In reading about attachment theory, David Wallin's description of Peter Fonagy's work was intriguing, so I went down that rabbit hole.
Fonagy developed Mentalization-Based Treatment (MBT) to improve emotional regulation, as distinct from Jon Kabat-Zinn's Mindfulness-Based Stress Reduction (MBSR). Fonagy sees our mental development as relational, but in order to have empathy for others, we need awareness of our own feelings, which can be helped with mindfulness work. However, in looking at the evidence of efficacy of these separate modalities, I question the attempt, since Freud, to make psychology into a natural science. Each of the various ways to help are useful, but there's an element of the unknowable in the way when we treat them scientifically.
According to Wallin, Fonagy's focus was on developing the understanding of the mental states of others, which he calls mentalizing, to let us understand the depths of ourselves and others. For instance, it can help heal old wounds if we understand that dad's rejection of us might be due to his depression and not our behaviour as a child. Other people's reactions to us aren't just caused by us, but there are always multiple factors at play affecting how people behave. It seems very similar to Theory of Mind. He met Bowby in the 1980s, and studied adults' behaviour relative to their own descriptions of childhood attachment, and found, when comparing severely deprived to well-connected adults, that a weak attachment was correlated with a weak "reflective functioning" (the ability to understand behaviours in terms of their thoughts, feelings, and mental states). From this, he says psychotherapy should be the "effort to restore or kindle patients' capacity to mentalize," to simultaneously feel our feelings and reflect on their meaning. To help people develop mentalizing requires a relationship that mirrors and guides emotional responses.
His description of mirroring is specific: it must be "contingent and marked." The reaction has to be accurate and not our own reaction to the other person's upset, but an empathetic reaction with them. For example, if a child is angry, we effectively mirror it by getting mad with them at whatever frustration they're having, without bringing in any of our own anger or frustration about the situation or that our kid is pitching a fit, or else "the child can feel overwhelmed by the contagious nature of his distress." This follows the work of Winnicott: "Only the child who expresses anger and finds the other survives (neither retaliating nor withdrawing) who has the opportunity to learn that the other is a separate subject, not an object." They have to be allowed to try this. Once we mirror them, then we can calm ourselves down, so they can copy our regulation then move towards determining if the problem is best resolved with acceptance or change.
In a therapy situation, this appears to be a call for therapists to stop being a neutral container, sitting completely unreactive while their client emotes, but instead to react with the client. (It also brings into question some applications of "gentle parenting" that don't register the child's frustration but instead present instructions like a broken record.) The movement away from neutrality is reminiscent of Carl Rogers' view that therapists shouldn't try to be detached and robotically unresponsive, merely watching emotions unfolding with a steely resolve.
However, Rogers described the complexity of reflecting feelings in 1975 and raised a concern back then:
"It became quite natural to lay more stress upon the content of the therapist's response than upon the empathic quality of the listening. … This tendency to focus on the therapist's responses had consequences which appalled me … complete distortions of our approach."
He takes on the distortions to clarify his approach, first defining empathy:
"The state of empathy, or being empathic, is to perceive the internal frame of reference of another with accuracy and with the emotional components and meanings which pertain thereto as if one were the person, but without ever losing the 'as if' condition. … If this 'as if' quality is lost, then the state is one of identification."
And that made me rethink this bit of Epictetus (Enchiridion, ch. 16), who also wrote at length about what we should accept or change:
"When you see anyone weeping in sorrow because his son has gone abroad, or is dead, or because he has suffered in his affairs, be careful that the appearance may not misdirect you. Instead, distinguish within your own mind, and be prepared to say, "It's not that which has happened that distresses this person., because it doesn't distress another person; it is the judgment which he makes about it." As far as words go, then, do not be unwilling to show him sympathy, and even if it happens so, to lament with him. But take care that you do not lament internally also."
I had originally read it as a cold directive to be unaffected by others, but now I wonder if he had actually nailed empathy.
Rogers goes on to explain that we can understand other people's feelings by checking our own "psycho-physiological flow" within ourselves, which he assures us is "a very real thing." We feel sad when we see someone sad, and we can look to our own internal feelings to help to elucidate the other person's feelings for them. He writes,
"To be with another in this way means that for the time being you lay aside the views and values you hold for yourself in order to enter another's world without prejudice … voicing meanings in the client's experience of which the client is scarcely aware. … He moves into feelings and experiences that are only hinted at by the client and does so with sensitivity and accuracy."
In an interview with Victor Yalem (Irvin's son), Wallin clarifies,
"I also tend to assume that what we can't allow into our awareness of our experience--which also means what we can't talk about, what we can't think about--we tend to evoke in other people. So I'm inclined to believe that by paying attention to what's going on inside myself, I may get some clues as to what's going on that is most salient inside them."
It might bring some relief to those in the profession that this is outside the realm of AI, which can merely mimic feeling with others. As a recent Rolling Stone article explains a further concern,
“AI, unlike a therapist, does not have the person’s best interests in mind, or a moral grounding or compass in what a ‘good story’ looks like. A good therapist would not encourage a client to make sense of difficulties in their life by encouraging them to believe they have supernatural powers. Instead, they try to steer clients away from unhealthy narratives, and toward healthier ones. ChatGPT has no such constraints or concerns.”
To understand others by looking at our own internal state, Fonagy suggests, we have to be aware of these inner feelings, which is helped by someone mirroring back to us. Rogers also expressed this: "Empathy is correlated with self-exploration," and "an empathic way of being can be learned from empathic persons. … The more the therapist or teacher is sensitively understanding, the more likely is constructive learning and change." It's mirroring all the way down!
Rogers believes empathy between us is key to dissolving alienation as people feel more seen, valued, and accepted, so it's vital to help one another get in touch with a wider range of experiencing. It's how we feel understood and better able to develop a distinct identity. And it's all a domino effect in that the more empathy we demonstrate with others, being non-judgmentally receptive to their feelings, the more empathetic others can become, and the less alienated we'll all be.
Back to Wallin, it's interesting to me how mentalizing is contrasted to mindfulness because in places they seem identical. It seems necessary to our awareness of emotional states. He explains that Fonagy places mentalizing between states of embeddedness and mindfulness. There's an optimal place of connecting to others between enmeshment (or Rogers' state of identification) and what he describes as "bare attention" or a "single-minded awareness of what happens to us … a non-judgmental observation of the ongoing stream of internal and external stimuli." It's being fully present, but with another, and not losing ourselves in the process.
There's an intersubjective relatedness to mentalizing as it requires another person, but more than that, Wallin clarifies, mentalizing is a route to establishing a coherent self, whereas mindfulness is the path to transcend the self, to "undo self-imposed suffering caused by clinging to an illusory image of the self." Mentalizing frees us from the past as we make sense of the specific contents of our experiences, but mindfulness directs our awareness to the process of experience in general. There's still a place for embeddedness and mindfulness, though. Embeddedness is the beautifully immersive experience we have when we lose ourselves while listening to music or during sex. Mindfulness helps in developing our sense of attention as something we're able to direct so we can choose what to focus on and strengthen our internal observations in the moment to be able to better tolerate our emotional content. In that Yalem interview, Wallin adds, "I'd refer sort of fancifully to mentalizing and mindfulness as the double helix of personal liberation or psychological liberation."
A somewhat extraneous issue this raises is the variability with which "mindfulness" is defined. Just in this brief exploration we slipped between it being a present-moment awareness, which could include our awareness to the other person, a tool for stress reduction, and a path to transcend the self, which feels conflated with meditation. It might be all three, but, as Fonagy implies, as a path to transcend the self, it's less effective to connect with others. Research on mindfulness has been marred by this range of definitions as well as the range of techniques that "count" as mindfulness tools.
Mindfulness's use in stress reduction has been studied, but often without clear measurement criteria, attempts to optionalize specific qualities of whichever definition they're using, adequate randomized control, precise methodologies (e.g using an app or taking a class treated as the same), and/or being separated from other modalities (e.g. within MBCT or DBT), so the studies have been widely criticized (Bishop, 2002. Van Dam et al, 2019, Stefan & David, 2020, Goldberg et al, 2023). Van Dam et al points out a general concern that "statistically 'significant' differences have repeatedly been equated with clinical and/or practical significance." Bishop says of MBSR specifically, "There is insufficient evidence based on rigorous scientific methods to strongly recommend it at this time. … Clinicians are cautioned against attempting to use this approach as a 'cure all'." The questionable results have been promoted regardless, and we're all about it in many psychotherapy courses. Fonagy et al (2023) also acknowledges there are too few studies on mentalization to establish strong conclusions. The critiques offer suggestions for studying these techniques more rigorously, so it's possible. However, I wonder about the push for evidence-based techniques in psychotherapy in the first place. The brain can be explored with significant reliability, but the mind is a different sort of thing.
We know about the replication crisis in social sciences already, and, as much as we try to make therapy into an objective science, the complexity and variability of our minds seems to get in the way. In the soft sciences, it's difficult to isolate variables and hard to make exact predictions based on data anyway.
When being prescribed medications for mental disorders or illnesses, despite all the research, people are still their own guinea pig. We know generally what helps and what harms, and that's life-saving, absolutely, yet we still can't know for sure which will best help a specific person until they try the drug. The difference between meds and mindfulness and other modalities within talk therapy is that they have far fewer risks, although Goldberg notes, "to our knowledge, no systematic evaluation of harm and adverse effects of information mindfulness" exists, and Stefan & David caution that, "detachment may decrease motivational relevance in the face of personal goals and may encourage low intensity affect in cases where this would not be either needed or desirable." We don't want to make people so chill that they can't get their work done.
Mark Solms' fascinating book, The Hidden Spring, describes in clear detail what happens when we're experiencing consciousness, and ends with a final chapter on how close we are to being able to replicate a brain, neuron by neuron. There's tons of science in it and a sense of certainty in it all as he verifies the vital role of emotions: "This way of feeling our way through life's unpredicted problems, using voluntary behaviour, is the biological function of consciousness." So, we know a lot about the brain and consciousness, and yet, we still can't tell precisely which intervention will help a specific patient suffering from a mental illness without trying it on that individual. That part is still a matter of best guesses and painful trial and error. We are too variable and complex. A psychological intervention that really helps one person today might not help as well tomorrow, and might not help their identical twin at all.
Solms also theorized on the origin of empathy through play, which "gives rise to the formation of social rules. … PLAY might well be a biological precursor of thinking in general … psychotherapy - a form of 'continuous reciprocal prediction' - is also a form of PLAY." This "developmental achievement" of empathy can be narrowed down to a specific brain region, but that doesn't help explain how to do it or what it feels like to the uninitiated. Fonagy found a correlation between lack of empathy in adults and severe deprivation in childhood, and goes down the path of one-on-one re-connection with a trained therapist. (I'd be excited to pursue what the education system could do with this if provided adequate resources.) However, there's always a feeling out process to that work that depends to some extent on the therapeutic alliance.
A book on Motivational Interviewing (2012) is clear about this: unlike other medical fields,
"One of the better replicated findings in psychotherapy research is that therapists with many years of practice have no better client outcomes on average than those who are recently trained."
They suggest the problem is from a lack of immediate, direct, and reliable feedback on their efforts (implying that the client's self-assessment is unreliable), but I think the lack of noticeable improvement might be because there is no straight and consistent line between technique X and result Y no matter how much we assert that this new acronym is the real solution. I think all of these modalities are useful and "work," but only for some people at some times. We have far less certainty that we'd like to have, but we can still work with that. We've been working with these various methods for centuries.
So maybe it's acceptable if psychotherapy modalities are used without quite the same level or type of evidence as other fields of medicine. Freud and Jung have also been written off in some circles for the lack of scientific validity of their methods, yet they're foundational to many currently accepted theories. Perhaps some modalities are better seen as philosophies that guide the process of connecting with another human being alongside ancient Stoic and Buddhist texts, rather than a set of instructions to follow to provide a felt sense of optimizing progress. The science around things gives us a sense of certainty that feels comfortable and sturdy even when it's illusory. We crave that certainty. The alternative is recognizing the art of helping one another as a dance of trying and correcting over and over. We might not be certain about the effectiveness of mindfulness or mentalizing, but it might still be helpful and even virtuous to lament with others, taking care that we don't lose ourselves in the process.
