Minding Emotions: Cultivating Mentalization in Psychotherapy

To contextualize Elliot Jurist’s Minding Emotions: Cultivating Mentalization in Psychotherapy, it seems useful to situate it in relation to the series of contributions by Fonagy and Target (1996, 2000, 2007; Target and Fonagy 1996; Bateman and Fonagy 2004) which, under the heading “playing with reality,” created and began to elaborate the concept of mentalization. This work received an early major exposition in Affect Regulation, Mentalization, and the Development of the Self (Fonagy et al. 2002). That work might be seen as having introduced a paradigm shift, in Thomas Kuhn’s phrase, in psychoanalytic thinking about development, psychic structure, and psychopathology. While not radically incommensurable with earlier psychoanalytic theories, mentalization theory offered a substantial reorganization and extension of many earlier part theories. To apply Kuhn’s notions about scientific ideas further, the current volume might be seen as an aspect of “normal science,” an essential process in the further development of and integrative working out of advances implicit in the revolutionary notions constituting the paradigm shift. With notable concision Jurist carries the concept of mentalization into our understanding of emotion, and specifically into an elaboration of the concept of mentalized affectivity. In doing so, throughout this volume he brings together empirical research in psychology (including his own Mentalized Affectivity Scale as an appendix) and neuroscience with psychotherapeutic clinical data, material from autobiographical writings (including memoirs by Sarah Silverman, Tracey Smith, Ingmar Bergman, and Oliver Sacks), and contemporary developments in a number psychoanalytic schools of thought. Interestingly, while he acknowledges that mentalization concepts owe a debt to psychoanalytic theorizing, he does not identify them with any of the many schools of thought within psychoanalysis. He emphasizes wider integration within various psychotherapeutic schools and scientific and humanistic disciplines. His clinical examples are not psychoanalytic vignettes, but do involve his use of psychoanalytic principles in psychotherapy. He repeatedly emphasizes his intention to bridge the sorts of disciplinary divides described by C. P. Snow in 1959.

He begins his study of emotions by providing an exploration of three categories of emotional experience: identifying, modulating, and expressing emotions. Under the first of these headings, he takes up the clinically rich notion of aporetic emotions, the “category of not knowing what we feel” (p. ix). He considers this notion in relation to earlier psychoanalytic concepts, including alexithymia. He explores nuances of meaning involving emotion regulation, emotion modulation, and the role of mentalization in these activities. In his exploration of the expression of emotion, he begins to develop the theme of the clinical centrality of the communication of emotion, which will become an organizing principle in his argument for an overarching “communication paradigm.”

Using the ideas about emotion that he articulates, Jurist makes the case for mentalized affectivity as an essential constituent of therapeutic action. Regarding this much contested question, he asserts that all good therapists mentalize. He argues that this applies not only to those informed primarily by psychoanalytic principles but also to therapists practicing other forms of psychotherapy. He also underlines the importance of the therapist’s “stance of not knowing,” “joint mentalizing” between therapist and patient, and therapists’ “knowing when and when not to mentalize” (p. 131). As Jurist explores a variety of aspects of the therapist-patient relationship as it bears on increasing mentalized affectivity in the patient, some methodological issues seem to me to be left unclear. For instance, is it important that therapists mentalize because this lets them directly convey the “how to” of mentalization to their patients, thereby promoting greater mentalization and mentalized affectivity? This position seems supported when he writes, “therapists can actively encourage patients to compare and evaluate beliefs, formulating on a personal level what is related to the activity of ‘critical thinking’” (p. 134). This kind of approach has been advocated by others as an element of mentalization-based therapy (MBT). Alternatively, does Jurist, with his emphasis on the therapist’s “not knowing,” want to suggest a therapeutic stance centered on the therapist’s effort to understand the patient’s manner of mentalizing her affective experience, however apparently primitive or different from the way the therapist mentalizes? In this mode, increased mentalization in the patient might be thought of as following from therapist and patient reaching a joint comprehension of the patient’s theory of mind, or manner of spontaneously using mentalization.

This distinction seems to me significant insofar as the first therapeutic stance, involving a sort of suggestion of better modes of mentalization, derived from the therapist’s way of doing so, could easily run afoul of transferential compliance and countertransferential overinvestment in the therapist’s preferred notions of how the affective expressions in question might best be mentalized. The second stance I have described, which takes into account such complexities as transference, countertransference, and defensively disguised modes of mentalization, seems more consistent with Jurist’s emphasis on the value of truth and truthfulness (following the philosopher Bernard Williams [2002]) in the therapeutic process. But my second alternative may imply, more than Jurist would prefer, a focus on the patient’s truth, sometimes expressed as the Freudian notion of psychic reality. Fonagy and Target emphasize this notion in their early writings on mentalization and “playing with reality,” but it is a notion that Jurist seems to consider overused. ¹ In place of this earlier emphasis by Fonagy and Target, he appears to underline the social aspects of psychotherapy concepts and what he repeatedly describes as the “communication paradigm.” In his interesting account of justification in relation to subjective truth, he invokes the trio of accretion, secretion, and excretion. Accretion involves “accumulating knowledge by adding layers over time.” Secretion is described as “akin to the leaking out of secrets.” Excretion is related to discharge, “where something is dumped out and disposed of” (p. 138). But some ambiguity remains, I think, in Jurist’s account of the therapeutic process as it facilitates mentalized affectivity. While it may certainly be crucial that therapists mentalize, does he understand the joint mentalizing of therapist and patient as leading to affective content as the therapist would construe it, or to a joint comprehension of that content from the patient’s point of view, as an articulated and mutually understood expression of reality or truth as experienced by the patient? If what is sought is the latter, would communication of the mentalizing Jurist attributes to “all good therapists,” no matter the therapeutic modality or methodology, suffice?

In his penultimate chapter Jurist takes up the matter of mentalized affectivity in relation to a variety of contemporary schools of psychoanalytic thought. This part of the volume is useful not only in offering thoughtful perspectives on other psychoanalytic theories in terms of the insights and claims of mentalization theory, but also in the way it provokes reflection on the place of mentalization concepts in relation to their contribution to psychoanalysis. In considering Bion’s work, Jurist finds parallels between Bion’s ideas about “proto-mental experience” (beta elements) and aporetic emotions. Transformations of beta into alpha elements would then have something in common with the change that occurs when aporetic emotions become available as mentalized affects. In like manner Jurist considers Bion’s concept of the activity of thinking (1962) as addressing territory similar to the activity of mentalizing. He raises questions about Bion’s privileging of a focus on the present over the past and the future, and what Ogden (2015) understands as Bion’s privileging of the analyst’s intuitions.

Jurist takes up the more recent work of Antonino Ferro and his Bion-influenced but more intersubjective field theory. This includes Ferro’s concept of “proto-emotions,” which Jurist compares again to aporetic emotions. These are transformed through “alphabetization” into emotions, in a manner perhaps comparable to the process of mentalization. Both Ferro and Jurist agree here on a connection to mentalization. Where Jurist clearly parts ways theoretically with Ferro involves the latter’s view that empirical research and infant observation are useful only in “generating metaphors” (p. 148).

In considering the contributions of relational psychoanalysis, Jurist cites the work of Lewis Aron on the validity of the patient’s observations about the psychology of the analyst as concurring with some of his own views, including that “the regulation of emotions often involves others” (p. 152). Jurist reviews Jessica Benjamin’s evolving perspectives on mutual recognition in psychoanalysis, and finds her emphasis on mutuality compatible with his understanding of the interpersonal aspects of the development of mentalization. Philip Bromberg’s concept of “standing in the spaces” between dissociatively separated self-states has been connected, as Jurist notes, by Bromberg with mentalization, but not with any concept of a unitary self, as articulated by mentalization theory. Jurist finds rich soil for the cultivation of mentalized affectivity in Donnel Stern’s accounts of unbidden affective experience in the context of “relational freedom,” but wonders about the absence of a role for reflective functioning and modifications of autobiographical memory in Stern’s account of therapeutic action. Jurist questions the tendency of the relational school to privilege process over content in describing therapeutic action, and what he sees as tendencies to diminish the value of science, narrativity, and “the embrace of truthfulness, and the communication paradigm” (p. 160).

These considerations about the relations between mentalization theory and mentalized affectivity as a concept with other current lines of psychoanalytic thought invite us to also consider the position of the mentalization school in the larger world of psychoanalysis. Does it make sense to consider it as a new paradigm in Kuhn’s sense? It seems to me that this characterization might better fit the relational school, which seems to strive for the requisite incommensurability with earlier approaches, emphasizing its rejection of drive and structure concepts and, at times, the value of self-knowledge. The thrust of mentalization theory, as Jurist asserts, is integrative. This includes the bringing together of science with the humanities, empirical research with clinical experience, and insights from a variety of psychoanalytic schools often seen as incompatible. To the extent that mentalization theory derives much from extensions of developmental and psychopathological concepts from the tradition of structural theory, mentalization might be understood as a developmental line, leading to the elaboration of particular psychic structures. This would seem likely to create gaps with other theoretical stances, many of which have rejected much of structural theory. Mentalization theorists, from Fonagy and Target on, have nevertheless artfully and innovatively incorporated aspects of various theories, such as those of Bion, into their conceptual framework in a way that enriches psychoanalytic understanding of a wide array of clinical phenomena. Jurist, in the current volume, continues in this tradition, and illuminates the understanding of emotions for psychoanalysts, psychotherapists, research scientists, developmentalists, and humanistic thinkers of many stripes. Perhaps it is not surprising that no more than other theories does this one define a unique method of arriving at any individual’s particular psychic truth.