing construct validation, given the current state of mentalization research. It is also possible to examine the advantages and disadvantages of using and developing disorder-specific measures in comparison to a general approach to mentalization. Clinical change mechanisms that have an impact on mentalization (change) and those that are influenced by mentalization (change) necessitate rigorous study designs. Future studies may examine the role of mentalization in more depth by utilizing control groups and examining a wider range of treatment approaches and patient populations.
Despite the fact that more research is needed to definitively define the role of mentalization in psychotherapy, the results of this systematic review have at least one practical implication: the patient’s mentalizing capacity matters, and psychotherapeutic treatment should (also) be tailored to this.
