Mentalization in the Context of Cognitive Behavioural Therapy for Generalised Anxiety Disorder

Abstract

Mentalization has been linked to emotion regulation, attachment and the ability to cooperate with others. Researchers hypothesised that mentalizing might be one of the significant factors of therapeutic change, with highly mentalizing therapists believed to be more effective at developing mentalizing in their clients. To date, most research has focused on personality disorders. Limited evidence has revealed compromised mentalizing and deficits in brain activity in the areas responsible for mentalization in those with Generalised Anxiety Disorder (GAD). No research to date has examined the presence and the role of mentalizing in those with GAD undergoing Cognitive Behavioural Therapy (CBT) or their therapists. This mixed-methods case study used conversation analysis (CA) on a corpus of audio recordings to examine mentalization interactionally in individuals with GAD undergoing CBT. Correlational statistics were also employed to explore potential relationships between therapists' and clients' mentalizing, therapists’ mentalizing and clients’ levels of worry, and clients’ mentalizing and their worry levels. CA analyses of three dyads of therapists and clients recruited from NHS mental health services in England showed that, despite therapists' regular invitations to mentalize, only about half of the clients’ responses presented mentalizing. Interactions focused on meaning, meaning
expansion, and using immediacy to bring the client into the present moment in high-affect situations appeared to be the most effective conversational structures for eliciting mentalizing. Conversational turns heavily focused on the CBT framework, lengthy psychoeducation, and interruptions during high affect discussions hampered mentalization.

A positive therapy outcome was observed only in dyad A, which adapted the CBT protocol to include interventions targeting interpersonal difficulties. This was also the only dyad to observe a strong positive relationship between the client’s mentalizing (MZQ) and their level of worry (PSWQ). No other significant relationships were found in this dyad or in dyads B and C, which experienced in effective treatment, between any of the variables.

CBT for GAD might prioritise affect, meaning expansion in addition to cognition elicitation, and adapt its protocols to include interpersonal factors. Future research might further explore the role of mentalizing in those with GAD and study adapted protocols. The utility of CA in CBT training and therapy with GAD should also be further investigated. Limitations, links to the literature, and contributions were discussed.

Date of Award	2025
Original language	English
Awarding Institution	Canterbury Christ Church University