Cognitive behavioral therapy promotes mentalizing

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7
COGNITIVE BEHAVIORAL THERAPY
PROMOTES MENTALIZING
Thr¨
ostur Bj¨
orgvinsson and John Hart
Bateman and Fonagy defined mentalizing as
making sense of the actions of oneself and others on the basis of intentional mental
states, such as desires, feelings, and beliefs. It involves the recognition that what
is the mind is in the mind and reflects the knowledge of one’s own and other’s
mental states as mental states. (2004, p. 36)
They proposed that a lack of capacity to mentalize underlies borderline
personality disorder and perhaps most psychopathology, and they developed
mentalization-based therapy to enhance mentalizing capacity. Nonetheless,
Bateman and Fonagy explicitly note that there may be many roads to facilitate
mentalizing capacity and that facilitating mentalizing may be a common
thread throughout effective psychotherapeutic interventions (see also Munich,
Chapter 6).
Consistent with Bateman & Fonagy’s (2004) view, we build an explicit bridge
between cognitive behavioral therapy (CBT) and mentalizing, and we contend
that interventions employed in CBT are effective in promoting mentalizing. We
begin by noting how some concepts from cognitive therapy dovetail with mental-
izing and then illustrate how cognitive therapy interventions enhance mentalizing
capacity.
Handbook of Mentalization-Based Treatment. Edited by J. G. Allen and P. Fonagy.
2006 John Wiley & Sons, Ltd.

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158 HANDBOOK OF MENTALIZATION-BASED TREATMENT
COGNITIVE THEORY
Although many cognitive and behavior models for therapeutic changes have
been developed, Dobson (2001) identified three fundamental propositions that
all CBTs share: cognitive activity affects behavior; cognitive activity may be
monitored and altered; and desired behavioral change may be effected through
cognitive change. Many pertinent theories have been developed, including cogni-
tive therapy (Beck, 1964, 1976), rational emotive behavior therapy (Ellis, 1962),
and mindfulness-based cognitive therapy (Segal, Williams & Teasdale, 2004). In
this chapter, when we refer to CBT, we are considering evidence-based therapies
that share the three fundamental propositions Dobson (2001) identified.
We agree with Allen’s (Chapter 1) emphasizing the verb, mentalizing, to reflect
cognitive or mental activity. In a similar vein Hayes, Strosahl and Wilson (1999)
wrote,
When we speak of “minds” we are referring here to individuals’ repertoire of public
and private verbal activities (using our technical definition of verbal): evaluating,
categorizing, planning, reasoning, comparing, referring, and so on. Although we
will use the noun form, the mind is not a thing. The brain is a thing, replete with
white and gray matter, midbrain structures, and so on, but the mind is a repertoire,
not a place. “Minding” would be more accurate, if cumbersome, description. (p. 49)
Thus mentalizing is construed as an activity, involving a set of skills, in which
people engage in effective and adaptive functioning when relating to others as
well as to themselves.
Mentalizing can be implicit or explicit as skills can be declarative or proce-
dural. From a social-cognition standpoint, Fiske and Taylor (1991) described
people as cognitive misers, that is, as being unable to process the infinite num-
ber of perceptions, interactions, and events that occur throughout the day. Owing
to the cognitive limitations in fully processing every situation, we take short-
cuts. Although these shortcuts are intended to be an effective use of cognitive
resources, accuracy is often sacrificed. From this viewpoint, effective mentaliz-
ing is often done implicitly. Effective implicit mentalizing involves the automatic
selection of behavioral responses and assumptions based on such mental pro-
cesses as intuition, prototypes and exemplars, or heuristic biases; these can
be quick, efficient, and even protective when we must respond immediately
to threatening or dangerous stimuli. However, such responses can be – and
often are – completely wrong, at which time more explicit processes are needed.
Explicit mentalizing can override impulsive and risky urges that might get us
into trouble, and mentalizing can prevent us from jumping to conclusions before
we embark on an ill-advised behavioral course. Cognitive therapy is concerned
with hitting the metaphorical pause button (Allen, 2005); patients are asked to
stop and think. “What went through your mind before that happened?” is a com-
mon question cognitive therapists ask to make automatic thought process more

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COGNITIVE BEHAVIORAL THERAPY PROMOTES MENTALIZING 159
explicit. Cognitive therapy thus promotes mentalizing in making patients more
aware of the nature and function of their negative thinking.
As the foregoing implies, we are not only cognitive misers but also motivated
tacticians (Fiske, 2004; Fiske & Taylor, 1991). Depending on our motivation,
we can switch from implicit, resource-saving cognitive miserliness to more
thoughtful and thorough strategies for forming impressions and undertaking
actions. To be effective, we think only as hard as we must according to our
evaluation of the situational context. For example, we tend to be more moti-
vated to size up thoroughly our new internist than the person who comes to
install our cable television. Yet a person who had a previous traumatic experi-
ence with an assailant posing as service person coming to their home would be
motivated to make a more thorough assessment. Effective mentalizers are able
to adapt, being sensitive and flexible in utilizing cognitive resources to navigate
their interpersonal environment.
This selective marshaling of cognitive resources implies that explicit thought is
necessary to employ effective strategies. Yet Ferguson and Bargh (2004) review
recent research that indicates that automatic attitudes also can be sensitive to
context and flexible to novel situations. They suggest that automatic attitudes are
functional in that they provide us with evaluative information about an object
within the current situation that is sensitive to the meaning of the object and its
relevance to our goals. Moreover, they assert that we seem to have the ability to
automatically appraise and evaluate novel objects by integrating, outside of our
awareness, evaluative information from multiple sources to deliver an evaluation
about the whole object. Nonetheless, automatic attitudes about other persons,
which involve implicit mentalizing skills, do not do all the work; the importance
of developing explicit attitudes also has been demonstrated.
How do people become effective implicit mentalizers? Much of our behavior
has been shaped by contingency-based learning, such as the successive approxi-
mations of trial-and-error and practice that are employed in acquiring the target
skill of riding a bicycle. Other kinds of responding are more rule-driven, which
allows us to respond to stimuli in precise and effective ways when the slower
contingency-based learning would be maladaptive or even dangerous. We do
not use contingency-based learning to avoid certain types of danger, because it
would be too slow and ineffective. We typically employ rule-governed behavior
when behavioral consequences are subtle, future-oriented, cumulative, or prob-
abilistic. Rules are often remote from contingency learning inasmuch as they
are hypothetical and probabilistic (Hayes et al., 1999). Rule-governed behaviors
allow us to be effective cognitive misers, saving effortful thinking for the vari-
ous important matters that may arise throughout the day. According to Skinner
(1974), rule-following behavior is the veneer of society, whereas contingency-
shaped behavior “comes from the depths of the personality or mind” (p. 140).
Artists, composers, and poets may follow rules by imitating the work of others,

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160 HANDBOOK OF MENTALIZATION-BASED TREATMENT
but they exercise their creative expression by acting in idiosyncratic ways and
are reinforced by their natural excitement or joy. As Picasso reportedly once
quipped, “Good taste is the enemy of creativity.”
Yet Hayes and associates (1999) pointed out that rule-governed behavior is not
without disadvantages. A number of studies demonstrate that excessive use
of rule-governed behavior can lead to insensitivity to the environment. Rule-
governed behavior is less sensitive to changes in the environment than behavior
guided by immediate experience. Rule-governed behavior often leads to rigidity
and diminishes flexible thinking and behavioral responses. Flexibility requires
mindfulness, a concept that overlaps with mentalizing (see Allen, Chapter 1).
Langer (1997)•developed her concept of mindlessness through a series of stud-
•Q1
ies of the pitfalls that automatic responding and inflexible thinking entail. In a
now famous study, Langer and her associates instructed a research subject to
make copies on a photocopier. An experimental confederate was instructed to
interrupt with one of three requests: “Excuse me, may I use the Xerox machine?”
“Excuse me, may I use the Xerox machine because I have to make copies?” Or,
“Excuse me, may I use the copy machine because I am in a rush?” Subjects
let the confederate interrupt when any reason was given, despite the nonsensi-
cal nature of the request to make copies since that is the only plausible reason
to use a copy machine. Why one would be mindless in such a situation has
been the source of much investigation and conjecture. Mindlessness and being
miserly often have unfortunate consequences. Mindlessness can take us out of
the moment and cause us to miss important experiences that are out of the rou-
tine. A more mindful approach is more open, aware, and flexible, such that it
can lead us in a new and creative direction.
Langer’s concept of mindfulness is similar to our understanding of explicit men-
talizing. According to Langer and Moldoveanu (2000), mindfulness consists
of several interrelating elements: openness to novelty; alertness to distinction;
sensitivity to different contexts; implicit, if not explicit, awareness of multiple
perspectives; and orientation to the present. To the extent that the object of atten-
tion is personal or interpersonal, all these facets of mindfulness are consistent
with mentalizing. In Langer’s construct, mindfulness is a psychological state that
uses “basic skills and information to guide our behavior in the present rather
than like a computer program” (p. 23). As philosophers Prinz & Clark (2004)
wrote, “A mind whose ideas are mixed like bricks rather than chemicals would
be an inhuman mind, and it would be a mind unfit for this world” (p. 61).
One key facet of mentalizing and mindfulness is self-awareness, which encom-
passes our capacity to become the object of our own attention and depends on
actively identifying, processing, and storing information about the self (Morin,
2005). According to Trapnell and Campbell (1999), thinking about the self can
take two forms: self-rumination and self-reflection. Self-rumination has been

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COGNITIVE BEHAVIORAL THERAPY PROMOTES MENTALIZING 161
linked to negative mood, whereas self-reflection is associated with more pos-
itive moods. The difference can be depicted in the statements “Oh no, why
did I do that?” as opposed to “Huh, I wonder why I did that?” Self-reflection
implies motivation stimulated by interest and curiosity in thinking about oneself
in contrast to the guilt, anger, and disappointment that is characteristic of self-
rumination. Grant (2001) extended this motivational theme to another closely
related concept, psychological mindedness (PM(), “a form of metacognition: a
predisposition to engage acts of affective and intellectual inquiry into how and
why oneself and/or others behave, think, and feel in the way that they do”
(p. 12). We contend that mentalizing represents the skills necessary to foster and
utilize PM as Grant construed it. Furthermore, Grant argued that “The proposed
model of PM is of relevance to clinical practice because the self-monitoring
and self-evaluation of one’s cognitions, emotions, and behaviors is central to
the successful practice of CBT ” (p. 14). Hence CBT requires and enhances
mentalizing capacity and PM.
Allen (2003) proposed that “We are not behaviorists; we learn intuitively to
postulate hidden mental causes to make sense of behavior, and behavior makes
no sense otherwise” (p. 98). We disagree. We are cognitive-behaviorists. What is
the benefit of knowing the mental states of others if not to anticipate the behavior
of others? We assume the benefit of the feeling of being loved by one’s significant
other is the security of the predictability that he or she continue to behave
lovingly toward us in the future. Despite the acknowledged improbability of a
spouse acting lovingly toward their mate without having loving mental states,
nonetheless what would be the difference? Mentalizing about our significant
others may be the glue that holds loving experiences together.
COGNITIVE THERAPY
The distinction between effective and ineffective mentalizing is fuzzy; does the
behavior or the consequence define the concept? Allen (Chapter 1) points out
that mentalizing is a value-laden concept, entangled with ethics and virtue. This
further complicates the picture: how badly or ineffectively does one have to think
about another person in order to be an ineffective mentalizer or to not mentalize
at all? How distorted or maladaptive can the person’s thoughts be before he
or she becomes an ineffective mentalizer? A successful con man or swindler
may be skilled in considering the thoughts, feelings, and desires of others with
the intention to deceive. Is the swindler mentalizing? Not entirely, according
to Allen’s view. Recognizing that mentalizing is a skill with many gradations,
we follow his lead that mentalizing entails adaptive and flexible mental activity
compatible with moral and ethical considerations, and we will use the word in
this sense.
We have argued that mentalizing indicates that the person has acquired sets of
skills. He or she is able to apply flexible thinking across various situations,

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162 HANDBOOK OF MENTALIZATION-BASED TREATMENT
is socially adept, is able to be empathic, and is capable of dealing effectively
with interpersonal challenges. How does one foster mentalizing in persons who
are deficient in applying these skills? How do we address maladaptive or dis-
torted thinking about other persons, negative automatic thoughts that arise in
interpersonal situations, or the tendency to jump to conclusions? Challenging
maladaptive thinking patterns is the centerpiece of cognitive therapy (Clark &
Beck, 1999). Beck and Weishaar (1989) define this centerpiece as a “collabo-
rative process of empirical investigation, reality testing, and problem solving
between therapist and patient. The patient’s maladaptive interpretations and
conclusions are treated as testable hypotheses” (p. 285). Cognitive therapy is
an ongoing, fluid process in which collaboratively planned interventions are
intended to become part of the patient’s way of experiencing the world and him-
self or herself. Challenging the maladaptive negative thoughts extends beyond
examining the content of a belief or the truth and falsity of any particular thought
to how the process of thinking functions within a person’s life and the world
that he or she lives in.
Cognitive therapy focuses on supporting the patient to challenge maladaptive
thinking through collaborative empiricism and on helping patients evaluate the
evidence for their interpretations or meaning-making conclusions. We challenge
patients’ assumptions or negative thoughts by asking them to consider questions
such as: “What is the evidence that he or she did not like you?” “How do
you know that the person was angry with you?” “If the person were angry
with you, then how would you cope with the situation?” This process is not
intended to arrive at any particular correct answer inasmuch as there are many
possibilities; rather, the process provides practice in flexible and creative thinking
about alternative thoughts and strategies in response to a disturbing situation. In
the process, patients develop a keener sense of how their mind works and how
the ways their mind works influence their thoughts, feelings, and behavior.
Conceptualizing a patient within cognitive theory takes into consideration aspects
of the patient’s past that have contributed to the formation of the most central or
deep-seated maladaptive core self-beliefs or schemas (Beck, 1976; Beck et al.,
1979). Beck postulated that, when these maladaptive core beliefs or schemas
are activated by negative life events, these beliefs fuel symptoms of depression.
These symptoms are maintained by automatic negative thoughts and maladaptive
behaviors (e.g., procrastination and avoidance). According to Beck (1964, 1976),
these core beliefs or schemas tend to fall into two broad categories: helplessness
and un-lovability (see J. S. Beck, 1995 for detailed discussion). Specifically,
Beck postulated that these maladaptive schemas or beliefs can be organized
around four views: self, others, the world, and the future. Persons, Davidson and
Tompkins (2000) argued that the most prominent maladaptive beliefs or schemas
pertain to self and others – the territory of mentalizing. Depressed patients, for
example, are likely to have distorted and negative core beliefs or schemas, such
as “I am inadequate,” “I am inept,” or “I am a failure.” These patients often

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COGNITIVE BEHAVIORAL THERAPY PROMOTES MENTALIZING 163
experience automatic negative thoughts about various situations triggered by
serious life events, such as “I cannot handle this!” or “Why bother? This isn’t
going to work.” These automatic negative thoughts that stem from distorted
schemas in turn fuel depressive mood, hopelessness, and procrastination.
Cognitive therapy emphasizes the automatic aspect of maladaptive thoughts that
often arise without the awareness of the patient, without any effort or inten-
tion. Several techniques, which are beyond the scope of this paper, have been
developed to address automatic negative thoughts (see J. S. Beck, 1995; Persons
et al., 2000). It is important to note, as Gluhoski (1994) admonished, that cog-
nitive therapy is not merely a collection of techniques. Rather, the patient and
therapist develop a collaboration intended to promote an inquisitive, exploratory
attitude toward thinking – in effect, a mentalizing attitude. Two main therapeutic
tools are frequently used to challenge automatic thoughts (a process called cog-
nitive restructuring): the Socratic method and the thought record. The Socratic
method entails guided questioning to help patients become more aware of their
maladaptive interpretations of events. The thought record, which mirrors Beck’s
cognitive theory, entails documenting the situation that triggered the automatic
negative thoughts in conjunction with emotions and behaviors. Most importantly,
the thought record promotes alternative ways of thinking about events, reinforc-
ing the experience of multiple mental perspectives. Several different versions of
the thought records exist, and it is unclear what particular method is most effec-
tive (Beck, 1995; Persons et al., 2000). Clearly, however, employing thought
records in some form is effective in alleviating depressive symptoms (DeRubeis
& Crits-Christoph, 1998).
To illustrate how cognitive therapy potentially facilitates mentalizing, we present
a case illustration of a patient who became very defensive when he met with
his inpatient treatment team at the Menninger Clinic. The treatment team had
told this middle-aged lawyer that he used humor and intellectualization to avoid
emotional experience. The patient had said that he genuinely wanted help, to
be understood, and to collaborate with the treatment team members to reach
these goals. In cognitive therapy terms, we established that he had an intense,
pervasive fear and avoidance of humiliation and embarrassment; therefore, he
had a strong urge to be right. This is illustrated in the example below, where the
patient became angry when there was a diversion from his expectation; a trivial
issue became major power struggle. The core belief or schema that was activated
in the following illustration was his basic sense of inadequacy and vulnerability.
This core belief was reflected in his conditional assumptions, “If I am wrong,
then I will get criticized” and “If people disagree with me then they are out to
get me.” Conditional assumptions are typically expressed in contingent “if –then”
statements. Maladaptive if–then statements are associated with imperatives or
rigid rules of thought and behavior not only for the patient but also for those in
the patient’s interpersonal world. For example, this patient had the imperative
that no one should ever get the best of him and that he must never be wrong.

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164 HANDBOOK OF MENTALIZATION-BASED TREATMENT
The following illustrates a therapeutic interaction between the patient and his
cognitive therapist following a meeting with the treatment team.
PATIE N T : “When I meet with my team I get very defensive, and
yesterday I got very angry. In our individual meeting,
my doctor said that I needed to stay in the hospital
one week longer, but later in the clinical rounds she
said that I only needed to stay a couple of days.”
COGNITIVE
THERAPIST:
“And that made you angry?”
PATIE N T : “Yes, so I called her on it.”
COGNITIVE
THERAPIST:
“What reason would she have to say that?”
PATIE N T : “She was just trying to save face in the team.”
COGNITIVE
THERAPIST:
“So it came down to her own thoughts and feelings
about herself being more important than your
treatment. Is that how you understood it?”
PATIE N T : “Well she was wrong. What she said was one week and
I wanted to make sure the rest of the treatment team
knew it.”
COGNITIVE
THERAPIST:
“So what I understand you to be saying is that you
wanted to make sure that the treatment team knew
that you were right?”
PATIE N T : “Yeah, this is like we discussed before. If I am wrong I
feel embarrassed or humiliated.”
COGNITIVE
THERAPIST:
“And what does it mean to be embarrassed?”
PATIE N T : “I don’t know. I may have forgotten. If it’s a work deal,
then I can get angry and go on the attack. If I’m with
friends, then I just make a big joke out of it.”
COGNITIVE
THERAPIST:
“Do you think it was the doctor’s intention to embarrass
or humiliate you?”
PATIE N T : “I guess it felt like it, but my experience of her is that
sheisnotthekindofpersontodothat.”
COGNITIVE
THERAPIST:
“So, your initial thoughts and feelings about what was
going on actually turned out to be contrary to how
you experience your doctor?”
PATIE N T : “Yeah.”
COGNITIVE
THERAPIST:
“So I wonder why you reacted so strongly on your first
interpretation of this situation, rather than basing it on
your previous experience with your doctor?”

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COGNITIVE BEHAVIORAL THERAPY PROMOTES MENTALIZING 165
PATIE N T : “I guess that’s what I’m here for. It wouldn’t be too
hard to figure out that this has something to do with
my dad, who always thought I was wrong and didn’t
hold back from telling me.”
COGNITIVE
THERAPIST:
“Did this seem similar to experience you might have had
with your father?”
PATIE N T : “My doctor is obviously not my father.”
COGNITIVE
THERAPIST:
“Do you think your approach to this was effective?”
PATIE N T : “Oh no, it was completely ineffective – I got nowhere.”
This illustration demonstrates the patient’s misreading the mind of his doctor, a
failure of mentalizing. He attributed motivations and intentions to his doctor that
were contrary to his previous experience of her. The patient’s core belief is that
he is inept or inadequate. When this basic belief is activated, he feels embar-
rassed and inadequate. This patient feels vulnerable when he is wrong or makes
mistakes. Therefore, he operates under the conditional assumption that, if he is
wrong, he will be criticized. Feeling criticized, he becomes overwhelmed with
embarrassment and humiliation. The therapy did not focus primarily on the con-
tent of his thoughts that led to the threat of embarrassment or humiliation (e.g.,
viewing his doctor as if she were his father); rather, the interventions emphasized
the patient’s relationship to these feelings, that is, what these emotions mean to
him, how he interprets them, what behaviors they trigger, and what other inter-
pretations he might consider. In addition, the therapist focused on the function of
his thoughts and feelings and how they thwarted him in reaching his stated goals
(“I got nowhere”). His goals shifted from being understood and maintaining a
collaborative, helping relationship with his doctor and treatment team to avoid-
ing embarrassment and humiliation. The therapist then challenged the patient
to explore if he was willing to commit to his stated goal of being understood
and working together and at the same time allowing himself to experience the
feelings of embarrassment and humiliation.
Another theme was at work with this patient: he was willing to sacrifice accuracy
for coherence. Despite the fact that he was arguing over whether he was right
or not, he was willing to overlook the accuracy of his actual experience of his
doctor for the sake of maintaining the coherence of his basic belief system. That
is, he maintained that people would take advantage of him, particularly when
he perceived that he was being questioned, challenged, or otherwise not taken
seriously. Research by Swann and his associates (Swann, Rentfrow & Guin,
2002) has demonstrated that we are motivated by self-verification. That is, to
satisfy needs for prediction and control, we seek to evaluate ourselves in ways
that will verify our existing self-concept. We will distort information not to make

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166 HANDBOOK OF MENTALIZATION-BASED TREATMENT
ourselves feel more positive but rather to gain a better sense of consistency and
coherence as to what we already believe about ourselves. This is all well and
good if the self-views are positive but, according to Swann, people will gain a
better sense of security and predictability even if they confirm negative beliefs
about themselves if they hold a generally negative self-concept. The patient
we described seemed to be motivated to confirm his self-concept that he was
a vulnerable person, not be taken seriously, easily humiliated, and basically
ineffective in getting his needs met. His petty and argumentative attitude was
directed toward verifying negative core beliefs about himself.
Although people are motivated to seek self-verification, this motivation can be
overridden when they feel it is in their best interest. A fundamental task of
cognitive therapy is to help people become more effective motivated tacticians.
To experience himself in a new light, the patient must be willing to feel the
tension and negative feelings that dissonance with his self-concept creates. We
encouraged the patient to reappraise his feelings as part and parcel of a desired
process of change rather than automatically deflecting disconfirming evidence
of negative self-beliefs. Cognitive therapy helped this patient to develop the
adaptive notion that people can have flexible thinking or be able to take others’
perspectives. Hence we were encouraging him to have others’ minds in mind,
that is, to mentalize.
Segal, Williams and Teasdale (2002, 2004) have developed a cognitive therapy
for depression enhanced by mindfulness training, an approach that overlaps con-
siderably with mentalizing (Allen, 2006). In this therapy, patients are trained
to purposefully pay attention to the present moment in specific, non-judgmental
ways. Mindfulness training involves learning de-centering skills in which patients
come to realize that thoughts are just thoughts and not fully representative of
one’s reality. One of the tenets of mindfulness-based cognitive therapy holds
that negative thoughts underlying a dysphoric mood involve critical process-
ing modes that are automatic in nature. These critical processing modes have
become automatic through well-practiced, habituated, cognitive routines; but
they are nonetheless extremely dependent on highly controlled central processing
attentional resources. Mindfulness training endeavors to shift to a cognitive-
processing mode that is fully in the present and attentive to moment-to-moment
experience regardless of the emotional valence. According to Segal and his
colleagues, this mindfulness mode encourages the free and open experience of
thoughts, feelings, and bodily functions; hence it reduces the experiential avoid-
ance that constitutes various forms of psychopathology.
Keeping in mind Bateman and Fonagy’s (2004) definition of mentalizing as “mak-
ing sense of the actions of oneself and others on the basis of intentional mental
states, such as desires, feelings, and beliefs” (p. 36), we propose that experien-
tial avoidance is commensurate with ineffective mentalizing – particularly with
what Fonagy and colleagues (2002) call mentalized affectivity, namely, feeling

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COGNITIVE BEHAVIORAL THERAPY PROMOTES MENTALIZING 167
and thinking about feeling simultaneously. Pivotal in experiential avoidance is
the intolerance of emotion. In Leahy’s (2003) cognitive behavioral model, our
responses to feeling states are organized around emotional schemas. By definition,
schemas organize abstract forms of behavior, desires, attitudes, and attributions
in contrast to the more prolonged process of recalling a multitude of specifics that
guide even the most basic social interaction (Moscowitz, 2004). Leahy (2003)
advanced a model in which emotional experience reflects universal concepts
and processes while allowing for individual differences in particular beliefs and
response strategies. The nature of these beliefs and strategies will determine how
problematic emotional experiences will become.
Habitually, the socially phobic person ineffectively mentalizes the emotional
schemas of others. For example, persons with social phobia often hold the belief
that being anxious means being weak or incompetent; consequently, they may
misread the minds of others by assuming that others hold this same set of beliefs.
Under the scrutiny of others, an emotional schema can be activated that guides an
ineffective response associated with various safety behaviors. A socially phobic
person may wish to be approached by others in a social situation but may expend
a great deal of energy in looking calm, cool, and collected – an effort that comes
off looking aloof and angry. Such a person will look unapproachable, reinforcing
negative beliefs about self and others. The initial detection of anxious feelings
will signal vulnerability to negative evaluation.
Consider the case of a college instructor who had socially anxious reactions dur-
ing his classes. He believed that, if his students knew he was anxious, then they
would conclude that he was ineffective as teacher, because teachers that are anx-
ious do not know what they are talking about. Despite this man’s best effort to
hide his emotional state, he was unable to do so. One of his particularly troubling
and uncontrollable physiological symptoms was profuse sweating – prominently
on his forehead – that was hard to hide even if, as a safety behavior, he wore
short-sleeve shirts in the middle of the winter. To promote effective mentalizing,
he was encouraged to reflect on alternative perspectives from his vantage point as
well as that of his students. Because of his intolerance of uncertainty, no amount
of challenging maladaptive assumptions would produce the certainty to which
he aspired. In fact he became quite good at recognizing and challenging his mal-
adaptive assumptions by becoming a better mind reader. Nonetheless he retained
residual anxiety whenever he entered a classroom. Practicing mindfulness skills
helped him observe and accept his experience of anxiety. To address directly
his emotional avoidance, exposure techniques were employed. These techniques
activated his emotional schemas, facilitating both acceptance and change. Thus,
in a variety of ways, the treatment improved his mentalizing capacity.
Thus we are working with what Leahy (2003) called individuals’ theory of
emotions, that is, the theories built on the basis of emotional experience. Indi-
viduals build theories about a variety of mental activities, including intrusive

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168 HANDBOOK OF MENTALIZATION-BASED TREATMENT
thoughts, recurring traumatic imagery, the nature of worry, or the meaning
of panic symptoms. For example, the cognitive activity of worry serves to
reduce the physiological response of anxious arousal, including such physiolog-
ical responses as heart and respiration rates as well as galvanic skin temperature
(Borkovec, Alcaine & Behar, 2004). Worry is linguistic in nature and is typi-
cally experienced as self-talk. The relative left-hemisphere activation involved
in anxious self-talk might help to dampen right-hemisphere processing of more
intensely emotional experience associated with imagery and visceral responses.
Worry is reinforced by patient’s excessive focus on catastrophic fears that rarely
come true, thus reinforcing the perceived protective nature of worry. In addition,
worry is a mental activity that interferes with active problem solving; chronic
worriers would rather fret than engage in effective activities. CBT encourages
people to engage in real and effective problem solving despite increased anxi-
ety. Hence, excessive worriers are not being effective in keeping their mind in
mind. And excessive worries about avoided situations prevent them from experi-
encing disconfirming evidence that is invaluable in modifying their rigidly held
schemas.
Emotions provide us with information concerning the state of affairs of others,
our environment, and ourselves. Emotional awareness – mentalized affectiv-
ity – promotes change, and avoidance of emotion blocks change. Inadequate
or maladaptive emotional processing inhibits our ability to communicate effec-
tively about what is on our minds. Constricted emotions and impaired emotion
regulation makes emotional experience a poor source of information and not
useful in navigating patients’ internal and external worlds. Emotional avoidance
often takes the form of maladaptive covert and overt strategies to avoid unwanted
and intolerable emotional experience as seen in the form of unnecessarily risky
behaviors, obsessive-compulsive rituals, substance abuse, and so forth (Hol-
land, 2003).
Mentalization-based treatments build on creating agency within the patient and
a framework for understanding their mind as they keep other persons’ minds in
mind (see Allen, Chapter 1 and Munich, Chapter 6). One of the main strengths
of cognitive behavior therapy is the easily understood framework it provides
for therapy. In our experience, patients are very receptive to this framework;
it makes intuitive sense and provides a platform to tackle maladaptive thinking
patterns. The collaborative work that takes place is aimed at helping the patient
be his or her own cognitive behavioral therapist (Heimberg & Becker, 2002).
CONCLUSION
Plainly, the ability to understand the minds of others as well to have some clar-
ity about what is happening in one’s own mind promotes adaptive functioning.
In this chapter, we have conceptualized mentalizing as a psychological process

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COGNITIVE BEHAVIORAL THERAPY PROMOTES MENTALIZING 169
that uses sets of cognitive skills that promote personal wellbeing and adaptive
interpersonal functioning. In addition, we have illustrated how one might con-
strue the therapeutic action of CBT as promoting mentalizing; in effect, cognitive
therapy provides highly structured ways of practicing mentalizing.
“Mentalizing” has become a part of the vernacular of the Menninger Clinic. Even
without full appreciation of the concept’s roots in psychoanalysis, attachment
theory, and developmental psychopathology (Fonagy et al., 2002), patients and
staff members seem to use “mentalizing” in a meaningful pragmatic way to
describe a more flexible and reflective style of thinking. Hence, as we construe
it, CBT interfaces well with the institution’s emphasis on mentalizing as well
as providing systematic and well-researched strategies that effectively promote
mentalizing.
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Queries in Chapter 7
Q1. This reference has not been listed in the reference list. Please provide the
reference details.