INTRODUCTION
In the articles by Li et al[1], Jiang et al[2], and Yu et al[3], several interventions are mentioned that influence somatic illness and healing or treatment progress when offered within an interdisciplinary working team[4,5]. Motivational psychological nursing and multidisciplinary nursing interventions reduce anxiety and depression in patients with immunological diseases, and psychosocial care supports patients with cancer in their bio-psycho-social well-being and treatment process. Patients’ treatment satisfaction and life satisfaction are intertwined with professionals’ work satisfaction and resilience. The latter refers to adequate affect regulation and reflective functioning, and further to the concept of mentalization that is currently considered one of the most important theories in the field of psychodynamics[6-9].
MENTALIZATION
Mentalization is the most fundamental common factor to all psychotherapeutic methods[10-12]. In this respect, an understanding of the theory and practice of mentalization is also beneficial for all clinical, psycho-therapeutic, and social professions, both in terms of their own mentalization abilities and those of their patients[13,14]. The predecessor to the concept of mentalization was the theory of mind[15]. This is the understanding of recognizing the feelings, intentions, and desires of the other person and thus being able to predict their behavior[16,17]. The basis for this is the ability to perceive oneself and the other person as independent, thinking, feeling, and acting beings[18]. The theory of mind concept emphasizes the importance of the other person’s ideas, intentions, and beliefs in order to predict the other’s behavior, while the concept of mentalization also highlights one’s own mental and affective states and the ability to reflect on them[19,20].
The concept of mentalization refers to the ability to understand both one’s own behavior and that of other people and to adequately interpret the underlying mental processes or emotional states[21-23]. The decisive factor here is not only the specific behavior of the other person, but also one’s own ideas about the inner experience of the other person. These can be intentions, desires, attitudes, or motivations. Mentalization is therefore the interpretation, imagination, or assumption of what is going on in the other person or in oneself, based on specific behavior. The basis for mentalization, therefore, requires a fundamental understanding of psychological and emotional processes, and also an understanding that our own ideas and thoughts about the world are only an approximation of reality and do not necessarily correspond to it. Mentalization is a cognitive and emotional process that enables us to understand the behavior of others and our own behavior and to assign meaning to it[24]. This also includes understanding misunderstandings and being able to clarify them. This requires both the ability to view oneself from the outside and to see into others, as it/they were[10,25,26].
THE MENTALIZING TEAM
From the perspective of evolutionary biology, mentalization represents a decisive survival advantage. By actively understanding the other person, communication and cooperation become much more effective, which simplifies coexistence within the group. However, it is not only understanding and anticipating actions that is an advantage, but also the ability to deceive and manipulate[6]. Fonagy and Bateman trace the origins of mentalization to psychoanalysis and attachment theory[10]. In psychoanalysis, Freud assumed that mental processes precede an action, thus laying the foundation for the concept of mentalization[6]. This ability can only take place in the presence of another human being. Impulses are converted into thoughts that can also be communicated. In this way, frustration and affect tolerance can be developed, which is fundamental to the ability to mentalize[10,27,28]. Through the development of mentalization, an individual is no longer dependent on the caregiver to regulate emotions, but can perceive their own emotions and use them as relevant indicators of their own state of mind and for emotion regulation[27,28]. This is because mentalization in the sense of affect regulation first involves perceiving and recognizing feelings and mental states, followed by the ability to attribute relevance to this information, and furthermore, that this information has a representative character from which psychological and behavior-based strategies for changing mental and affective states can be derived[6,29,30]. So-called mentalized affectivity represents the highest form of affect regulation, which no longer takes place unconsciously or in dependence on caregivers. One’s own affects can be consciously experienced and reflected upon, thereby revealing their meaning[6]. The latter process is highly necessary for teamwork, especially when complex and highly affect-loaded inter-relational processes have to be cared for[31,32].
MENTAL OVERLOAD
Mentalization can fail for various reasons, due to stress, particularly high affectivity, intense relationships, or trauma[33]. In mental overload or even disorders, the failure of mentalization is both a trigger and a cause of the disorder[34]. This leads to more frequent misunderstandings, making it more difficult to take up other perspectives and identify one’s own emotions or mental states[35]. Since the ability to mentalize is based on interpersonal relationships, a failure in mentalization can be contagious, which is often attempted to be compensated for with coercion or control. This can cause relationships to fall into a cycle of mentalization failure[36,37].
The level of emotional arousal is decisive for the ability to mentalize or, conversely, for failure to do so[36]. If the level is low to medium, mental representations can be used in a flexible way. If the level of arousal is too high under stress, the ability to mentalize is limited because less attention is paid to the affective states of the other person[37,38]. Increased affective attachment stress affects the activation of the brain, moving action from cortical to subcortical systems that are involved in stress response, making social relationships more opaque because controlled and accurate mentalization is no longer possible. This occurs in the fight-or-flight responses mentioned above, but also in traumatic interpersonal experiences[36,39].
Mentalization also fails when the ability to mentalize is abused. In this case, the affective state of the other person is used appropriately, but the conclusion is used to deliberately hurt the other person. This is also considered an exaggerated or excessive ability to mentalize, which, however, has a self-destructive effect in the long term[36,40]. The complete loss of mentalization ability occurs in the face of existential threats that result in flight or fight responses. In such situations, slow and process-oriented mentalization would not be an advantage for survival[6].
MENTALIZATION-BASED THERAPY
In mentalization-based therapy, one of the main mechanisms of action is the validation of patients’ affective and mental states and the stabilization of mentalization ability[41]. Nevertheless, the patients’ perspective can still be carefully questioned[42]. Supportive interventions should be chosen that interrupt deficient or inadequate mentalization[43] in order to reflect on affective states and rigid attributions. The focus is shifted away from facts but toward experience and the nature of reflection. The patient’s narrative should be respected, while at the same time adopting an attitude of not knowing. Another intervention is to reflect on successful mentalization experiences, again focusing on the affective experience of the experience. Empathetic validation should help to identify and categorize affective and mental states in order to make them understandable. This is most successful when therapists immerse themselves in the patient’s reality and understand it affectively, communicating this as well. States in which mentalization does not occur should be interrupted in order to return to experiencing and mentalizing. Improving mentalization ability appears to be one of the fundamental mechanisms of action of successful therapy[44-47].
GETTING A TEAM STRENGTHENED
As part of a project run by the Department of Psychiatry at the Clinic Favoriten in Vienna, staff were offered internal training on mentalization and mentalization-based therapy between February 2024 and March 2025, with the effects of this training to be recorded in accompanying research. As part of the training, staff from all departments were trained once a week in a case-based manner and accompanied by (ongoing) monthly supervision provided by a certified mentalisation-based treatment (MBT) trainer. All professional groups within the ward, from specialists to support staff, were invited to participate. In the end, doctors, nursing staff, occupational therapists, social workers, and psychologists took part in the training, including additional monthly workshops on MBT. They were informed about the accompanying research study and gave their informed consent to participate voluntarily in this ongoing study.
The training was designed to teach employees the relevant competencies and skills that influence mentalization ability. The aim of the mentalization project was to improve the quality of communication between ward staff and patients, and to further analyze the employees and patients. The general aim was to raise awareness among all employees about communication with patients. The goal of the evaluation was to determine whether changes in mentalization and affect perception can be observed across the professional groups. The question in the present study was whether changes in mentalization ability and also in symptom burden can be observed in the staff group after the training. To this end, surveys of the staff were conducted at two measurement points before and after the training.
CLINICAL AND ORGANISATIONAL IMPLICATIONS
To compile the sample, the clinic management provided the research group with a list of volunteers who participated in the training. In a first step, these individuals were contacted in writing via their professional email addresses and asked to participate in the study. If they responded positively, they were given the questionnaires, consisting of sociodemographic data with a declaration of consent, D-MentS, and Brief Symptom Inventory (BSI). The Mentalization Scale, in its current form D-MentS[48], is a self-assessment questionnaire for evaluating subjective mentalization ability and contains 28 statements that can be rated on a 5-point scale ranging from 1 (does not apply at all) to 5 (applies completely). It measures both the capacity to understand one’s own affective and mental states and those of others, as well as the motivation to mentalize and deal with mental states. The test also shows coherence with the big five: Empathy, emotional intelligence, openness, extraversion, conscientiousness, and anxiety or neuroticism.
The Brief Symptom Inventory 18 (BSI-18)[49] contains 18 questions, with six items each on the topics of depression, somatization, and anxiety. The 18 symptoms can be rated from 0 (not at all) to 4 (very severe). It is a self-rating questionnaire based on the symptom inventory Symptom Checklist 9, which was one of the most widely used assessment tools in the clinical field. Since the original test was relatively long, two shorter versions were developed, including the BSI-18. This measures psychological distress over the last seven days. Reliability and validity have been confirmed, particularly for larger samples. While anxiety and depression can be measured accurately, this is not the case for addictive disorders[50].
Twenty participants in the training course were recruited as test subjects. Of these, 15 were female, and 5 were male. The test subjects were 40.05 years old on average (SD = 10.97; range = 25-59). In terms of marital status, 11 people were single, 7 were married, and 2 were in a relationship. In terms of nationality, 19 people were from Austria, and one was from Slovakia. The highest level of education was a university degree for 16 people, an apprenticeship for 2 people, and a high school diploma for 2 people. In terms of profession, 8 people were medical doctors (psychiatrists), 5 were nurses, 3 were therapists (occupational, physical therapy, etc.), 1 was a psychologist, 1 was a social worker, and 2 were physicians in training. According to practice-oriented research designs, the number of test subjects is almost equivalent to a full survey, as nearly all employees who participated in the training were included. Thus, the sample size of 20 participants naturally could be much larger, but participation in the training with the respective survey was voluntary without any incentive, and of course, is ongoing. The ethics committee’s approval was obtained, as well as the informed consent of all participants.
SLOW IMPROVEMENTS AND INTERNATIONAL RESEARCH CONTEXT
An interesting finding at baseline was the comparison of professional groups before MBT-training (Figure 1): Medical doctors showed good to moderate values in mentalization capacity (mean: 31.9, min-max: 24-41), nurses low (mean: 29.9, min-max: 18-39), while social workers/psychologists/music therapists/occupational therapists showed the highest scores (mean: 34.3, min-max: 25-40). Further, female and younger professionals showed better mentalization abilities.
Figure 1 Mentalization capacities in professional groups working in an acute psychiatric ward with a supply mandate for > 220.000 citizens (baseline before mentalisation-based treatment training).
Although there was an increase in the DMentS values between the two measurement points (DMentS total T1 = 86, T2 = 96, Z = 0.966, P < 0.05), there was no significant change in the overall BSI values between the two measurement points (BSI total T1 = 7, T2 = 6, Z = 0.783, P = 0.38). Although changes were observed, they were not highly significant. The sample size was probably too small to detect an effect of moderate strength. Thus, the hypothesis of an improvement in mentalization ability and symptom burden after training can be confirmed with a trend in mentalization capacity.
Taubner[47] used reflective functioning values to examine the effect of psychoanalytic case supervision on the mentalization ability of early intervention staff. A change in mentalization ability was observed in terms of the experience of relationship quality and stress levels in a sample of 65 people, most of whom were female. Georg et al[51] examined the improvement in the mentalization ability of early intervention staff who support families through home visits. A sample of 73 individuals was surveyed over a period of seven weeks with four measurement points, revealing a significant improvement in the working relationship.
Welstead et al[52] examined 92 professionals to determine whether a two-day workshop would influence their understanding of mentalization ability and change their attitudes toward personality disorders, and found a significant change in their knowledge of mentalization and personality disorders. Polnay et al[53] investigated the effect of a four-part mentalization workshop on the understanding of personality disorders in a sample of 16 physicians and did not arrive at a clear conclusion. Steinmair et al[54] measured mentalization via the Movie for the Assessment of Social Cognition scores in health care providers after the completion of an MBT training, and found significant improvements. Kirsch et al[55] investigated the mentalization ability of 38 students at three different universities who received intensive small group support over a period of six months, regularly undergoing various forms of mentalization training based on a specially designed curriculum. The results showed a “significant improvement in mentalization ability, an increase in epistemic trust, and a decrease in epistemic mistrust”. Improvements were also seen in the areas of psychopathology and symptoms: A reduction in depression and agoraphobic fears, as well as an improvement in personality functioning[56,57].
The question would be the sustainability of the improvement in the mentalization ability of staff, whether it falls back to its original level after a longer period of time, or whether it continues to develop. In combination with the collection of patient data, a wide range of potential questions can be raised, such as the relationship between the mentalization ability of staff[56] and the development of patient health. One interesting question would be to what extent the mentalization ability of staff influences the health status of patients, as all studies[1-3] that initiated this editorial had shown in a similar way. Further trainings are needed as several examples have pointed out.
OUTLOOK
Especially in the form of continuing educational efforts, programs[57] are highly appreciated, for example, in the context of professionalization in psychotherapy training. One possibility would be a self-reflection or self-evaluation as a form of self-mentalization[58]. As this study is an ongoing one, special interest can be put on the capacity of mentalization of the self (D-MentS-S, a subscale of the D-MentS): Further ongoing investigations showed an increase with middle effect size (MentS-Self: Z = 1.999, P = 0.046, r = 0.48) between the time points and significant negative correlations between mentalization and symptom burden for the second time point (P = 0.022, Spearmans’rho = -0.536)[59].
CONCLUSION
The studies above show that even brief interventions can result in a significant improvement in mentalization ability. The present (ongoing) study cannot demonstrate highly significant findings, but shows differences in mentalization capacities among different professional groups. This can have an impact on the working relationship and indicate which professional groups could benefit the most from mentalization training. But it remains unclear which accompanying functions are additionally influenced. To carry out further measurements and collect data at a third or several further measurement points in time would be interesting and should be focused on. Further the effect on patients’ treatment and their outcome is interesting[60].
Peer review: Externally peer reviewed.
Peer-review model: Single blind
Specialty type: Psychiatry
Country of origin: Austria
Peer-review report’s classification
Scientific quality: Grade A, Grade B, Grade B
Novelty: Grade A, Grade B, Grade B
Creativity or innovation: Grade A, Grade B, Grade C
Scientific significance: Grade A, Grade A, Grade C
P-Reviewer: Deng J, Lecturer, China; Peng ZW, Associate Professor, PhD, China S-Editor: Bai SR L-Editor: A P-Editor: Zhao YQ
