In memory of Lew Aron, psychoanalyst, scholar, teacher and friend.

Mentalization — the effort to make sense of our own and others’ actions, behavior, and internal states — is something we all do. And it is a capacity that all psychotherapies aim to improve: the better we are at mentalizing, the more resilient and flexible we tend to be. In his new book — Minding Emotions: Cultivating Mentalization in Psychotherapy — Elliot Jurist reviews and reconceptualizes mentalization in psychotherapy, focusing on how to help patients understand and reflect on their emotional experiences. The book interweaves clinical vignettes with discussions of memoirs by comedian Sarah Silverman, poet Tracy Smith, filmmaker Ingmar Bergman, and neurologist Oliver Sacks. Joshua Maserow spoke to Dr. Jurist for Public Seminar. Read the discussion below.

Public Seminar [PS]: Over a decade ago you co-authored Affect Regulation, Mentalization and the Development of the Self with Peter Fonagy, György Gergely, and Mary Target. Is Minding Emotions an outgrowth and extension of the positions, arguments and research you wrote about in that text? How does the notion of mentalized affectivity differ from mentalization?

Elliot Jurist [EJ]: Yes, I see Minding Emotions as an elaboration of the 2002 book, reflecting my interest in incorporating philosophy and literature in psychology and psychoanalysis. The book is an interdisciplinary study that is intended as a contribution to research, theory and practice. I argue that emotions are a crucial basis for human agency, illustrating this with clinical material and autobiographical narratives by Sarah Silverman (the comedian), Tracy Smith (our poet laureate), Ingmar Bergman (the filmmaker), and Oliver Sacks (neurologist, and inventor of a genre of science writing).

I would like to elaborate on some of the ways that mentalization theory has evolved since the earlier book — hopefully, avoiding being too technical. First, the role of mentalization as part of psychotherapy has been articulated to a much greater degree. Bateman and Fonagy have developed “mentalization-based therapy” (MBT), an evidence-based treatment for severe personality disorders, which has shown success, in particular, in that patients continue to improve post-treatment. MBT has been adopted by a number of national health care systems in Europe, although it is less well known in the US. There is also growing interest in the idea that success in psychotherapy entails improvement in mentalizing (although this would not have to imply that it the exclusive aim of the work). I will have more to say about the implications regarding better mentalizing as an aim of psychotherapy in response to your second question. Second, our understanding of the relation between attachment and mentalization has deepened and become more complex; for example, the original assumption that mentalization emerges from secure attachment, it turns out, is not entirely correct, in that recent empirical research suggests that mentalizing abilities can be discerned in infants, rather than at 3-4 years old, as false belief experiments had suggested. Moreover, there is now a greater appreciation and understanding of how attachment and mentalization can function antagonistically; for example, borderline patients sometimes lose their ability to mentalize, when their attachment systems are activated in inappropriate contexts, like a work environment. Third, mentalization theory has undergone a shift, where it relies less fully on attachment, and more on the notion of communication. Attachment exists in many species of animals; human communication has evolved as a way to help us to be able to cooperate to an unparalleled degree. Communication also marks our fundamental sociality, which has been underestimated in psychoanalysis, and it is at the heart of psychotherapeutic work. Parenthood is construed anew, in this account — as an effort to bring to being children that are competent to function within a given culture, not just autonomous, individuated agents. Understanding mentalization in terms of communication leads to a recognition of the function of psychotherapy as a kind of communication repair shop. A series of new terms from the work of Sperber, Gergely and others, have been applied to psychotherapy, such as “epistemic trust” and “epistemic vigilance.” Epistemic trust denotes the capacity to be receptive to the knowledge that others might possess and share; epistemic vigilance represents the capacity to discern and evaluate who and when to trust (or not). If a patient’s capacity for epistemic trust has been damaged, that person might be inclined to hear anything that a therapist says about him/her as manipulative or as an attack. Epistemic trust implies that patients must be open to listen to and learn from therapists in order to benefit from therapy; epistemic vigilance depends more on patients’ resources, that is, not just where they value the input of the therapist and share agreement, but where they might disagree, where a patient might question the therapist or convey that he/she might be mistaken.

Finally, let me address the significance of mentalized affectivity, which focuses on the affective aspect of mentalization, and thus can be considered as a response to those who have been critical that mentalization seems to be overly cognitive. Mentalized affectivity shares much in common with the term “emotion regulation,” although it involves a different ratio of cognition/affect, where affects can live and breathe, rather than being subdued by cognition. Mentalization can be about beliefs, values, and not just emotions. The concept of mentalized affectivity comes from my clinical psychology dissertation, was first published in the 2002 book, and developed since then by my students and me (see: Greenberg, et al., 2017), and my articles on the subject.

PS: What do you hope Minding Emotions will contribute to contemporary psychoanalytic thought? In other words, what might readers encounter in it that has been hitherto un- or under-explored?

EJ: Psychoanalytic readers will be exposed to new ideas about emotions, ranging from “aporetic emotions,” emotions that are opaque and confusing, to more creative use of emotions, which I explore through the autobiographical writings that I have mentioned. In one sense, emotions have always occupied a central place in psychoanalytic practice; in another sense, they have been viewed skeptically, as threatening to the primacy of drives. Even relational psychoanalysts have not focused adequately on emotions. Among contemporary psychoanalysts, post-Bionians have been interested in describing and contending with so-called proto-emotions. There is overlap with my view of emotions, although I am agnostic, rather than dogmatically negative, on whether such emotions can be put into words. In general, there has been surprisingly little attention to how psychoanalytic ideas about emotions fit with or differ from a wider sampling of the literature.

In my book, psychoanalytic readers will encounter constructs and research from other fields, which they may or may not be familiar with, such as the process and mindfulness models of emotion regulation, autobiographical memory, and autobiographical narrative. It is salutary for those devoted to psychoanalysis to be acquainted with and learn from other perspectives, even if they ultimately disagree. In many ways I would locate my position as consistent with an intersubjective or relational perspective; my original contribution is in specifying what we mean when we claim that the work is about the relationship, namely, that we help people to cultivate mentalized affectivity. A key point is that mentalizing, even about oneself, entails being open to the mentalizing of others, and joint mentalizing. The aim of psychoanalysis falls short of the ambition of self-knowledge; rather one gains a sense of familiarity and comfort with the self, and thus a capacity to deal with whatever happens, including, inevitably, giving negative affects their due.

PS: What are some of the ramifications of lacking an optimal ability to mentalize affectivity? Can one lack a satisfactory ability to mentalize affectivity while retaining a robust capacity to mentalize?

EJ: I am ambivalent about our potential to achieve an optimal ability for mentalized affectivity, as it requires an ongoing effort, and, to be forthright, some amount of failure. The good news is that with effort one can become better at mentalized affectivity, and that, as our research suggests, it might be a useful direction as a way to predict and make sense of well-being.

Your question about mentalizing well without mentalized affectivity is captivating, but not easy to answer with strong conviction. Mentalizing, in general, should not be taken as pathological, although I can easily imagine a mentalizer who risks indulging thinking at the expense of action (which we might connect to the defense of intellectualizing). Hamlet’s problem! Fonagy has outlined various, flawed kinds of mentalization, such as hyper-mentalization (where there is an avoidance of reality, with unquestioned assumptions and/or excessive inferences) and pseudo-mentalization (where one holds beliefs with too much certainty). When it comes to psychotherapy, it is rather impossible to imagine how mentalizing could be promoted without including emotions as objects. Regardless of differences among psychotherapy orientations — such as psychodynamic or CBT, they must engage patients’ emotions in order to be effective.

PS: Following on from the above questions, what are some of the deleterious consequences of a block in being able to effectively mentalize affectivity?

EJ: Not being able to use mentalized affectivity would mean living without knowledge of oneself or others. And when we refer to others, it can be intimate others, that is, people who know you well and presumably might offer perspectives that can help you to be able to understand yourself, and general social others (representing the values of the culture). Our research has shown that people who have various kinds of psychopathology have trouble with processing emotions, a component of mentalized affectivity, and less so with the other two components, identifying or expressing emotions. I am interested in links between the components of mentalized affectivity and specific kinds of psychopathology. However, I am also intrigued by a new approach to understanding psychopathology, the “p factor,” (p is for psychopathology) which suggests there is a single dimension that can predict liability to mental disorders and accounts for the assorted manifestations of psychopathology that can ensue. Rather than the familiar categories of psychopathology, the p factor is based on an aggregation of three domains (externalizing, internalizing and psychotic experiences), ranging from low to high.

PS: I was really excited by the discussion centering on the relationship between mentalized affectivity, therapeutic action and truthfulness. Can you briefly outline how these concepts hang together in your conception of healthy therapeutic process?

EJ: I am pleased to hear this, as this is where I see myself developing mentalization theory in a new way. What appeals to me about the term “therapeutic action” is that it is not restricted to changes that occur during psychotherapy; its meaning transcends this to include the aspiration for growth after psychotherapy comes to an end. Mentalized affectivity represents the desire, not just to no longer to feel badly, but to feel well. As I have suggested, feeling well is not just a matter of having positive emotions; it requires us to tolerate, fathom, and make use of negative emotions. That is where the connection to truthfulness becomes manifest. Loewald discerned this, referring to the love of truth (he was a student of Heidegger). I prefer to use the term truthfulness: nothing guarantees our ability to attain truth, yet there is a lot at stake in being bound to the underlying conditions of truthfulness, which the philosopher Bernard Williams avers as “accuracy and sincerity.” Therapists should be less defined by the wish to make brilliant insights than by the willingness to be self-correcting, and to acknowledge their part in enactments. Therapists who mentalize exemplify a non-knowing stance in contrast to other therapists who work with emotions, like EFT (emotion-focused therapy) or DBT (dialectical behavioral therapy) therapists. Truthfulness emerges between therapists and patients in various forms that I articulate — accretion, secretion and excretion. Without truthfulness, there can be no mentalized affectivity. Mentalized affectivity that is rooted in truthfulness elevates the quality of communication. So, one could say that mentalized affectivity, therapeutic action and truthfulness are bound together through the aim of communication. I want to emphasize that what I mean here by communication deserves more fleshing out than I have done here. Perhaps the most challenging aspect of this dawning perspective is that psychotherapy must involve social life, not just private life, and mentalized affectivity is about cultural memory, not just individual memory.

PS: You appear to be one of a handful of psychoanalytically-oriented scholars committed to empirical research. In fact, your research team has generated some intriguing findings using the mentalized affectivity scale, a self-report measure assessing mentalized affectivity. Can you tell us a bit about those findings as well as how you maintain an interdisciplinary commitment to theoretical and empirical knowledge building?

EJ: Actually, there are many, and certainly many who are more accomplished than I am. There is a well-established cadre of psychoanalytically-oriented researchers who interact on a lively list-serve that has approximately 700 members! Psychoanalytic research is more ignored than it is non-existent, and is a central focus of the remaining doctoral programs that identify as psychoanalytic. My intellectual identity has roots in philosophy and has also been formed by being the editor of Psychoanalytic Psychology for a decade, and now editing a series of books for Guilford Publications, Psychoanalysis and Psychological Science.

During the nine years that I spent as the director of the doctoral program in clinical psychology at CCNY (CUNY), we moved in the direction of training students to do research in a more serious way. For example, the program has always run a mental health training clinic, The Psychological Center, in Harlem, serving children and adults, since its inception in the late 60s. There is amazing clinical work that takes place there; however, until fairly recently, we held beliefs about what we accomplished, but we lacked any data to confirm who we helped and why. Anyone who loves and cares about psychoanalysis should embrace research, given that it is the language that can be understood across the boundaries of different modalities.

Our measure, the Mentalized Affectivity Scale (MAS) is currently being used at the Psychological Center, its first use on a clinical sample, along with a number of other measures. It has been translated into 9 languages so far, so we are particularly excited about learning from its use cross-culturally. In terms of what we have learned so far, subjects who had a diagnosis of psychopathology were better at identifying but worse at processing emotions. That they might need help with processing was not a surprise; however, the finding about identifying did surprise us. Is it an artifact of that if someone has a diagnosis, he/she is likely to have logged time in psychotherapy and therefore, become practiced with identifying emotions? We are cautious about interpreting this finding, as it would seem that some kinds of psychopathology would entail trouble with identifying. We should also keep in mind, too, that we do not know if the subjects who affirmed an interest in identifying emotions were able to identify them accurately.

In the Epilogue to my book, Minding Emotions, the final section is entitled “Science, But Not Just Science,” where I emphasize that it is the quality of research that counts, not merely doing research. There is a proliferation of research in the field of clinical psychology, not all of it so great, which has coincided unfortunately with a de-emphasis on clinical training. As a philosopher and a psychologist, I am committed to thinking as the basis of good research, and I encourage researchers to be sensitive to the concerns that clinicians have (as well as to be open to literary sources), and clinicians to be curious about research, which can correct biases and stimulate us to think further.

The study of emotions, as I see it, requires both science and hermeneutics. Mentalized affectivity is constructed as an interdisciplinary concept that combines what we do not yet know about emotions with the hope that, with effort, we can have more granularity about our emotions, a wider palette of emotions, and more flexibility about how they are deployed.

PS: Finally, what is next? Do you have other book and research projects in gestation?

EJ: I am contemplating several new projects. I intend to continue my work on emotions, autobiographical memory and narrative, and creativity, perhaps in the form of a popular book on “How to Do Things with Emotions.” My publisher has asked me to consider a volume that would compare different psychoanalytic perspectives with the accent on how they differ clinically, not just theoretically. I am also interested in a project with some colleagues about mentalizing across the lifespan, particularly focusing on how parents mentalize about their children in their own psychotherapy (and how therapists respond to this).

Finally, I would like to pursue ideas from Minding Emotions concerning the need for psychotherapy to change as an institution, given the different expectations of people coming to psychotherapy.

On the research front, my team is continuing to put the MAS to work — looking forward to seeing the results of the research at the Psychological Center, where both therapists are completing the measure as well as patients, thus rendering it less reliant on patients’ self-report. We have become interested in exploring whether the component of expressing emotions might have different cultural meanings, for example, coded with some amount of negative valence by East Asians. In order to pursue this, we have conducted a qualitative study, asking the translators of the MAS to tell us about their experience translating the measure, specifically where they had difficulty and why. We are also continuing to focus on mentalized affectivity and well-being, as we have promising results indicating that the MAS predicted well-being better than a number of other commonly used measures, like the Difficulties in Emotion Regulation Scale (DERS), the Emotion Regulation Questionnaire (ERQ), the Reflective Functioning Questionnaire (RFQ) (Reflective Functioning questionnaire), and the flexible regulation of emotional expression scale (FREE).

 

Elliot Jurist is Professor of Psychology and Philosophy at the Graduate Center and The City College of New York, CUNY. From 2004-2013, he served as the Director of the Clinical Psychology Doctoral Program at CUNY. He teaches doctoral level courses on Clinical Practicum, Ethical and Professional Issues, Practicum in Supervision and Consultation, Contemporary Psychoanalytic Theory and Psychoanalytic Conceptions of Mind, Character and Agency. Minding Emotions: Cultivating Mentalization in Psychotherapyis available for purchase on the Guilford Press website here, and on Amazon here. To read an excerpt please click here

Leave a Reply