The Mind Under Threat and Re-establishing Communication

I recently saw a post on Twitter that captured an experience I have had multiple times this week. The scene was a client commenting on the COVID-19 pandemic and a therapist being unsure of how to respond. The therapist in question seemingly had little to add other than acknowledgement, affirmation, and silence. As I wandered through the comments section, I found numerous accounts of individuals describing their therapists’ reactions to COVID-19. For example, some described their therapist as speechless; others felt their needs were not prioritized effectively. A select few revealed having uniquely meaningful and improvisational moments (Ringstrom, 2007) with their therapists, but this was not the norm. These exceptions appeared to have in common an abandonment of business as usual and a willingness to enter into the process, rather than control it (Bromberg, 2012), a theme we will return to shortly. However, a more common theme seemed to be a collapsing of internal space (Safran & Muran, 2000) and the inability for two minds to work together to create a new perspective (the essence of effective psychotherapy).

This is where the concept of mentalizing comes into play. This seemingly esoteric word refers to our human ability to reflect on our minds and the minds of others (Allen, 2012). We use mentalizing to think, feel, and understand ourselves, others, and the world around us. A simple example of mentalizing would be genuinely trying to understand all the possible reasons why someone would go to a bar on St. Patrick’s Day in the midst of a public health emergency. Another example would be trying to identify, understand, and evaluate anxious thoughts while contemplating self-quarantining. When we mentalize effectively, we take our thoughts seriously, while being aware of the difference between being afraid of something and being certain something will happen. We consider possible alternatives, rather than getting stuck in one way of thinking. This separation between mental states and reality eases anxiety and allows us to think clearly in times of crisis. On the other hand, problems can also arise when we avoid emotions and uncomfortable facts and pretend there is no risk at all. This type of failure in mentalizing leaves individuals vulnerable to making decisions that are not rooted in a complete understanding of reality and risk (think of sharing a pint of Guinness with a coughing friend in a crowded pub while lauding your singular and spectacular immunity to any illness). A third failure in mentalizing is believing only in what one can see. For example, someone might view an employer not commenting on the pandemic as evidence their employer doesn’t care about their well-being, or a therapist may believe a client missed an appointment because they are not serious about treatment. In these examples, the mind behind the behavior is being left out of the equation. There are countless reasons these individuals acted as they did. The client who missed may have been overwhelmed by other responsibilities, or the employer may be too preoccupied evaluating options to communicate their intentions. Common qualities of mentalizing failures include feeling absolutely certain about something, being overwhelmed by emotions, ignoring facts, being cut off from emotions, or being clueless about what to think/say.

It is no surprise that therapists are prone to the same cracks in mentalizing as our clients. It is worth noting here that the presence of a trusted other person remains the most effective (and neurologically efficient) means of coping with distress and anxiety (Bateman & Fonagy, 2016; Coan et al., 2006). Many of us are fortunate enough to have technological options to maintain connection with our safe havens (e.g., human safety nets), despite social distancing. Maintaining connection is crucial because high stress and problems in meaningful relationships are the two most likely contexts for human beings to lose the emotional protection of our mentalizing abilities (Bateman & Fonagy, 2016). However, being together without being able to mentalize is more like being apart. We become trapped in our current views and unable to learn from and lean on one another. This is likely the state of affairs in the opening Twitter example. When mentalizing and communication breaks down, therapists and clients alike are unable to keep our minds from falling into unhelpful ways of processing information. Below are some examples of comments I have heard from friends, family, and clients as well as some responses that may help restore mentalizing. In the interest of transparency, I’ll say I have not always selected a helpful response in the moment. Thankfully, understanding misunderstandings is one of the best ways to practice mentalizing (Bateman & Fonagy, 2016).

 

When Mind Becomes Fact (psychic equivalence)

Example: “My small business went bankrupt, and my life is over.”

Mentalizing responses:

• Kindness and validation of emotions (START HERE)
• Take a break or pause (e.g., shift to another relevant topic until mind is back online)
• Be curious and genuinely interested in the person’s perspective (don’t suggest different ways of thinking until the person is not overwhelmed and can think flexibly)

 

Pretending Nothing Changed (pretend mode)

Example: “I’m just going to go about my life, because this is all one huge overreaction.”

Mentalizing responses:

• Gently provide evidence and ask about reactions to the data
• Share your own experience of the situation (remember this is your experience, not theirs)
• Use humor or an unexpected response to “jump-start” mentalizing

 

Needing to Do Something or See Something Change (teleological thinking)

Example: “I’d be safer with a gun, because people are going to start getting crazy.”

Mentalizing responses:

• Empathize with the underlying emotions/needs (e.g., needing to feel safe)
• Share your dilemma (e.g., “That would make me worry about you and may actually increase your risk”)
• Do something tangible and appropriate to help (e.g., offer crisis resources or problem solve for places the person can go to feel more safe)

 

Enter the Process

A final suggestion for both clients and therapists is to enter this chaotic process, rather than trying to control it. This means being transparent about uncertainty and being open when caught off guard by unforeseen challenges. How can we help our clients mentalize effectively?  The answer is by mentalizing ourselves (Bateman & Fonagy, 2016). This requires us to acknowledging distress, rather than avoid it. It requires leaning into conversations that fall outside of the standard “therapeutic frame.” And it means being aware of our own mental states (e.g., thoughts, beliefs, hopes, feelings, etc.) and prioritizing clear and honest communication over trying to be wise and clever.

 

Troy Becker, Psy.D., is an early career clinical psychologist out of Columbus, Ohio, where he specializes in working with individuals with eating disorders. He has additional training and professional interests in treating trauma and personality disorders. Troy is a graduate of the Wright State University School of Professional Psychology where he researched positive body image and completed clinical rotations in a wide range of settings including university mental health and opioid/substance use treatment.  

 

References

Allen, J. G. (2012). Restoring mentalizing in attachment relationships: Treating trauma with plain old therapy. American Psychiatric Pub.

Bateman, A., & Fonagy, P. (2016). Mentalization-based treatment for personality disorders: A practical guide. Oxford University Press.

Bromberg, P. M. (2012). The shadow of the tsunami: And the growth of the relational mind. Routledge.

Coan, J. A., Schaefer, H. S., & Davidson, R. J. (2006). Lending a hand: Social regulation of the neural response to threat. Psychological science, 17(12), 1032-1039.

Ringstrom, P. A. (2007). Scenes that write themselves: Improvisational moments in relational psychoanalysis. Psychoanalytic Dialogues, 17(1), 69-99.

Safran, J. D., & Muran, J. C. (2003). Negotiating the therapeutic alliance: a relational treatment guide. New York: Guilford Press.  

 

To contribute to the special series on COVID-19, send blog posts of up to ~1,000 words (read full submission guidelines here) to Analysis Now blog co-editors Justine Duhr at justinetduhr@gmail.com and Robert Levin at rob@robertlevinlcsw.com

 

 

 

If you enjoyed this post, we recommend:

Special Series on COVID-19 by Justine Duhr, MFA, and Robert Levin, LCSW
Thinking Analytically in the Time of COVID-19 by Sandra Green, LCSW