Mentalisation and Fragility: Reflections from a Workshop
When working with emotional fragility, the first task is not deep emotional breakthrough but restoring the capacity to think under pressure. Mentalisation, the ability to understand behaviour in terms of underlying thoughts and feelings provides a stabilising foundation for dynamic work. By slowing down moments of confusion and rebuilding reflective function, therapists create the conditions for deeper, safer emotional processing over time.
Closeness without overwhelm
A recent workshop on the integration of mentalisation with Intensive Short-Term Dynamic Psychotherapy offered a useful reminder: when working with fragile patients, stability and gradual capacity building is paramount before any depth work can take place.
What Is Mentalisation in Psychotherapy?
Mentalisation, at its simplest, refers to the capacity to understand behaviour, one’s own and others’, in terms of underlying mental states. It involves holding feelings in mind without being overwhelmed by them. It allows a person to recognise that thoughts are interpretations, not facts, and that emotional states shift over time.
Why Mentalisation Matters in Emotionally Fragile Patients
In fragile presentations, this capacity can fluctuate. A patient may think clearly while calm, yet lose reflective function as soon as affect rises. Emotional activation can quickly lead to shame, confusion, or dissociation. When that happens, technique alone is not enough. The therapist must restore the conditions for thinking.
Mentalisation and ISTDP: Stabilisation Before Mobilisation
The workshop emphasised that mentalisation is not a retreat from emotional work. It is a preparatory layer of capacity building. Before deeper experiential interventions are possible, the patient needs sufficient reflective stability to tolerate what emerges.
The core elements of therapist mentalising
Tentative language
“It sounds like…”
“I’m wondering…”
“I might be wrong…”
Shared perspective
“Are we still thinking together?”
“Are we losing it?”
Curiosity over certainty
Attention to process, not just story
Regulation before depth
Recognising Mentalisation Breakdown in Session
This has practical implications. When confusion appears in session, the question is not “What does this mean?” but “Can we slow this down?” Rather than pressing for insight, the task becomes re-establishing orientation: noticing what just shifted, identifying changes in the body, and restoring shared attention.
Slowing Down: How Therapists Restore Reflective Function
In this sense, mentalisation sits beneath more active forms of dynamic intervention. It strengthens the observing ego and supports anxiety regulation. Without it, emotional mobilisation risks flooding rather than integration.
What stood out most was the simplicity of the idea. When feeling becomes too much to bear, therapy must first help the patient think again. From there, deeper work can proceed with greater safety.
For clinicians accustomed to working toward breakthrough moments, this can require restraint. It asks for patience with incremental progress and attention to subtle markers of capacity. The aim is not to avoid intensity, but to time it carefully.
Capacity Building Before Breakthrough
Fragile work often unfolds in small movements: a quicker recovery from confusion, a longer pause before withdrawal, a brief ability to reflect on shame rather than collapse into it. These are structural shifts. They accumulate.
The integration of mentalisation with dynamic practice does not dilute either model. It clarifies sequence. Regulation and reflection precede depth. Stability supports transformation.
In complex cases, that ordering can make the difference between destabilisation and durable change.
Mentalising in-session
Mentalising in-session is a collaborative calibration. Below are some clean examples of therapist and client mentalising during difficult moments.
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Client (activated):
“He just kept interrupting me. It was unbelievable.”Therapist (mentalising stance):
“Listening to you now, it sounds like there’s anger there. I’m not sure, does that fit?”What’s happening:
The therapist names a possible state.
Signals uncertainty.
Invites correction.
Keeps ownership with the client.
This prevents:
Premature pressure.
Misattunement.
Escalation.
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Client:
“I don’t even know what I’m feeling. It’s just too much.”Therapist:
“Something feels intense right now. Are we starting to lose track of it together?”This does two things:
Normalises confusion.
Brings therapist and client back into shared reflective space.
It restores “we are thinking.”
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Client (looking down):
“This is stupid. I shouldn’t even be upset.”Therapist:
“I notice you turned the feeling against yourself just then. What happened inside?”This keeps attention on process rather than content.
It mentalises the shift:
Feeling → self-attack. -
Client:
“I don’t know why, but I feel… something physical. It’s confusing.”Therapist:
“Let’s slow it down. As that sensation shows up, are you able to stay with it, or does it start to blur things?”This avoids eroticisation.
It focuses on capacity and regulation. -
Client:
“You probably think I’m ridiculous.”Therapist:
“I’m curious what led you to imagine that about me.”That keeps:
Curiosity.
Differentiation of minds.
Ownership of interpretation.
No defensive reassurance. No counterattack.
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Client:
“You always go quiet when I talk about this.”Therapist:
“Part of you wonders if my silence means something negative. What’s it like saying that to me right now?”This:
Acknowledges the perception.
Brings attention to here-and-now.
Invites reflection without invalidating.
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Item descriSometimes modelling helps.
Therapist:
“As you’re describing that, I’m aware I might be misunderstanding you. Help me check I’m getting this right.”This demonstrates:
Minds are separate.
Misunderstanding is repairable.
Certainty is not required.
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Client (withdrawn):
“I don’t know. I’m just blank.”Therapist:
“Okay. Let’s pause. Are you feeling blank, or is it hard to put words to something?”This helps to differentiates:
Absence of feeling vs Overwhelm of feeling.
If this reflection resonated, you might explore:
Explore more in reflections
FAQ: Mentalisation, ISTDP and Emotional Fragility
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Mentalisation refers to the ability to understand behaviour in terms of underlying thoughts, feelings, and intentions. In therapy, it involves helping a person notice what is happening inside them while remaining reflective rather than overwhelmed. When emotional intensity rises, this capacity can temporarily collapse. Restoring mentalisation allows deeper work to proceed safely.
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Emotional expression involves experiencing and communicating feeling. Mentalisation involves thinking about feeling while it is happening. A person may express emotion intensely but struggle to reflect on it. In fragile presentations, strengthening reflective capacity often needs to precede deeper emotional processing.
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Mentalization-Based Treatment (MBT) focuses on stabilising reflective function and improving the ability to understand mental states in self and others. Intensive Short-Term Dynamic Psychotherapy (ISTDP) works more directly with anxiety, defences, and underlying emotion. In practice, mentalisation can support ISTDP by strengthening the patient’s capacity to tolerate emotional activation.
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In emotionally fragile presentations, affect can rise faster than the nervous system can regulate. When this happens, reflective thinking may narrow or collapse, leading to confusion, withdrawal, or dissociation. Therapy often involves slowing the process, restoring regulation, and rebuilding the ability to think under emotional pressure.
Written by Rick Cox, MBACP (Accred)
Psychodynamic Psychotherapist, UK & Online
