Alan Sugarman on the Therapeutic Action of Mentalization

"Clarifying that we help our patients change by promoting a process of insightfulness has the potential to reduce the unfortunate tendency to artificially separate interpretation from the relationship with the analyst as the mutative factor in the psychoanalytic process. Central to this technical approach is the importance of attending to the formal organization of patients' minds, as key mental structures and modes of mental functioning are manifested in the interaction between patient and analyst. This emphasis on facilitating a process of insightfulness, with its goal of helping patients achieve and maintain a stable ability to mentalize, wherein key mental functions, not just contents, are subjected to self-reflection and affectivecognitive self-knowledge, reverses figure and ground and the traditional emphasis on knowing just unconscious mental content.

This approach is based on the idea that‘mentalization accounts for a continual, never-ending transformation of psychic contents through the multiplication and organization of representations. This permits the emergence of mental contents and structures of increasingly higher levels of complexity, leading to symbolization and abstraction’ (Lecours and Bouchard, 1997, p. 857). Our technical challenge becomes how to promote this process. Most patients show either circumscribed inhibitions of this process or a failure to have attained advanced modes because of early developmental interferences. A variety of benefits accrue from patients gaining insightfulness at an abstract-symbolic level of functioning (Bram and Gabbard, 2001). Self-other boundaries are strengthened as patients gain a cognitive-affective awareness that they have differentiated and conflicted minds that affect their behavior, and that others do also. Empathy improves with the realization that others' minds may be organized and function in different ways, or contain different feelings and beliefs. Interpersonal interactions are more easily understood and navigated by patients who can mentalize symbolically. Relationships feel safer as patients come to realize that others' actions are dictated by their mental functioning. Reality testing is facilitated, separation-individuation is promoted, and the primacy of secondary-process thinking is enhanced by symbolic mentalization. Finally, affect regulation is improved so that emotions can serve a signal function and not be experienced as overwhelming.

Promoting insightfulness improves self-regulation because patients' minds are better able to maintain homeostatic equilibrium as both their functions and contents become subject to conscious self-reflection and symbolic processing. Thus, patients' sense of self-as-agent are expanded. It should be noted that the role of the past has not been mentioned in this discussion of insightfulness. That is because this perspective does not emphasize the recovery of memories of the past as a crucial element in mutative action. Epistemological questions can be raised regarding whether it is even possible to do this with ‘memories’ of the past. Regardless, learning to mentalize symbolically seems most easily accomplished in the interactional field (Aron, 1996; Levenson, 1972; White, 1996) as patients transfer the organization and contents of their minds into it. Certainly memories from the past usually emerge as patients gain greater access to the workings of their minds. But this is a by-product of good analytic work, it is not essential to structural change. Some patients do need us to help them to understand regressions to or fixations at action modes of experiencing and communicating in terms of their pasts. These explanations are often necessary because patients can feel such shame or anxiety about their actions being seen and put into words. Their shame or anxiety needs to be assuaged before they can reflect more abstractly on the action. Some would argue that such shame or anxiety should be explored verbally instead of bypassed, i.e. Paul Gray (1994). In theory, this approach would be optimal. But some patients' shame or anxiety is experienced at such a concrete, action level that similarly concrete interventions may be necessary. Thus, the point of the genetic reconstructions that are sometimes necessary is not to help patients change by becoming aware of previously repressed mental content. Instead, it is a nonverbal confrontation that shame and/or anxiety are not necessary because their actions are understandable and containable. Hence, the impact lies with the analyst's nonverbal communication, not the content of his reconstruction, except insofar as the content is necessary to catch our patients' attention. Once again, technical interventions are guided by the dictate to promote symbolic insightfulness. This requires greater openness to ways of intervening with patients and deeper thinking into the impact of our interventions. So long as we maintain a commitment to freeing up our patients' mental processes, the more likely we are to transform and liberate their symbolic capacities (Friedman, 2002)." (pp. 980-982)

Alan Sugarman (2006). Mentalization, Insightfulness, and Therapeutic Action: The Importance of Mental Organiation. International Journal of Psycho-Analysis, Vol. 87, pp. 965-987.