MENTALIZATION IN ART THERAPY,

TYPES OF INTERVENTION

Author: Carles, Ramos i Portas

Barcelona, April 2022

Summary

Mentalization consists of the set of psychological processes that we humans follow

to understand ourselves and to understand others. In art therapy, we use art as a
tool to implement and consolidate our patients' ability to mentalize. In this essay I
explore how this happens and how mentalisation applied to art therapy modifies
the role of the therapist.

Keywords: art therapy, mentalisation, therapeutic bond, epistemic trust, ostensive

communication, relational psychoanalysis, art psychotherapy

Preface

Do we know what others feel? How do we know? We need to know how others feel to
understand them, to be able to empathise, but also to predict their behavior. Whether it is
taking one action over another, or choosing how to approach someone, understanding the
other is essential for survival in a social species like ours. How can we obtain enough certainty
out of our subjective experience?.

We can intuit what others feel by how they act, from the non-verbal language they convey, to
what they tell us in words. However, we will not obtain certainty of how they feel unless we
obtain confirmation that what we intuit and assume, fits with reality. From our observation of
the other, we imagine how they should feel. From what we imagine, we make one decision
or another in our interactions. If we want to go beyond our imagination and our subjectivity,
we will have to silence ourselves and find proof that our intuition is correct.

We know how the other feels and we know about ourselves thanks to the set of psychological
processes that are mobilized in every communicative procedure, the sum of these processes
Peter Fonagy calls mentalization. According to him mentalisation consists of the ability to
read and interpret mental states of others and of oneself. It includes a great variety of actions,
among which, as I have indicated, imagination stands out. We make an "image" of the other
from what we see, hear, feel and then interpret. Mentalization also includes curiosity or better
said, interest in what we don't know. Without this interest we probably would not approach
each other. In turn, mentalisation also implies the activation of memory. We bring our past
experiences to the present to understand what is happening now. For instance, he might have
said to me one thing and afterwards did a diiferent one; now he says the same he said … and
I reckon he may do the same as well.

Mentalization integrates the predisposition to consider points of view other than one's own.
Without considering other perspectives, our understanding would be extremely limited. Like
in a mirror, I can see that my reaction has been excesive because the way I see others react
to it.

The ability to symbolize and understand symbolic language like we do in art therapy all the
time when we work with the metaphor is part of the mentalizing functions as well, as is the
ability to foresee or predict situations. Ultimately, one coud say that mentalisation gathers the
wide range of resources that we, humans use to understand ourselves and others. In short,
Mentalization brings together a set of functions that allow us to understand others and
ourselves.

In art therapy, in addition there are images and artistic objects as well as the process followed
to create them that act as another form of non-verbal communication, reflecting the inner
world of their creators, thanks to which we can understand our patients in greater depth. Thus,
the subject of this essay will be mentalization applied to the art therapy practice. In the
following sections we will see how art in art therapy can help to expand our ability and the
ability of our patients to mentalize.
Introduction

A few years ago, we invited Neil Springham to Metafora's MA students in Barcelona to talk
about mentalization in art therapy. His talk presented us with the contributions of Fonagy and
Batema, which we will see fit quite well with the practice of art therapy, that is, providing an
instrument that helps us to understand our patients in greater depth and, in turn, providing an
extremely useful guide to structure tclinical interventions.

I begin by defining what is meant by mentalization, how it is articulated and what functions it
integrates. Next, I summarize the different types of mentalization described by Fonagy
according to the polarities in which they run. Next, I describe some of the multiple capacities
that mentalizing processes mobilize and I conclude the section by describing the
psychological processes that, according to Fonagy characterize the absence of mentalizing.

In a second section, I use several examples taken from clinical practice to see how
mentalization occurs in art therapy and how it can be encouraged.

The third and last section of the article is dedicated to the role of the therapist who works from
the framework of mentalization. Intervention strategies and techniques promote this way of
working and distinguishes it from other therapeutic approaches. I end with a brief section of
conclusions.

What is Mentalization?

Peter Fonagy and Anthony Bateman, starting from the Theory of Mind and the latest
advances in neurology, developed mentalization as a theoretical basis on which to base a
treatment for BPD (Personality Disorders) which they called MBT (Mentalization Based
Treatment). At the same time, they provided a new way of exploring psychological functioning
that was going to revolutionize the way of understanding psychotherapy. Mentalization not
only integrated different approaches to date at opposite poles such as cognitive-behavioral
therapy and psychodynamics, but also linked them with the most recent neuroscience
studies, supporting their contributions with a multitude of research works. All this represented
a substantial change in clinical psychology that, as we will see, will influence the practice and
training in art therapy.
 Mentalization refers to a mental activity, predominantly preconscious, often intuitive and
emotional, that allows the understanding of one's own behavior and that of others in terms
of states and intentional mental processes, needs, desires, feelings, beliefs, goals,
purposes and reasons.

Fonagy and Bateman (2012)

In other words, mentalization describes the mental activity that we humans carry out to
interpret our own behavior or that of others through the attribution of mental states —looking
at you, I could say something is wrong today—. Mentalization is the tool that helps us give
meaning to our own behavior and that of others —as I see you going along I get an idea of
what is happening to you—. Neuroscience locates this type of decoding activity in the
activation of different neuronal circuits mainly of the cerebral cortex.

How does mentalization occur? What functions does it involve? What mechanism do we use
to confirm that what we suppose happens to the other is what really happens? Mentalization
is the tool we use to understand, which is not synonymous with clairvoyance or infallibility,
however, without it the understanding of the other and of oneself is not possible.
Mentalization, as we will see, is a complex phenomenon that integrates different mental
activities, the first of which is curiosity, without which the others would hardly be generated
—What will there be on the other side of the hill?—. Starting from curiosity, perhaps I will
approach the slope, climb to the top and discover. If I want to know what is happening to my
partner I will have to feel genuine interest -curiosity- without this interest there will be no
mentalization possible, but not only curiosity as in the case of the hill; I will have to put aside
my presumptions and approach, pay attention to her behavior, listen to what she says,
appreciate the tone in which she or he speak to me, wait for the right moment to intervene
and in all this recognizing, perhaps in reality I will never come to know anything if I do not
count on her or his collaboration, because mentalization does not occur in a vacuum, you
cannot mentalize in solitude, mentalization is a collaborative work.

Mentalization integrates reflective reasoning, understanding of non-verbal language, intuition,

empathy, the ability to predict situations, the elaboration of memories, the ability to symbolize
and above all, imagination. We imagine how others feel from what we see and from what we
see, we imagine ourselves. Sometimes we are right and many other times we are not, it is
true, in any case, there is no other way to understand what happens to others and what
happens to us other than through mentalization.
Most of the time the mentalization that occurs to us is implicit, that is, without us realizing it.
For example, you see a group of suspicious-looking guys approaching down a dark street
and without thinking -implicitly- you cross to the other side of the street. You have mentalized
spontaneously, automatically; in an unthinking way you noticed them, you took into account
the context, you interpreted a certain way of walking and a suspicious attitude -that seemed
to you- dangerous. In milliseconds you made a complete reading of the situation, a possible
prognosis and automatically made a decision, all without thinking!

Of course, you could be totally wrong and what you perceived as challenging was nothing
more than the uninhibited walk of a group of teenagers in a festive attitude leaving a nightclub.
It could very well be that influenced by past experiences or prejudices of some kind you made
a wrong reading of the situation. Right or wrong, in any case you interpreted the situation
using a combination of mental processes that it is called "implicit mentalization".

At the opposite pole is the explicit mentalization, the one that we activate consciously. For
example, we decide to avoid talking about politics on Christmas Eve because we know that
doing so would lead to a conflict with our relatives that we do not want. That is, we imagine
what could happen from the knowledge we have of others and perhaps even from the memory
of previous situations in which there was conflict. From these memories we make a prognosis
-right or wrong- and as in the previous example, we make a decision, only in this case it is no
longer implicit-automatic but explicit-conscious.

Mentalizing is nothing new, even if we didn't call it that, there couldn't even be psychotherapy
without it. What is new is verifying that it has a biological basis, that it has -as we will see- its
origin in early childhood, that it can be learned and what is also new is that mentalization and
art therapy are very much compatible.

The Mentalization. It is identified as a basic human process…it is a mechanism of change

common to all forms of psychotherapy because it addresses a fundamental human
capacity to apprehend our own mind and the minds of others.

Fonagy, Bateman, & Bateman (2011)

You mentalize when you put yourself in someone else's place, which indicates that you
imagine what it must be like to be in their place, to be in someone else's shoes. Your
imagination, of course, is not a process isolated from reality, it is nourished by perceptions,
past experiences, prior knowledge. Perhaps you have experienced a similar situation before,
a disastrous Christmas Eve arguing about the destination of the reserved funds, for example.
Perhaps without even realizing it, you appreciated a detail in the way your co-worker behaved
when leaving the office, he raised his eyebrow when you mentioned that day on the beach
you spent together and you understood that it was better not to bring it up.

How and when did we learn that the movement of an eyebrow means something? Your
partner's eyebrow told you that you better leave the subject of the beach and you got it — I
better shut up—. You did the same with your colleague as that day you no longer remember
when you were a couple of years old and your mother made a horrified face when she saw
you putting dirt in your mouth, your reaction: "I better not do it." We learned to Mentalize when
we were very young, we learnt no verbal language seeing our mother's response, her smile
was a yes, her frown was a no, her open gesture, her eyebrow ... that's where we learned to
Mentalize.

We learned from our mothers’ gestures which things not to put in the mouth and a few years
later not to do certain other things, whatever they were. What happens, however, when the
mother (or the mother figure) was not there in the beginning to "teach" us to mentalize?
According to Bowlby (1969) when the affective bond is not there and when it fails, the
pathology appears years later.

Children who are deprived of the continued care and attention of a mother or surrogate
mother for any reason are not only temporarily disturbed by such deprivation, but in some
cases may suffer long-term effects.
J Bowlby (1956)

The development of mentalization is closely linked to those first years of life. Without an
understanding of the mental mechanisms involved in early childhood attachment, it is difficult,
if not impossible, to understand how attachment is established in adulthood. If the first
affective ties were insufficient or did not exist, mentalization does not develop. Fonagy and
Bateman reinforce this idea when they state that for mentalization to develop, the existence
of a secure affective bond is essential; when this did not exist or was insufficient, the objective
of psychotherapy would be to provide it.
The Polarities

In order for the baby's mentalization to unfold entirelly, there must be a sufficient level of trust
in the mother. "If mom doesn't like me putting dirt in my mouth, I won't do it, because she
deserves all my trust." If the baby learned that he cannot trust his or her mother, either
because she is not there when he needs him or because she does not attend to his needs,
the ability to mentalize will not develop. the baby won't understand its mother's gesture and
will keep eating dirt . How does the baby come to trust its mother? Trust, epystemic trust as
it is called in psychology, appears as a result of a relationship that had been previously
established, when the child needed his mother she was there, if he was hungry she fed him,
if he was cold she sheltered him, if affection she caressed him. We call this type of relationship
a safe relationship, that is, a predictable relationship, it will not change. When the affective
bond was strengthened, when mom responded to the baby's need automatically in response
to her, epystemic trust appeared. From that moment on, Mentalization is fully deployed and
we were able to learn, among other things, what a frown hides.

In psychotherapy, the same evolution of the attachment scale occurs as in early childhood.
From a safe therapeutic bond, a climate of trust is generated from which mentalization can
be deployed in depth. Thus, the first interventions in art therapy, like the first ones in
childhood, should be aimed at establishing and strengthening that bond.

Fonagy and Luyten (2009) propose that different forms of mentalization take place
dynamically, oscillating between four opposite polarities, each of them identified with the
activation of different neuronal systems. Thus, they distinguish between:

1. Mentalization Automatic (implicit) - Controlled (explicit)

2. Focused on internal features - Focused on external features
3. Self oriented - Other oriented
4. Cognitive processes - Affective processes

1) Implicit (automatic) versus Explicit (controlled).

Implicit mentalization triggers an immediate reaction to an event, it is the emotional response
to the "first impression", It is activated deep down in the reptile brain in the Amigdala. That
first impression is given by our immediate perception, the reading we make of non-verbal
language. We meet someone and when we see him we automatically react, "I said it without
thinking", "he saw me come in and turned around", "he skipped a stop sign and she got mad"
Whatever the reaction, the implicit mentalization is based on subjective perceptions that will
be to a greater or lesser degree conditioned by our previous learning, this type of
mentalization occurs without us being aware of it. In the dark street example above, the
sidewalk was changed automatically. As I said, maybe it was done out of prejudice or maybe
due to a bad experience in the past, but in any case the reaction was to protect yourself from
possible danger. Implicit mentalizing often acts as a coping mechanism that requires an
immediate response.

Obviously, this basic form of mindset, while it can be useful on occasions where an immediate
reaction is required, is often fueled by subjective perceptions and assumptions that need to
be validated. Without this validation, the answer may be very little or not at all correct.
Validation is found at the opposite pole, in the activation of the process of explicit
mentalization which is located in the Cortex area of the brain. That's where we assess the
situation, weigh the pros and cons, take into consideration elements other than our immediate
perception, and assess the most appropriate response.

Just as implicit mentalizing can coexist with intense emotional states, explicit mentalizing is
incompatible with high levels of arousal. In the face of a dangerous situation, our perceptual
channels are even more alert than normal, while our ability to mentalize explicitly is reduced
to a minimum. We all know that in the face of a heated discussion the ability to reason
decreases, "first calm down, take ten breaths and then we'll talk" we say. Every therapist
knows that when faced with an excess of emotion in their patient, there is no room for
reflection and their function will be limited to accompanying them and trying to reduce the
intensity of the excess of emotion, obviously before trying any other type of approach.

Both modes of mentalization deal with external data, visible such as non-verbal language, or
sensory data in general such as the tone of a monologue, the way they dress, physical
appearance, etc. Not so, as we will see in the other polarities.

2) Based on Internal / External characteristics

When mentalization is aimed at understanding internal processes such as thoughts or
emotions, whether of oneself or of others, we are talking about internal mentalization. When
it is aimed at understanding sensory signals such as non-verbal language, art imagery, we
are talking about its opposite, external mentalization. .
Just as in implicit mentalization we have seen that all the information came from sensory
perception -I see then I react- we could define this new stage of mentalization as, I imagine
then I react; I imagine how you feel, I presuppose how you think and from there I respond...
or in the case of external mentalization, I see how you move, I hear how you speak and I
presuppose what happens to you. Some people are hypersensitive to external features, while
others appear to be completely uninterested in facial or body expressions, appearing unable
to read such expressions

Mentalization, whether it is based on internal or external characteristics, allows us to "read

the mind" of the other and consequently allows us to empathize with him: from what you say
or from what I see, I imagine how you should be and act accordingly.

3) Self-oriented / Other-oriented
You learn to mentalize in relationships with others, initially with the mother figure and later
with all the other relationships that we establish during the course of our lives. The baby sees
himself in his mother's eyes and at the same time sees her as a differentiated being. In the
relationship with her he will learn to see himself and to see the other. In this way mentalizing
others and mentalizing oneself will be intimately linked for life.

In our daily lives we find people who are very capable of mentalizing others and not very
capable of doing so with themselves or vice versa. In any case, as Fonagy says:
"Understanding the inner world of others implies the recognition that others have minds, with
desires, thoughts and feelings different from ours".

4) Cognitive processes — Afective processes

The ideal mentalization would integrate cognition and affect in the same way, however, as in
the other polarities, we find people with greater difficulty in mentalizing emotions and greater
ease in developing processes that require logical thinking. Different types of psychopathology
are characterized by one or the other, intellectualizing emotions or investing in emotion
analytical processes that do not require it.
Mentalizing Capacities

We have seen how mentalization brings together different mental activities which involve
different capabilities, these I call, mentalizing capacities so they mobilize psychological
process of mentalisation. Distinguishing some capacities from others will help us direct our
interventions in one direction or another. If we see that our patient mobilizes a certain
mentalizing capabiliy, we will encourage it in various ways, mentioning it or perhaps
underlining its importance, giving it more space for it to expand.

Rosana, admitted to the psychiatric unit of a general hospital, was referred to art
therapy by her psychiatrist due to major depression with the hope that artistic activity
could serve to overcome her resistance to receiving any other type of approach or help
other than the administration of medicine. In the first session Rosana wonders why she
has been referred to art therapy, to which she comments: "I don't give a damn about
art and besides, I am very bad at manual labor of any kind." The therapist
acknowledges her difficulty by saying that people often find it strange to make "art" in
a hospital and even more so when they don't have any previous experience; even so
she invites her to open the cabinet door while telling her: "perhaps there is something
in there that catches your eye". Rosana looks at it incredulously, hoping to find inside
prescription drugs or medical supplies. She opens the door and says "it's a bit strange
to see all this here, really", instead os sanitary material there are paint cans, brushes,
colored crayons... she looks at her for a while and asks: " Why do you have a box full
of lipsticks here?" —I thought maybe someone could do something with it —the female
therapist answered- Rosana smiles, takes the box and spreads the colored lipsticks on
the table. The therapist welcomes her patient's curiosity silently. A little later says: "It
seems you have chosen sort of feminine kind of material, isn't it?." Rosana smiles and
begins to use it, filling the paper with a few strokes. Curiosity has given rise to a
drawing, a form of symbolization. She spends the rest of the session drawing with the
lipstick. At the end, the therapist says: —You said you wouldn't know what to do, but
look what you made…—. Rosanna smiles and says — Time flew by. Rosana continued
her therapy during the time she was in the hospital until her discharge.

We can see here that the therapist is following the moves of her client, waiting for her to take
the first step, inviting her to explore the cabinet. Not interfering in her curiosity, but welcoming
it silently, and comenting on her decision to use the lipstick in a way that Rosana could start
using it without feeling clumsy. She realised she was able to express herself with a new media
other than words, and besides, also important, it was fun, "time flew by". They did not talk
about her symptoms nor about the reasons she was referred, not yet too early for that. At first
a therapeutic bond had to be created, framing the capacities was a form of getting there,
closer to mentalisation.

Mentalization integrates various capacities. Recognizing them when they occur in the
sessions can very useful to the therapist as he will guide hisor her interventions, either by
encouraging or emphasizing these abilities. Below I briefly describe some of the most
relevant:

Inquiry capacity. This function refers to the interest in discovery, interest, curiosity, one of
the essential capacities that we associate with a healthy life. In the example above, when
Rosana opens the closet and finds the lipstick, she discovers something new that intrigues
her and prompts her to experiment. One more step will be when the interest in discovering
the other appears.

Symbolic capacity. It refers to the ability to understand, create and manage onself in
metaphorical language. Important in art therapy as images and artifacts usually mean more
than what they look. This capacity includes as well the "as if" condition present in play and in
the sense of humor.

As we will see in the next section, at the opposite end we find a stage in which humor, poetry
or metaphor have no place, where the only meaning that exists is the literal. The emergence
of symbolic ability in art therapy is especially welcome as it gives direct access to the patient's
inner world while its absence often prevents it.

Ostensive capacity. This describes a person's ability to articulate relevant information. That
is, the ability to communicate what is important to us, for example looking straight in the eye
to our interlocutor when we want to make sure they liste or by changing the emphasis in the
speech. It refers as well to our ability to recognize the ostensive from the superfluous.

Often in art therapy artistic production reflects that ability better than words. In the work or in
the process of creation it is where the ostensible message is expressed while in the verbal
discourse it might be hidden.

Multivision capacity. Ability to see the same phenomenon from different perspectives. In art
therapy we see that it is certainly acceptable that there are different visions of the same work,
while to one member of an art therapy group the composition of a painting seems confused
and entangled, to another it seems informal and carefree and to another third it seems
determined and brave.

Social Capacity. Ability to establish affectional bonds. The artistic activity in art therapy has
this inherent function. Creating an artistic object together with someone interested in what
you have just done generates complicity and this strengthens the affectional bond, without
which the therapy could not prosper. Art in art therapy, among other things, serves for one to
feel accompanied.

Focusing ability. The ability to bring attention to the here and now. Artistic activity, insofar
as it mobilizes the sensory-motor apparatus, forces us to focus our attention on the present.
For example, while handling a piece of clay, the wet contact of the clay is felt on the hands in
such a way that the inner monologue decreases and the ability to focus attention on the
present increases. As a result, it is common to hear Rosana say: "it's funny, time passed
without realizing it."

Psychological Processes in the Absence of Mentalization

Most of us oscillate between the extremes of the polarities described depending on the
moment and the circumstances. In the clinic, however, we meet people who find it very difficult
to mentalize in one way or another or who cannot mentalize at all, the already mentioned
capacities are not mobilezed, as if they have been suspended in one of the polarities
described without being able to swing back and forth. the opposite end. They may be able to
perceive nuances in non-verbal language, but misinterpret it or are unable to read the minds
of others, not even being able to guess what they might be feeling.

Fonagy and Bateman have observed that the lack of mentalizing seems to respond to three
different pre-mentalizing mental structures:

1. Psychic equivalence mode

2. How-if mode (pretend)
3. Teleological mode

1. The Psychic Equivalence Mode, the internal and external world are equivalent, what is
imagined is reality, thoughts do not reflect reality but rather create it. Emotions are on the
surface, reactions are immediate. Emotions are the only reality, it seems to say: if I'm afraid,
what difference does it make, I'm afraid and that's enough. This mode is characteristic of
magical thinking in which fantasy, blind belief and reality are confused. An example of this is
paranoid ideas, like a child’s fear of monsters under the bed.

In art therapy it is characterized by the inability to see second readings of the artistic work,
there is no metaphor, although the therapist can see in the artistic work connections with the
patient's internal world, he or she will not only be able to see them but any attempt at focusing
the conversation on the metaphor will arouse anxiety that is difficult to sustain and will be
rejected, perhaps even in a hostile way. From the psychic equivalence what is perceived is
what it is, this mode is characteristic of magical thinking in which fantasy, blind belief and
reality are confused.

Kevin, an eight-year-old boy with a borderline diagnosis, wanted to make sure that the
clay monster he made in the first session was locked inside a shoebox that could only be
taken out of the box on the day that, and for whatever reason, it was angry. The monster
was scary because the monster was fear itself incarnated!

Faced with someone in psychic equivalence mode, we will feel confused, not knowing what
to say, perhaps hypnotized in a powerful aesthetic contransference in which there are no
words because we do not know what can be said. If we were looking for a parallel with
contemporary art, expressionism would be, forgive the redundancy, its maximum expression,
that is, nothing to say because the work says it all, emotion permeates the work to the point
of muting words. At other times, the therapist may even lose patience, angry at our
interlocutor's lack of dialogue skills, at his extreme literalness, at his lack of vision. It is not
possible to talk about what he did because talking about it would provoke an anxiety that is
difficult to control.

2. The Pretend Mode is characterized by a feeling of emptiness, there is no contact between

feeling and expression. It often takes the form of an excessive intellectual focus, the person
acts "as if" they are someone else, a fictitious personality is adopted, in art therapy the patient
acts as if she is an art critic or as if she is the art therapist. In this mode it might seem like
she mentalizes herself since the analysis capacity is used, but it is only an appearance. Zelig,
a character from a film of the same name by Woody Allen, is transmuted into the people with
whom he comes into contact, with the psychoanalyst he becomes a psychoanalyst, with the
baseball player a coach, with the musician a music producer.
In art therapy, we often meet patients in this mode when they act as if they were expert
therapists, "this stain means... and the violet in the background, spirituality... and that broken
line, destiny...". In the as if mode, unlike the previous mode, we find that the works are done
in a very short time, they seem like schemes or scratches made in a hurry with little or no
emotional charge at all. The security in the session, that is to say the absence of anxiety, is
provided by the spoken language. It is as if artistic work itself is dangerous because it can
arouse emotions that you don't know if they can be sustained, artistic work is scary!

Aina is a 50-year-old medical doctor, homeopath and yoga practitioner. She suffers from
depression with recurrent episodes of anguish since her divorce ten years earlier. In art
therapy sessions her work is extremely careful, it seems as if she were in an alchemy
laboratory mixing colors drop by drop with a small brush. Everything is under her control,
she changes her glasses, puts on an apron she brought in from home. She has the
material that she will use in an orderly manner on the table, as well as her wristwatch to
control the time of completion. At the end she has an explanation for each part of the
drawing, she also comments on the effects of the session, "Today's session has been
very relaxing, much more than in the previous one, … it depends on the colors Iuse,
whether they are cold or hot ranges I feel one thing or another…" . The therapist's
interventions are systematically interrupted by her methodical descriptions. If the therapist
points her comments in one direction she contradicts with the opposite, the exchange
between the two of them looks like an academic discussion, as if she was pretending to
be a therapìst.

When we meet someone in this way, we may easily lose the thread of the conversation, feel
bored, as if what is being communicated to them is trivial, as if our interlocutor works on
autopilot, filling the time with empty words, often expressed in a monotonous tone without
affect modulation.

3. The Teleological Mode the action is understood in observable terms, what I see with my
senses is the only reality, only what can be seen or touched has meaning "if I don't see it I
don't believe it", it is the literalness taken to the extreme, concreteness taken to the limit.
Behavior for someone in a teleological mode does not carry any meaning; Raising the
eyebrow does not mean anything, nor does frowning, clearing your throat, looking at the
ceiling, tapping your fingers… all of this is perceived as grimaces or as random movements
with no possible connotation. The Teleological Mode is characteristic of logic devoid of
feeling, the art therapist is seen as if she were an art teacher, not as someone who tries to
understand, accompany and consequently can mobilize emotions.
Another characteristic of the Teleological Mode is the avoidance of responsibility,
responsibility -if not fulfilled- generates guilt and guilt is an emotion that has no place in the
teleological mode, in the teleological mode there are no emotions. If you stumble on the street,
it is the fault of the city council, in this way the blame and the responsibility always fall on
others, on the institutions, on the government, on the world... If the therapist takes her
vacation, it is experienced as a persecutory action and consequently as an abandonment.
Nor is internal pain understood, neither one's own nor that of others. An inmate of a
penitentiary center said: "I hit him and hit him but I didn't feel anything, so I kept hitting him
until I didn't know how, he died and I continued without feeling anything."

In art therapy, the patient in teleological mode does not know how to put into words what she
has done, she intuits the emotions implicit in the work, but she does not want to talk about
them nor does her therapist do it either, if finally the work is talked about it will be done from
a formal perspective, a description of the textural and technical characteristics.

Javier, a patient with bipolar disorder treated in private practice, made a Pollock-type
abstract painting, that is, he threw paint directly from the pot onto the paper on the floor
and walked barefoot over the painting. When he finished the painting, he put it on the
table, the paper still wet, it dripped red paint, giving the impression that it had been
sacrificed to some living being. Javier, with his hands still dyed in color, commented with
a smile "red in china is a symbol of good fortune." ignoring any parallelism with blood or
with some kind of ritual.

If we find a person in Teleological mode with some kind of problem, we will want to have a
quick and effective solution at hand. Perhaps we think of lists of viable alternatives and things
to do. We will be tempted to give practical advice or think of alternative strategies, knowing
that anything that is not tangible will be useless. We will feel the relationship as calculated,
organized, extremely cold.

The function of the therapist who works under the mentalizing umbrella is to stop non-
mentalizing processes when they occur to prevent them from spreading in a group or in
individual therapy to prevent them from becoming entrenched. In this way, the role of the
therapist is much more active than that proposed in other orientations.

Years ago we fell into the trap of mentalizing ourselves instead of our patients to end up
exhausted after each session, offering them suggestions, naming feelings, trying to
 understand their artistic work... Instead, we should focus on non-mentalizing when it
occurs and intervening in ways that give patients the opportunity to mentalize.

,, , Moore & Marder (2020)

Moore and Marder's quote is especially relevant insofar as it proposes to modify the role of
the therapist as soon as a position of power is relinquished. The therapist knows no more
about his patient than the patient knows about himself. The therapist has to learn, her patient
will show her the way to herself, which will necessarily force her to mentalize.

The position of the therapist, as we will see in the next section, is much more active in a
mentalizing relational therapy than in a traditional psychoanalytic therapy. The purpose of the
therapist's mentalization is not only to understand his patient but also to invite him through
imitation to do what he does, that is to mentalize together.

Mentalization in Art Therapy

Mentalization happens in art therapy in the same way as in verbal therapy, but it also happens
in relation to the artistic activity and the resulting objects. Mentalization occurs when the object
ceases to be an object that inspires terror, that is, when it exceeds the psychic equivalence
mode. The clay dough is no longer a monster, but a reflection of how I feel or what I
experienced at a given time.

Mentalization occurs when, in the teleological mode, the object ceases to be an object and
becomes artistic, when it is allowed to contain emotions, when it enters the domain of
metaphor. Mentalization occurs when the painting can become a metaphor for the
experience.

Mentalization occurs when the “as if” mode is abandoned. When the resulting object ceases
to be an element that can be translated into verbal language, when art is so explainable that
its presence becomes unnecessary, when art goes from being a scheme to becoming the
container of one or multiple emotions.

There is no doubt that the art making incorporates a good part of the mentalizing abilities set
out above, such as the inquiry without which there would be no experimentation, or the
ostensible capacity without which there would be no nuances or contrasts, or the symbolic
one without which the painting would be no different from the pattern of a kitchen apron.
However, mentalization as described in this article will not entirely occur until the work is
exposed and commented on by the therapist,including other participants in the case of group
sessions.

Art in art therapy is not governed by non-mentalizing psychic processes, the artist may be
well aware that her work speaks of herself even if it does not know exactly what it is saying.
Mentalization occurs in the relationship is not an isolated activity. we need the other to confirm
our experience.

The art making serves to channel emotions, as in sleep, also serves to digest experiences
and in therapy serves to understand and understand in greater depth, ie to mentalize.

Mentalization is an intrinsic part of Art Therapy. In art therapy we enhance imagination and
creativity, we arouse curiosity, we use metaphor as a means of communication, we change
perspective to understand the image of the other, the works act as a memory of lived
moments that we can return to whenever we want.

In art therapy, the art work and the creative process rarely point to a literal meaning. They act
as metaphors. The therapist does not look for a fixed interpretation as if it were a tarot card,
but tries to understand the inner world of her patient using the artistic work as a means, why
would she have done that now and not before? Did he do it with his back to me and not from
the front? What does this work suggest to me?

The answers to these questions will obviously be subjective impressions that will need the
collaboration of the author to know if we are right. The process of information exchange
between therapist and subsequent patient will unfold mentalization.

The use of art, writing or other forms of expressive therapy allows the internal to be
expressed externally and can be verbalized at a distance through an alternative medium
and from a different perspective.

Fonagy & Bateman (2004)

If there is an outstanding feature in art therapy, it is that we use non-verbal forms of

communication. In art therapy, the art making activity opens a door to the patient's internal
world that otherwise remains inaccessible, both the creation process and the resulting object
bring us closer to the way of feeling and processing emotions. But in art therapy we not only
create images, we also talk about them, in a group we compare different perspectives or
sometimes in individual sessions we contrast our vision with that of our patient. The work in
any case helps us to mentalize by putting a safety distance that reduces the anxiety that direct
contact can produce. The work acts as a metaphor, we can talk about what it suggests to us
without tallking directly about the feelings that hide.

Enrique was unable to talk about the difficulties he was experiencing in his marriage that
led him and his wife to marital art therapy sessions. In the initial session they decided to
work together. The therapist put a large sheet of paper on the table and invited them to
draw together. Enrique stand on one side of the table while Laura stand on the opposite,
both standing and facing each other. Enrique decisively drew a horizontal line on the paper
separating it into two parts, making it clear which space would his and which remained to
Laura's. Next, he drew the bottom of the sea with all kinds of fish, sharks, octopuses and
sea monsters. Laura from the opposite side could not see what her husband was doing,
she associated the horizontal line instead with a horizon. She painted the sea as we can
see it from the beach, the sun in the sky, glittering on the surface of the waves and,
curiously a sinking boat. Neither one nor the other realized that both had been painting
the sea, only that seen from different perspectives, what for one was the horizon for the
other was the surface of the sea, both with a shared fear, shipwreck in a sea of monsters?
It was hardly necessary to speak, the drawing served each of them to put themselves in
the place of the other. From the drawing it was easier to approach the other. The
mentalization had happened with hardly any words used.

As in the example described, often in art therapy we find that what words do not express gets
expressed by the art making. Depending on what the therapist considers will talk about the
work or will leave it unsaid, that is when the images are really worth a thousand words.

The first traits of artistic expression appear in early childhood at about a year and a half of
life. The scribble and the first words will coincide in time to later give way to symbolization.
From that day on, the doodle will cease to be the trace of a gesture as it was in its beginnings
to become forever more the symbolic expression of something or someone like a vocal sound
will become an articulated word with a specific meaning. From that day on, the images and
with them any other artistic manifestation -potentially- will hide a meaning. To find meaning
we will have to use the same cognitive tools that we use to understand other non-verbal
languages, such as gestures or facial expressions. We will have to compare, imagine, see
from different points of view, take into account different variables, memories, cultural contexts,
etc. In short, we will have to mentalize.

It always fascinated me to see how people from distant cultures could understand gestures
in the same way, a sneer or an inquisitive look is understood in the same way by a European,
an Asian or an African. The language of gestures is learned even before the spoken language.
In the experiment "The Visual Cliff" by Joseph Campos, a six-month-old baby approaches the
mother by crawling on a piece of glass. When she smiles at him, the baby crawls over, when
she doesn't, the baby stops. The baby "decodes" - mentalizes - the gestures of his mother
and according to how she expresses herself, the baby responds. We learned at an early age
that a certain gesture means curiosity and interest. We learned to differentiate between looks
of desire, boredom or sadness. We began to translate looks and gestures before we learned
to walk and we learned it in the same way regardless of the culture to which we belong.

In the same way that we can decode a look, see it in the nuances of different emotions, joy,
excitement, rejection, fear. We can also visualize emotional qualities and nuances in the
stroke of a drawing, in the composition of a painting, in the way in which the dialogue between
emptiness and fullness occurs in a sculpture, but also in the way in which materials are
manipulated. The stroke is the trace of a gesture and as such, it can be affirmative, doubtful,
daring, courageous, fearful... In the same way, the manipulation of the material can be
hesitant, resolute, curious, intriguing... So in art therapy, non-verbal language is not limited
only to the resulting final object, it is also expressed in the way in which the creation process
is developed.

In a group that I led a few years ago, all the participants were women except for one man,
Ricardo, and myself. Curiously, in the three years of the group's life, gender was never
discussed. Only in the images from time to time could one see a more or less explicit
reference to the genre that was never directly discussed until, shortly before the end,
Ricardo decided to model a clay bust and did so in a somewhat unique way. With a
broomstick that he found in a corner of the room, he molded the bust with blows, hitting
the piece of clay with force, first one side and then the other, and little by little it took the
shape of a bust. Obviously, the repeated bumps in the mud caught the attention of the
other members of the group, preventing them from concentrating on their own work. At
the end, when everyone had been waiting for some time sitting in a circle, Ricardo ended
up putting wire glasses on his creation. The resemblance of the bust with me was
surprising, I also wear glasses. The whole group found the coincidence hilarious, they
began talking about the similarity and from it the theme of gender appears for the first
 time. Ricardo was able to talk about what it meant to him to be a man surrounded by
women at a time when masculine identity was being highly questioned.

Art objects are an objectified metaphor, a visual allegory. However, as in spoken language
visual metaphors do not point to a single meaning. Depending on what object or image it is,
depending on when it was made, depending on who made it and under what circumstances,
the meaning will shift from one place to another. Marcel Duchamp said that the work of art
does not reside in the created object, it only exists in the mind of the artist and the viewer.

The creative act is not performed by the artist alone; the viewer puts the work in contact
with the outside world by deciphering and interpreting its internal qualities and thus adds
its contribution to the creative act.

The Essential Writings of Marcel Duchamp (London, 1975)

Duchamp's proposal radically changed the art scene, influencing the way we approach art to
this day. His contributions were especially significant to understand the artistic work in art
therapy. If we consider the work in art therapy as he proposed, as a negotiated agreement
between artist and viewer, ie, therapist and user, then how could the therapist unilaterally
interpret the meaning of his patient's work? From the Relational orientation, the work is not
only considered in itself as an aesthetic object, but it is used as a reason to mentalize.

Rita is a twelve-year-old girl who likes to do three-dimensional work. Rita makes a

volcano.with a cylinder of toilet paper to which papier-mâché is attached on the sides
like the slopes of a mountain, A characteristic of all her works is that they easily break,
dismember or, depending on the material used, fall apart. However, the volcano today
stands firm and straight. The therapist's comments go in that direction, thanks to them a
conversation begins about the impossibility of "doing anything right" (a sentence that her
mother often repeats to her at home). Rita is happy today, the volcano stands upright
and she says: "it can finally explode and feel angry."

The therapist can imagine where the meaning of the work points, but she cannot impose her
vision, only through negotiation will the work gain meaning. Depending on when, depending
on which patient and in what context of the session or treatment, the work will take on one
meaning or another. Thus the work in art therapy is not very different from other forms of non-
verbal language. A certain grimace, as in art, meant one thing or another depending on the
moment.
Imagining is a form of mentalization, thanks to this ability we can glimpse the mental state of
others and our own. Our imagination will give us a subjective image that we will have to
contrast by other mentalizing means to achieve a more precise knowledge of reality. Thus,
the artistic object in art therapy is a call to mentalize. Staying with whether I like the work or
not, like staying with the work having a specific meaning like a word in the dictionary is wrong,
the work of art is an invitation to mentalize and that is why art therapy has been encouraging
mentalization long before even when this term was invented.

The art therapist, unlike other psychotherapies, is more active, sometimes showing how to
use certain material, even if necessary teaching how to handle it or even using it herself.
Understanding or insight, as in other psychodynamic therapies, continues to be important in
art therapy, but we do not consider it necessary linking them with past experiences. In art
therapy we do not make interpretations of the transference, instead we accompany the patient
in his or her creative process without interfering with it. We consider that the therapeutic
elements are found in the therapeutic relationship and/or in the artistic production, not in the
interpretation.

The role of the therapist

Mentalizing interventions often begin by examining interpretations based on external

characteristics, and from these, generate plausible scenarios about internal mental states,
in particular the subtleties and complexities of people's internal world.

(Fonagy 2012, p.23)

As Fonagy explains, the therapist uses what the patient contributes in the here and now of
the session as a basis for trying to understand the internal world of her patient and does so
through a series of interventions that aim to expand the capacity of mentalizing. The therapist
will not delve into the past unless the patient brings it to the present and in this case the
therapist mentalizes with the patient about what he brings, that is, she will not try to find a
cause in the past, nor achieve an insight by connecting the past with the transference, which
does not exclude that the therapist uses the transference to, as Fonagy says, "generate
plausible mental states". That is, imagining possible scenarios and thus better empathizing
with her patient.
From what has been said, it follows that "mentalizing" interventions are different from those
that follow an Insight-oriented psychoanalytic technique or those that pursue a change in
behavior or a restructuring of the personality. For this, as we will see, the role of the therapist
must alternate interventions of different kinds. Fonagy describes the position of the therapist
who works from mentalization as follows:

The therapist must work from the humility derived from not knowing, must have patience
and take the necessary time to identify different perspectives, must legitimize their patients
by accepting the possibility of different points of view, must actively question the patient
about their experience , you should carefully avoid what doesn't make sense (saying
explicitly when something is unclear)

Fonagy (2010)

Fonagy describes the role of the therapist as one of balance between polarities, his function
is to keep the mentalization alive and stop or redirect the session when it moves away from
the center.

In practice, this orientation forces us to be more active, which does not necessarily mean that
we are giving art topics or lessons. The therapist has to be more active in being more aware
and less distant. Being in the here and now of the session is essential. The therapist observes,
intervenes, recognizes, accompanies, listens, asks for clarification when the discourse is
confusing, confronts when necessary, gets up from the chair and goes to the material cabinet
if this relieves excess tension, participates in the child's play if necessary etc. This position
differentiates him from the analytic position that considers the therapist as a neutral and
distant figure, who analyzes from a distance and intervenes from time to time with
interpretations of the unconscious. The therapist working from a relational-mentalizing
orientation must adopt a more humble posture, sometimes if necessary acknowledging his
inability to understand his patient.

From a relational orientation that centers mentalization, therapy must be contingent, that is,
open to different possibilities in opposition to a therapy in which the possibilities are reduced
to those determined by the therapist. In art therapy, this situation is provided naturally by the
artistic medium; we cannot assert that an image has a single meaning; an image or an art
object of any kind -as we know- can generate multiple meanings or none at all. In any case,
it is in the relationship with the therapist that the image will or will not take on meaning.
In a therapy that uses mentalization as a working tool, the therapeutic relationship is at the
center because it is in the relationship itself, more than in the interventions of the therapist,
where the healing elements are to be found. The insight of any given moment is important,
although ephemeral, as it appears and disappears, yet the relationship in which the insight is
generated remains. We could say that the relationship is the container of understanding. In
art therapy, the images or objects created in the session remain long after the treatment is
finished. The image acts as the trace of an experience. All of us know of countless objects
that remind us of a past relationship, like the grandfather's pocket watch, the music box from
childhood, the drawing on the wall, etc., and this image stays with us all our lives.

The relationship cannot be unidirectional, distant, remote or administrative, but must be based
on ostensive communication, that is, a type of communication in which the intention of what
is to be communicated is obvious, the message is underlined either with the look, with the
gesture, with the tone of voice, etc. so that the patient does not have the slightest doubt about
what is being communicated to him and likewise, the communication with the therapist must
also be ostensive, there should not be room for ambiguity.

The way in which we propose to structure the interventions is by enhancing the previously
mentioned mentalizing capacities. Fonagy proposes that interventions be guided by the
following parameters:

Transparency. The content of the mind is opaque, we cannot assume or interpret unilaterally,
there is only one way to know what the internal world of the other is like and that is through
intersubjective communication.

Don't know attitude. Due to the aforementioned opacity, the therapist does not know more
about his patient than what he knows about himself and with this attitude he must face the
session. In art therapy we know that the same thing happens with artistic work, the therapist
cannot know about the work of his patient, the meaning of the artistic work, as Duchamp said,
consists of a negotiation between spectator and author.

Curiosity. Curiosity is the engine of mentalization. The therapist wonders about what is
happening, is curious to know what is behind what is shown and asks his patient to help him
understand. For his part, the art therapy patient may be curious to know what can be done
with this or that material, what is done with the works when he is not there, because they are
kept in a closed place...
Pause button. The therapist stops the action when the level of emotion exceeds a limit that
prevents mentalizing or awakens an intolerable level of anxiety.

Sitting in the emotion. With this expression, Fonagy and Bateman propose not to run away
from emotions when they appear but to accept them without acting on them, in art therapy,
artistic activity often fulfills this function

Clarification of assumptions. When assumptions occur in communication, the therapist hits

the stop button, this time to ask for clarification. It's about creating a parenthesis... "I don't
quite understand what you're saying, could you explain it to me in a way so that I can
understand you better?

Here and Now 90/10%, work in the here and now. 90% of our communications are not based
on what is happening in the present, but in the past, only 10% refers to what is happening
now. Part of the work of the therapist is to bring the patient to the here and now.

Identification of non-mentalizing language. You have to press the stop button when forms
of language appear that are far from mentalizing language, words such as: always, only,
never, all or the use of plurals to express personal opinions. The therapist invites the patient
to paraphrase what is being said and to explore what can be hidden or avoided under a non-
mentalizing expression.

From this orientation, the therapist is inevitably much more vulnerable, if he makes a mistake,
he recognizes it and perhaps uses it to encourage his patient's mentalization, if he does not
know something that he considers important, he asks it and does not wait for his patient to
tell him spontaneously at some point in the future. The role of the therapist ultimately consists
of accompanying the patient side by side as equals, not in front or above. The work of
discovery and learning will be done together, therapist and patient.

Antonio, a 17-year-old boy in a juvenile detention center, normally very talkative,

today is abnormally quiet. Carmen, the art therapist, is used to very lively sessions,
so today her patient's silence seems strange to her. She watches the nervous
movement of Antonio's leg under the work table, Antonio can't concentrate on his
work. The therapist realizes this, appreciates the nervous movement of Antonio's
leg and tells him: "perhaps I'm wrong, but seeing you restless, it occurs to me that
 perhaps your leg wants to tell us something...". Antonio smiles and then -his leg-
recounts an episode of violence that occurred in the residence that same morning.

The therapist began her interventions by naming an external characteristic, the

nervous leg, which led her to imagine a plausible scenario. A feature that you can
share with your patient using humor as a way not to arouse anxiety. At the same
time, she questions her own assessment by saying that perhaps she is wrong, with
which she invites her patient to correct her if she is indeed wrong or to let the leg
tell what he cannot.

Conclusions

Art therapy was born from artistic practice in health environments, hospices and psychiatric
hospitals in the middle of the last century to evolve, either as a form of psychodynamic
psychotherapy (Jungian, Kleinian, Group Analytic...) or as a specialty within the educational
field, or as a variant of mediation or Community Art in the field of Social Justice. At the
beginning of Metáfora in 1999 we decided to guide Art Therapy training following a well-
established model such as the British. In the mid-1990s, with the contributions of Fonagy and
Mentalization, we witnessed the birth of a new paradigm in our profession that left behind the
preceding psychoanalytic orientation. In Art Therapy, art is a tool that helps to contain and
channel emotions, but it is also, an instrument at the service of understanding our patients.
And for patients, as I have tried to convey in this article, a means to expand their ability to
mentalize, that is, to understand themselves and others and thus gain a tool that provides
them with a better quality of life.
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