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Why Mentalizing Matters in Family Work

While the rest of us were sleeping, Driftwood clinicians Jacob Umanzor, Michelle Whetstone, Natalie Hisey, and Vanessa Kennedy logged on to a London-based webinar at 3:30 AM to train in a treatment modality few therapists genuinely understand. This training aimed to equip mental health professionals with the necessary skills to undertake mentalization-based work with families. Vanessa, Natalie, Jacob, and Michelle represented a minority of American providers confident enough to take on this often-elusive subject. So, what is Mentalization-Based Treatment (MBT), and how does it apply to family work at Driftwood?

Mentalization-Based Treatment with Families (MBT-F) – developed by psychologist Peter Fonagy – is an imaginative mental process that supports clients and family members in overcoming relational roadblocks and gaining a deeper understanding of each other's points of view. Because mentalization-based work occurs at the core of all effective therapeutic processes, the therapist's role is to understand, model, and reinforce effective mentalizing.

The training was hosted by the Anna Freud Centre, a leading UK research hub for mental health interventions with children and families. Named for the daughter of Sigmund Freud and founder of child psychoanalysis, the center builds on Freud's legacy of transmuting psychoanalytic theory into evidence-based practices for family work. Michelle, Natalie, Jacob, and Vanessa learned new methods from Fonagy and his colleagues for engaging clients and families in activities and exercises that confront and alter problematic relationship patterns.

I enjoyed watching these clinicians turn their insights into action during this month's Courageous Family Program, Driftwood's monthly two-and-a-half-day workshop for clients and their family members. Here's what I learned:

What is Mentalizing?

Mentalizing refers to our capacity to interpret behavior in relation to mental states, such as needs, desires, thoughts, and feelings. We say it is an imaginative mental activity because it requires us to conceptualize what's going on inside the mind – what goals, intentions, or reasons lie beneath human behaviors. Mentalizing extends beyond empathy because it requires us to make sense of the complexities of our own mental states and the mental states of others. Self-awareness is a crucial first step in mentalizing, but it doesn't stop there.

Mentalizing is a skill we all naturally possess. It is crucial to our sense of self, emotional intelligence, social resiliency, and cognitive flexibility. However, mentalizing veers off-course when we assume the mental states of ourselves or others without curiosity. Difficulties with mentalizing play a role in a wide range of common mental health challenges like depression, substance abuse, anxiety, and personality disorders.

Why is Mentalizing Important for Family Work?

The treatment team's first task in family work is to understand the entire family's dynamics and how they intersect with a client's mental health condition. For example, there may be dynamics within the family that inhibit a client's ability to progress in their recovery. In a dysfunctional family dynamic, this might look like unspoken expectations, passive-aggressive communication, enabling behaviors, or judgmental assumptions.

In childhood, we're taught how to mentalize by our primary attachment figures. As adults, we may still mimic the judgments, assumptions, and non-verbal cues modeled by our parents. If we haven't learned how to mentalize effectively, it's because we haven't seen it enough in action. We can heal from ineffective mentalizing with the help of a skilled therapist. Effective MBT-F practitioners slow down communication between family members and model emotional vulnerability in real-time. Therapists step into the role of the attachment figure and use mentalizing as a platform to heal these primary attachment wounds. The result is a working model for how this family can interact in a healthy manner.

Courageous family work requires a curious, non-judgmental approach to the familial patterns that blind us. It creates an environment where family members can express themselves without previous roadblocks to communication. Healthy dynamics might look like direct and kind communication, transparency, taking responsibility for one's own emotions and responses, and expressing appropriate boundaries.

What are the core principles of effective mentalizing?

I wanted to learn to mentalize my own family like a pro, so I asked Driftwood Clinical Director and Mentalizing Guru Jacob Umanzor to give me a few tips that he learned from his MBT-F training. The following are some of the core principles of effective mentalizing in family work:

1) Genuine Curiosity. Curiosity means entering a childlike state of wonder. The challenge is to proceed as if everyone we interact with is the expert of their own mind. It is not our job to tell others how they feel. But, if we can leave our assumptions at the door, we're creating a safe space for everyone to share vulnerably.

2) Awareness of Impact on Others. Mentalizing goes beyond empathy. It creates an understanding of the impact of one's behavior on the people around us. Unfortunately, instability in mental health and substance abuse can make it hard for us to be aware of our impact on others. Shame, guilt, and remorse will naturally come up when our behavior doesn't align with our values. When we feel reactive, the challenge is to sit with that shame and ride the wave of discomfort.

3) Perspective Taking. If our minds are too rigid, we limit our ability to see from someone else's eyes. Holding space for and being open to others' experiences helps increase our understanding of them as fallible human beings, just like us.

4) Capacity to Trust. To create a sense of safety for others, we must first trust one another to be honest. For example, if another person states the intention behind their behavior, we should take them at their word.

5) Narrative Continuity. The typical family culture is to not talk about breakdowns in communication or conflicting narratives about the past. A shared family narrative can add to a sense of connection – but we can't know someone else's experience until we ask.

Want to learn more about Driftwood's approach to family work? Read about the Courageous Family Workshop and find links to family resources.