Cited by 565Personality Disorders and PsychopathologyPsychoanalysis and Psychopathology ResearchPsychotherapy Techniques and Applications

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Mentalization: Ontogeny, Assessment, and Application in the Treatment of Borderline Personality Disorder

Choi-Kain, Lois W., Gunderson, John G.·2008·American Journal of Psychiatry

DOI 10.1176/appi.ajp.2008.07081360

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Abstract

This article aims to review the development of the concept of mentalization, its applications in the understanding and treatment of borderline personality disorder, and the issue of its assessment. While conceptually derivative of theory of mind, Fonagy's concept of mentalization concerns more affectively and interpersonally complex understandings of oneself and others, reflecting abilities that enable an individual not only to navigate the social world effectively but also to develop an enriched, stable sense of self. The components of mentalization can be organized around self-/other-oriented, implicit/explicit, and cognitive/affective dimensions. Concepts of mindfulness, psychological mindedness, empathy, and affect consciousness are shown to partially overlap with mentalization within these three dimensions. Mentalization is assessed by the measure of reflective function, a scale to be used adjunctively on semistructured narrative interviews such as the Adult Attachment Interview. Its validity has not been fully tested, and its usage has been hampered by the time and expense it requires. Although the concept of mentalization is a useful heuristic that enables clinicians to adopt a coherent treatment approach, it may be too broad and multifaceted to be operationalized as a marker for specific forms of psychopathology such as borderline personality disorder. Research elucidating the relationship between reflective function, overlapping concepts, and features of borderline psychopathology is needed.

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Background
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Method
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Background
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Background
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Background
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Background
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Background
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MethodInfluential
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Background
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BackgroundInfluential
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“…Normann‐Eide, & Wilberg, 2013; Normann-Eide, Johansen, NormannEide, Egeland, & Wilberg, 2013; Waller & Scheidt, 2004; Holmqvist, 2008; Lech, Andersson, & Holmqvist, 2008; Choi-Kain & Gunderson, 2008; Solbakken et al., 2011b; Solbakken et al., 2012; Taarvig, Solbakken, Grova, & Monsen, 2014).”
Background
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BackgroundInfluential
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Background
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“In this regard, the concept of mentalization interfaces with other concepts such as metacognition, social cognition, and empathy (Choi-Kain and Gunderson, 2008; Davidsen and Fosgerau, 2015; Fosgerau et al., 2017).”
Background
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“In its content and process, the ability to mentalise spans four dimensions or components, namely: the cognitive and affective aspect; the self and others as objects; the automatic or controlled modes of functioning; and the internal and external attention distinction [6].”
BackgroundMethod
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Background
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Mentalizing in first-time fathers: reflective functioning as a mediator between attachment representation and sensitivity
Dinzinger, A., Ismair, S., Brisch, K. H., Sperl, W., Deneault, A., Nolte, T., Hitzl, W., & Priewasser, B. (2023) · Attachment & Human Development · doi:10.1080/14616734.2023.2258354 · Cited by 14
“…and RF is part of a wider literature inquiring the different developmental components of the mentalization construct (e.g. cognitive, emotional, first order, second order e.g. Choi-Kain & Gunderson, 2008; Wu et al., 2020), although this literature is beyond the scope of the current study.”
Background
Complexity of mentalization
Arabadzhiev, Z., & Paunova, R. (2024) · Frontiers in Psychology · doi:10.3389/fpsyg.2024.1353804 · Cited by 18
Mentalizing as a Predictor of Well-Being and Emotion Regulation: Longitudinal Evidence from a Community Sample of Young Adults
Schwarzer, N.-H., Heim, N., Gingelmaier, S., Fonagy, P., & Nolte, T. (2024) · Psychological Reports · doi:10.1177/00332941241261902 · Cited by 21
“Mentalizing is a multidimensional umbrella concept (Choi-Kain & Gunderson, 2008) encompassing a wide range of mental processes such as meta-cognition, mindfulness (emotional awareness of the self), self-monitoring (cognitive awareness of the self), theory of mind (understanding other people ’ s…”
Personality Disorder and Changes in Affect Consciousness: A 3-Year Follow-Up Study of Patients with Avoidant and Borderline Personality Disorder
Normann‐Eide, E., Johansen, M. S., Normann‐Eide, T., Egeland, J., & Wilberg, T. (2015) · PLoS ONE · doi:10.1371/journal.pone.0145625 · Cited by 13
“As emphasized by Choi-Kain and Gunderson [37], AC is related to other “conceptual cousins”, such as mentalized affectivity and alexithymia.”
Background
A role for epistemic trust in speech-language pathology: A tutorial paper
Clarke, A. T., Meredith, P. J., Rose, T., & Daubney, M. (2018) · Journal of Communication Disorders · doi:10.1016/j.jcomdis.2018.02.004 · Cited by 11
Characterological depression in patients with narcissistic personality disorder
Fjermestad‐Noll, J., Ronningstam, E. F., Bach, B., Rosenbaum, B., & Simonsen, E. H. (2019) · Nordic Journal of Psychiatry · doi:10.1080/08039488.2019.1664630 · Cited by 11
The Relationship Among Mentalization, Mindfulness, Working Memory, and Schizotypal Personality Traits in the General Population
Török, E., & Kéri, S. (2022) · Frontiers in Psychology · doi:10.3389/fpsyg.2022.682889 · Cited by 11
There must be more to development of mindreading and metacognition than passing false belief tasks
Hernik, M., Fearon, P. R. M., & Fonagy, P. (2009) · Behavioral and Brain Sciences · doi:10.1017/s0140525x0900065x · Cited by 11
Metacognitive improvement and symptom change in a 3‐month treatment for borderline personality disorder
Maillard, P., Dimaggio, G., Berthoud, L., de Roten, Y., Despland, J., & Kramer, U. (2019) · Psychology and Psychotherapy Theory Research and Practice · doi:10.1111/papt.12219 · Cited by 11
“This capacity has been labelled under different names, such as metacognition (Semerari et al., 2003), which is the term we will adopt henceforth, mentalizing (Bateman & Fonagy, 2004), theory of mind (Carruthers & Smith, 1996), or affect consciousness (Choi-Kain & Gunderson, 2008).”
Background
Awareness of breathing as a way to enhance the sense of coherence: Patients’ experiences in psychomotor physiotherapy
Ekerholt, K. (2011) · Body Movement and Dance in Psychotherapy · doi:10.1080/17432979.2011.568762 · Cited by 11
“This fits in with the concept of mentalisation (Choi-Kain & Gunderson, 2008) as ‘the capacity to conceive the conscious and non-conscious mental state in oneself and in others’.”
Background
Exploring Personal Recovery in Schizophrenia: The Role of Mentalization
Concerto, C., Rodolico, A., Mineo, L., Ciancio, A., Marano, L., Romano, C. B., Scavo, E. V., Spigarelli, R., Fusar‐Poli, L., Furnari, R., et al. (2023) · Journal of Clinical Medicine · doi:10.3390/jcm12124090 · Cited by 10
Measuring patient satisfaction in an outpatient psychiatric clinic. What factors play a role?
Romanowicz, M., Oesterle, T., Croarkin, P. E., & Sutor, B. (2022) · Annals of General Psychiatry · doi:10.1186/s12991-022-00379-1 · Cited by 10
“The concept of mentalizing was introduced as a theoretical model in the 1970s [16].”
Background
Affektive Mentalisierung als wahrgenommene Kontrollierbarkeit und Nützlichkeit von Emotionen
Biel, H. M., Löwe, B., Briken, P., Hennig, T., Krott, N. R., Jungclaussen, I., Liebherz, S., Weigel, A., & Reininger, K. M. (2022) · Die Psychotherapie · doi:10.1007/s00278-022-00633-7 · Cited by 13
Psychotherapy of Schizophrenia: A Brief History and the Potential to Promote Recovery
Lysaker, P. H., & Silverstein, S. M. (2009) · Clinical Case Studies · doi:10.1177/1534650109351930 · Cited by 11
“Just as psychotherapy has been found to promote metacognition in persons who do not suffer from psychosis (Bateman & Fonegy, 2001; Choi-Kain & Gunderson, 2008; Dimaggio, Semerari, Carcione, Nicolò, & Procacci, 2007), could it be tailored to help persons with schizophrenia make better sense of their…”
Background
Mentalisierungsbasierte Therapie bei Adoleszenten mit Borderline-Persönlichkeitsstörung – Konzept und Wirksamkeit
Taubner, S., Volkert, J., Gablonski, T., & Rossouw, T. I. (2017) · Praxis der Kinderpsychologie und Kinderpsychiatrie · doi:10.13109/prkk.2017.66.6.423 · Cited by 10
The Effect of Curiosity on Employee Performance: A Case Study in Indonesia
Suma, D., & Siregar, B. A. (2021) · Journal of Asian Finance Economics and Business · doi:10.13106/jafeb.2021.vol8.no3.1385 · Cited by 11
Vers un modèle du développement des dimensions de la mentalisation a l’adolescence
Badoud, D., Speranza, M., & Debbané, M. (2016) · Revue québécoise de psychologie · doi:10.7202/1040160ar · Cited by 15
Exploring implicit mentalizing as an online process
Fosgerau, C. F., Schöps, A. M., Bak, P. L., & Davidsen, A. S. (2017) · Nordic Psychology · doi:10.1080/19012276.2017.1374204 · Cited by 9
A clinically useful assessment of patients’ (and therapists’) mental functioning: M-axis implications for the therapeutic alliance.
Lingiardi, V., Colli, A., & Muzi, L. (2018) · Psychoanalytic Psychology · doi:10.1037/pap0000200 · Cited by 10
The Value of Thinking About Feelings Across Cultures: A Preliminary Investigation of the Mentalizing Values Scale
Aival‐Naveh, E., Rothschild‐Yakar, L., Park, J., & Kurman, J. (2022) · Journal of Cross-Cultural Psychology · doi:10.1177/00220221221077355 · Cited by 10
“Specifically, it was possible to expect that self-transcendence, which includes motivational goals such as caring for and helping others, would be relevant for other-mentalizing (which, in essence, overlaps with the construct of empathy; Choi-Kain & Gunderson, 2008).”
Background
Borderline Personality Disorder: A Comprehensive Review of Current Diagnostic Practices, Treatment Modalities, and Key Controversies
Azzam, S., Almari, R., Khattab, K., Badr, A., Balawi, A. R., Haddad, R., Almasri, R., & Varrassi, G. (2024) · Cureus · doi:10.7759/cureus.75893 · Cited by 13
Measurement of mentalizing: A systematic review and development of a construct validity framework
Hawksdale, H., Meng, B., Feigenbaum, J., Fonagy, P., & Nolte, T. (2025) · Clinical Psychology Review · doi:10.1016/j.cpr.2025.102657 · Cited by 11
Reliability and validity of the Chinese version of the Mentalization Scale in the general population and patients with schizophrenia: A multicenter study in China
Wen, Y., Fang, W., Wang, Y., Du, J., Dong, Y., Zu, X., Wang, H., Zhu, C., Zhang, L., & Wang, K. (2022) · Current Psychology · doi:10.1007/s12144-022-04093-9 · Cited by 12
“Our results are consistent with previous studies (Choi-Kain & Gunderson, 2008; Janczak, 2021) in terms of direction, i.e., low mentalizing ability is accompanied by insecure attachment patterns, although the correlation coefficients are low and some subscales are not correlated.”
Result
Mentalizing in individuals with state and trait risk for psychosis: a systematic review
Salve, F. D., Rossi, C., & Oasi, O. (2023) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2023.1214385 · Cited by 9
La mentalisation affective de la personnalité limite addictive : une revue de la littérature
Lecointe, P., Bernoussi, A., Masson, J., & Schauder, S. (2016) · L Encéphale · doi:10.1016/j.encep.2016.02.001 · Cited by 9
Mechanisms of change in brief treatments for borderline personality disorder: a protocol of a randomized controlled trial
Kramer, U., Grandjean, L., Beuchat, H., Kolly, S., Conus, P., de Roten, Y., Draganski, B., & Despland, J. (2020) · Trials · doi:10.1186/s13063-020-4229-z · Cited by 9
“Change in the patient’s socio-cognitive or mentalizing capacities is discussed as a putative mechanism of change in the treatment of BPD [52, 59, 60].”
Background
Impaired complex theory of mind and low emotional self-awareness in outpatients with borderline personality disorder compared to healthy controls: A cross-sectional study
Pourmohammad, P., Imani, M., Goodarzi, M. A., & Sarafraz, M. R. (2021) · Journal of Psychiatric Research · doi:10.1016/j.jpsychires.2021.10.009 · Cited by 11
Borderline personality disorder traits and mentalising ability: The self-other social cognition paradox
Grealy, M. K., Godfrey, E., Brady, F., O’Sullivan, E. W., Carroll, G., & Burke, T. (2022) · Frontiers in Psychiatry · doi:10.3389/fpsyt.2022.1023348 · Cited by 13
“Research on social cognition has the potential to bolster psychopathology models of BPD that emphasise social cognitive outcomes as a core deficit (55).”
Background
Borderline Personality Disorder:Toward Integration
Stein, D. J. (2009) · CNS Spectrums · doi:10.1017/s1092852900022999 · Cited by 9
“The Reflective Function Scale measures cognitive processes related to mentalization in an attachment context, but its validity is not yet fully established, and there are more widely used measures for adjacent concepts such as mindfulness and empathy.(72)”
Method
The Applicability of LLMs in Generating Textual Samples for Analysis of Imbalanced Datasets
Gopali, S., Abri, F., Namin, A. S., & Jones, K. S. (2024) · IEEE Access · doi:10.1109/access.2024.3463400 · Cited by 9
“The personality type prediction in psychology has significant application in many areas such as businesses [23], [30] health care [12], [44] mental health screening exams, screening during job interviews and so on.”
Background
A Validation Study of the Korean Version of The Mentalization Scale
Lee, S. L., & 이문희 (2018) · Korea Journal of Counseling · doi:10.15703/kjc.19.5.201810.117 · Cited by 8
The mediation effect of mentalization in the relationship between attachment and aggression on the road
Herrero‐Fernández, D., Parada‐Fernández, P., Arcos, I. R., Amaya-Carrillo, L., González-Sáez, M. E., & González, M. R. (2022) · Transportation Research Part F Traffic Psychology and Behaviour · doi:10.1016/j.trf.2022.03.009 · Cited by 8
Observer-based and computerized measures of the patient’s mentalization in psychotherapy: A scoping review
Hüwe, L., Laser, L., & Andreas, S. (2023) · Psychotherapy Research · doi:10.1080/10503307.2023.2226812 · Cited by 8
“A major limitation of using the RFS-AAI in research is the time required for its application (Choi-Kain & Gunderson, 2008).”
BackgroundMethod
The mediating role of mentalization and integrative self-knowledge in the relationship between childhood trauma and fear of intimacy
Riazi, S., & Manouchehri, M. (2024) · Frontiers in Psychology · doi:10.3389/fpsyg.2024.1384573 · Cited by 11
Effectiveness of rhythmic movement therapy: Case study of alexithymia
Malkina-Pykh, I. G. (2013) · Body Movement and Dance in Psychotherapy · doi:10.1080/17432979.2013.804435 · Cited by 8
Mindfulness-based interventions in secure settings: challenges and opportunities
Witharana, D., & Adshead, G. M. J. (2013) · Advances in Psychiatric Treatment · doi:10.1192/apt.bp.111.009167 · Cited by 8
“Choi-Kain & Gunderson (2008) identify three distinctions between the two concepts, in terms of interactions, temporal focus table 1 the ‘doing’ and ‘being’ modes of the mind Parameter Doing mode being mode Striving v. non-striving Monitoring and striving to close the gap between ideas of where we…”
Background

Authors: Choi-Kain, L. W., & Gunderson, J. G.
Affiliations: Harvard University (US)
ORCID: Choi-Kain, Lois W.
Venue: American Journal of Psychiatry
Publisher: American Psychiatric Association Publishing
Published: 2008-09
Volume: 165
Issue: 9
Pages: 1127-1135
ISSN: 0002-953X (ISSN-L)
1535-7228
DOI: 10.1176/appi.ajp.2008.07081360
OpenAlex: W2018329493
Cited by: 565
References: 59
Citations by year: 2026: 31 · 2025: 22 · 2024: 38 · 2023: 33 · 2022: 23 · 2021: 42 · 2020: 28 · 2019: 33 · 2018: 50 · 2017: 34 · 2016: 39 · 2015: 38 · 2014: 31 · 2013: 26 · 2012: 33
FWCI: 3.67
Type: journal article
Language: en
Open access: closed
Locations: American Journal of Psychiatry (publishedVersion)
PubMed (publishedVersion)
Topics: Social Sciences › Psychology › Clinical Psychology › Personality Disorders and Psychopathology
Social Sciences › Psychology › Clinical Psychology › Psychoanalysis and Psychopathology Research
Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
Keywords: mentalization, borderline personality disorder, theory of mind, reflective functioning, Adult Attachment Interview, mindfulness, psychological mindedness, empathy, self-other orientation, attachment, treatment of borderline personality disorder
MeSH terms: Affect, Borderline Personality Disorder, Cognition Disorders, Consciousness, Culture, Humans, Interpersonal Relations, Interview, Psychological, Mental Processes, Object Attachment, Psychological Theory, Severity of Illness Index, Narration

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Mentalization: Ontogeny, Assessment, and Application in the Treatment of Borderline Personality Disorder

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