The Connection Between Mentalization and Depression

Mentalization is a psychological skill that shapes our ability to process our own and others’ mental and emotional states. First identified through psychoanalytic theory, this ability is a key determinant of our psychological health and resilience. At its core mentalization involves the capacity to be aware of one’s emotions, thoughts, and beliefs, and to mindfully interpret the actions of others (American Psychological Association, 2021). Mentalizing largely determines one’s mood stability, coherence of thought, stress coping, capacity for empathy, and relationship experiences.

Developing this important feature of social cognition is a lifelong process. However, for those experiencing chronic or acute depression, mentalizing can be substantially more difficult. Symptoms including persistent low mood, decreased overall well-being, and limited ability to engage with the world can prevent individuals from staying mindful of internal states and relationship nuances. Regulating one’s emotions and thoughts and maintaining a fulfilling social life can become significant challenges.

Origins in Childhood Attachment Experiences

One’s ability to mentalize originates in secure, consistent attachment with a caregiver in childhood. Parents who remain attuned to their child’s daily experiences, provide feedback, and model emotion regulation skills teach their children to reflect on and understand their complex internal states (Rothschild-Yakar et al., 2019). Children who receive such support can maintain a more balanced perspective on the intentions underlying social interactions and stay open, flexible, and generous with themselves and others. Those who were not provided with this training are more vulnerable to emotional dysregulation under stress, and can lose their mentalizing ability once their nervous system is hyperactivated (Bateman & Fonagy, 2013).

Physiologically, mentalization skill is determined by the organization of our neural circuits through synaptogensis, or the formation of synaptic connections in the brain. Underdeveloped neural circuits lead to rapid emotional overwhelm when one’s nervous system is under stress (Luyten & Fonagy, 2016). Inherited genetic vulnerability can also predispose individuals to having limited mentalizing capacity. Thankfully, due to the brain’s natural neuroplasticity, the skill can be cultivated through mindful practice.

The Connection Between Mentalizing and Depression

Unhelpful mentalization habits include hypomentalizing and hypermentalizing. Hypomentalizing occurs when one is easily overwhelmed by their thoughts, feelings, and motivations, and struggles to discern those of others. Hypermentalizing involves overestimation of one’s ability to interpret behaviors, often resulting in black and white thinking about others’ intentions (Halstensen et al., 2021). The former can lead to apathy and diminished self-confidence and sense of identity, while the latter can result in feelings of emptiness and alienation. Although these habits can serve as protective mechanisms when faced with stress, they are ultimately oppressive and can lead to self-sabatoge. Within relationships a decreased ability to conceptualize and empathize with others’ emotions can increase emotional reactivity and lead to cutoff and withdrawal (Choi & Murdock, 2017).

Overtime these habits can create or reinforce symptoms of depression (Halstensen et al., 2021). For example, a 2019 literature review found that chronic, severe depression is often accompanied by mentalization deficits. Inversely, strengthening one’s mentalizing skills is a critical moderating variable for depressive symptoms including disconnect from one’s feelings and cognitions, rumination on certain thoughts, and difficulty emotionally differentiating from others. (Fischer-Kern & Tmej, 2019).

Because strong relationships are achieved through being sensitive to the mental and emotional states of others, negative beliefs and instances of rejection can be greatly damaging. In 1996 psychologists Geraldine Downey and Scott Feldman identified the common experience of rejection sensitivity whereby individuals develop anxious expectations of social rejection. Such sensitivity can undermine opportunities to cultivate fulfilling relationships. Fortunately, mentalization can help in navigating complex social dynamics and the nuanced emotions they generate.

Mentalization-Based Therapy

There are evidence-based therapy treatments designed to support those struggling with the challenges outlined above. For example, mentalization-based therapy (MBT) is a psychodynamic approach that is designed to improve mentalization skills. MBT therapists frequently utilize elements of object-relations, existential, narrative, and affect theory (Halsensen et al., 2021) While originally designed to help individuals with borderline personality disorder, recent research has demonstrated that MBT can also augment the treatment of depression (Malda-Castillo et al., 2019; Vogt & Norman, 2019).

The goal of MBT is to promote a more benevolent and flexible approach to exploring our internal worlds, and to increase control over one’s actions. MBT interventions promote social cognition and intersubjectivity, whereby our emotions and thoughts interact with those of others to create healthy relationships. Developing these skills helps individuals experience a more stable sense of self, increase affect regulation, recover more quickly from emotional downswings, and decrease interpersonal conflicts (Mentalization Initiative, 2021). This process also changes the brain’s neurological functioning through consistent practice.

The MBT Therapy Process

During both short term (20 weeks) and long-term (18 months) MBT treatment, the therapist creates a safe environment through providing consistent attunement, sensitivity, and validation. Through reflecting back what clients share and offering different perspectives, the therapist supports the development of affect regulation. This frequently involves increasing insight into attitudes and assumptions shaping instinctive emotional reactions. The therapist helps the client articulate their internal experiences and strengthen their internal representation of their mind’s activity. This process of naming feelings reduces amygdala activation and gradually changes formerly imbalanced synaptic functions (Costafreda, 2008). Because discussing emotionally charged situations can activate the attachment system, treatment may involve use of grounding techniques including breathwork and meditation.

Additionally, the therapist encourages the client to challenge automatic reactions such as self-blaming, black and white thinking, catastrophizing events, and assuming others’ motivations. Through cultivating mindfulness and new ways of relating to themselves, clients strengthen the orbitofrontal function of their brain that controls decision-making (Davidson, 2003). Relationship interventions include interpersonal problem solving and identifying alternative interpretations of others’ behaviors. Ultimately, the client experiences less internal confusion and develops a more integrated sense of self (Fonagy & Adshead, 2018).

Simple MBT Strategies

While MBT techniques are designed to be learned within the context of a supportive therapist-client relationship, there are strategies which are applicable on a personal level. Below are practices that can be applied to our own lives.

Nurturing Yourself

During depressive episodes it can be particularly difficult to maintain an attitude of self-compassion and prioritize self care. This challenge is often reinforced by negative self-talk critiquing one’s diminished capacities to function and enjoy life. Preventing internal spiraling requires that you distrust your self-view and remain curious about what your needs are at any given time. Try to stay mindful of impulses to make big decisions or life changes and choose to place them on hold. Additionally, practice positive self-talk that combats automatic critical thoughts. For example, in response to thoughts such as “I am a failure for struggling with my emotions,” say, “I have shown myself how strong I am by shouldering the burdens of depression, and it is okay to rest when these burdens overwhelm me.” Or, in response to thinking, “No one can tolerate me when I am depressed,” consider, “What would make me feel more seen and heard by my loved ones?” It is helpful to imagine what a compassionate friend might say in response to your painful thoughts.

Slowing Down Thoughts and Feelings

When depressed, thoughts, emotions, and behaviors can often feel tangled together. To slow down these processes and maintain compassionate, conscious awareness, practice regularly asking yourself what you are thinking, wishing, and feeling. Since emotions are signals stored in the body, also consider how your body is feeling and what it is making you want to do. These instincts can reveal and clarify our internal states. If there are unhelpful behaviors that you are trying to change, take note of when they occur and try to identify triggers. Reflect in hindsight on the role of antecedent thoughts, feelings, or events that led to the consequent behavior.

For example, getting out of bed may be made more difficult by the automatic thought that “Today is going to be as painful as yesterday was.” Or the desire to connect with a safe friend may be curtailed by thinking, “They will not be able to relate anyway, so it is pointless to share.” By reflecting on your mental contents in this way, you can more easily identify any restricted thinking that is making coping with depression more difficult. Also, when untangling thoughts and emotions becomes particularly challenging, consider breathwork techniques such as box breathing, diaphragmatic breathing, and alternate nostril breaths. These can soothe your limbic system and help you access your prefrontal cortex, which supports emotion regulation and decision-making.

Stay As Curious As Possible

Experiencing low energy and internal judgments when depressed can make it more difficult to interpret the actions of others and result in myopic thinking. Negative interactions acquire heightened meaning and can trigger significant distress. In response to this, imagine being an objective onlooker witnessing a difficult interaction you personally experienced. You may have felt wronged or maligned in a way that reinforced your negative beliefs and the desire to isolate. Ask yourself, what might be some reasons for the person’s behavior? If they were dismissive, perhaps they were preoccupied with a private issue. If they seemed confrontational, it is conceivable that they were acting out due to personal struggles or even grief. If they failed to attune to you and your needs, it is possible that they have a limited ability to empathize with others due to their upbringing. If they responded to you with aggression, perhaps they were projecting their insecurities onto your situation.

Adopting a not-knowing stance means acknowledging that we cannot be sure what other people are thinking or feeling, and leaves space for curious investigation. Instead of passing judgment on the other person, one maintains an open attitude. Mentalizing in this way can make it easier to express your thoughts mindfully if it becomes necessary to address the person directly, or to simply process your experiences in a healthy way. It also decreases the likelihood of acting impulsively and adopting self-sabotaging behaviors. By staying curious, you create opportunities to maintain meaningful relationships.

Rest in the Unknown

Finally, in the words of author and business owner Scott Galloway, “Nothing is ever as good or bad as it seems.” This mindset reminds us that not only is it in our survivalist nature to fixate on negatives, but it can also be easy to adopt rose-colored glasses about happier memories. Remembering that nothing is ever as good or as bad as it appears can help us hold a balanced view of life and our experiences and decrease internal judgment. The willingness to hold multiple perspectives at once requires practicing radical honesty with yourself. This creates space for developing non-judgmental focus on the present moment, and the possibility for positive action.

For example, mindfully slowing down thoughts and paying attention to one’s body can generate ideas such as taking a comforting bath or becoming curious about how a friend is doing. Also, as a simple mindful practice, try to avoid using the word ‘just’ in your thoughts and conversations, as this commonly indicates the closing down of mental processes. Instead, state your perspectives simply and honestly, and notice how defensiveness is replaced by greater feelings of self-acceptance. These simple mentalization practices can help to sustain hope while navigating the journey of depression.

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