ORIGINAL RESEARCH published: 03 February 2021 doi: 10.3389/fpsyg.2021.566254 Self and Other Mentalizing Polarities and Dimensions of Mental Health: Association With Types of Symptoms, Functioning and Well-Being Sergi Ballespí 1* , Jaume Vives 2 , Carla Sharp 3 , Lorena Chanes 1,4 and Neus Barrantes-Vidal 1,5,6 1 Department of Clinical and Health Psychology, Universitat Autònoma de Barcelona, Barcelona, Spain, 2 Department of Psychobiology and Methodology of Health Sciences, Universitat Autònoma de Barcelona, Barcelona, Spain, 3 Department of Psychology, University of Houston, Houston, TX, United States, 4 Serra Húnter Programme, Generalitat de Catalunya, Barcelona, Spain, 5 Department of Mental Health, Fundació Sanitària Sant Pere Claver, Barcelona, Spain, 6 Centre for Biomedical Research Network on Mental Health, Instituto de Salud Carlos III, Madrid, Spain Research suggests that the ability to understand one’s own and others’ minds, or mentalizing, is a key factor for mental health. Most studies have focused the attention Edited by: on the association between global measures of mentalizing and specific disorders. In Xavier Noel, contrast, very few studies have analyzed the association between specific mentalizing Université Libre de Bruxelles, Belgium polarities and global measures of mental health. This study aimed to evaluate whether Reviewed by: Szabolcs Keri, self and other polarities of mentalizing are associated with a multidimensional notion University of Szeged, Hungary of mental health, which considers symptoms, functioning, and well-being. Additionally, Yasuhiro Kotera, University of Derby, United Kingdom the level or depth of mentalizing within each polarity was also analyzed. A sample *Correspondence: of 214 adolescents (12–18 years old, M = 14.7, and SD = 1.7; 53.3% female) was Sergi Ballespí evaluated on measures of self- (Trait Meta-Mood Scale or TMMS-24) and other- sergi.ballespi@uab.cat mentalizing (Adolescent Mentalizing Interview or AMI), multi-informed measures of Specialty section: psychopathology and functioning based on Achenbach’s system, and measures of This article was submitted to psychological well-being (self-esteem, happiness, and motivation to life goals). Results Psychopathology, revealed no association between mentalizing polarities and higher-order symptom a section of the journal Frontiers in Psychology factors (internalizing, externalizing, and global symptoms or “p” factor). Self-mentalizing Received: 04 June 2020 was associated with self-esteem (B = 0.076, p < 0.0005) and motivation to life goals Accepted: 11 January 2021 (B = 0.209, p = 0.002), and other-mentalizing was associated to general, social and Published: 03 February 2021 role functioning (B = 0.475, p < 0.0005; B = 0.380, p = 0.005; and B = 0.364, Citation: Ballespí S, Vives J, Sharp C, p = 0.004). This association between aspects of self-other mentalizing and self-other Chanes L and Barrantes-Vidal N function has important implications for treatment and prevention. Deeper mentalizing (2021) Self and Other Mentalizing within each polarity (i.e., comprehension beyond simple attention to one’s own mental Polarities and Dimensions of Mental Health: Association With Types states, and mentalizing referred to attachment figures vs. mentalizing referred to the of Symptoms, Functioning characters of a story) revealed stronger associations with functioning and well-being. and Well-Being. Front. Psychol. 12:566254. Because mentalizing polarities are associated with functioning and well-being but not doi: 10.3389/fpsyg.2021.566254 with symptoms, a new hypothesis is developed: mentalizing does not contribute to Frontiers in Psychology | www.frontiersin.org 1 February 2021 | Volume 12 | Article 566254 Ballespí et al. Mentalizing Polarities and Mental Health resiliency by preventing symptoms, but by helping to deal with them, thus improving functioning and well-being independently of psychopathology. These findings support that promoting mentalizing across development may improve mental health, even in non-clinical population. Keywords: self-other mentalizing, polarities, symptoms, functioning, well-being, adolescents, non-clinical population, mental health INTRODUCTION research shows that mentalizing is non-specifically affected in the presence of psychopathology regardless the type of One pivotal challenge of neuroscience is to understand disorder (Sharp et al., 2008). Mentalizing problems are how one mind knows other minds (Amodio and Frith, prominent in personality disorders, especially in borderline 2006; Carruthers, 2019). Consciousness about one’s own and antisocial personality disorder, as well as in depression, mental states (emotions, intentions, desires, and thoughts) anxiety, social anxiety, trauma-related disorders, attachment and those of others is a high-order cognition that has been disorders, eating disorders, addictions, somatoform disorders, approached from several perspectives. Social intelligence autism, and psychosis (see Ballespí et al., 2018; Bateman and (Thorndike and Stein, 1937), social cognition (Heider, 1967), Fonagy, 2019; Luyten et al., 2020, for a review). This non- Theory of Mind (Premack and Woodruff, 1978), mind- specific association suggests that mentalizing is decreased when blindness (Baron-Cohen, 1990), Intra- and Inter- personal mental health decreases. Possibly for this reason, mentalization intelligence (Gardner, 1987), and Emotional Intelligence is commonly targeted to restore mental health, making it (Salovey and Mayer, 1993) are some of the myriad terms used a common factor in most psychological treatments (Allen across the Twentieth century to refer the human capacity et al., 2008; Fernández-Sotos et al., 2019). Taken together, to be aware of the states of the mind, i.e., the intentional this evidence suggests that mentalization is a key factor for states (emotions, feelings, and drives) that underpin human mental health. behavior (Allen et al., 2008; Choi-Kain et al., 2008). The proliferation of theories to approach this higher order The Current Study cognition reveals a persistent interest in this capacity, but To date, most studies have focused attention on the association also contributes to a proliferation of cousin-concepts referred to between global measures of mentalizing and specific disorders. In the same brain function. contrast, very few studies have analyzed the association between specific mentalizing polarities and global measures of mental Mentalization as a Multi-Dimensional health. Moreover, the role of each polarity of mentalization is Higher Order Cognition typically not evaluated. Measures of self- and other mentalizing In this context, the mentalization paradigm neither provides are usually used interchangeably in the literature, and the a new concept nor discovers a novel ability (Bateman and level or depth of mentalizing is not often distinguished when Fonagy, 2019), but organizes the field from a multidimensional comparing studies. To better understand the role of mentalizing perspective based on advances in neuroscience (Kim, 2015). in salutogenesis, the multidimensional nature of this capacity Mentalization refers to the brain’s ability to keep the mind needs to be considered (Luyten et al., 2020). in mind (Frith and Frith, 2003). In other words, it defines The first aim of this study was to evaluate whether different our capacity to be aware of the intentional mental states such polarities of mentalizing, specifically self- vs. other-mentalizing, as emotions, feelings, intentions, and thoughts that underpin are associated with different dimensions of mental health. one’s own and others’ behavior (Frith and Frith, 2006). The Recent debates further developed the classic definition of World mentalization paradigm provides a unified, transtheoretical Health Organization, whereby mental health is not only the and transdiagnostic perspective, and encompassing cousin- absence of mental disorders but also considers social- and concepts organized around four polarities (Allen et al., 2008). role- functioning along with psychological well-being (World According to this organization, mentalization can be automatic Health Organization (WHO), 2018). In fact, this wide-reaching or controlled, cognitive or affective, internally or externally definition of mental health has been refined considering “. . .a focused, and referred to one’s own (self) or others’ mental states dynamic state of internal equilibrium” as well as the “. . .ability (Luyten et al., 2020). to cope with adverse life events and function in social roles” (Galderisi et al., 2015, 2017). Consistently, mental health was Mentalization and Mental Health operationalized in the current study using the number of The ability to consider mental states makes possible to symptoms, one’s level of social- and role- functioning, and understand human’s behavior and to navigate our complex measures of psychological well-being (i.e., happiness, self-esteem, social world (Freeman, 2016). By contrast, problems with and transcendence or motivation to life goals). Basing on this this ability are associated with difficulties in social and multi-dimensional view, we hypothesized that self- and other psychological functioning (e.g., autism spectrum disorders) polarities of mentalizing might be differently associated to self- and poor of mental health (Katznelson, 2014). Further, and other- function. Frontiers in Psychology | www.frontiersin.org 2 February 2021 | Volume 12 | Article 566254 Ballespí et al. Mentalizing Polarities and Mental Health The Hypothetical Association Between (Fonagy et al., 2005). Thus, we hypothesized that both self- Self- Mentalizing, Inner Functioning and and other- polarities of mentalizing would be associated to externalizing symptoms. Internalizing Problems The capacity to be aware of one’s own mental states is useful to deal with one’s own suffering. Self-awareness or insight The Hypothetical Association Between into one’s own mental states is a common ingredient in all Levels of Self- and Other- Mentalizing psychological treatments (Allen et al., 2008). Specifically, self- Polarities and Level of Mental Health mentalizing is important to be aware of- and to understand The degree or depth of mentalizing processes is not typically what one is feeling (Oldershaw et al., 2010; Lumley et al., 2017), evaluated in research. The awareness of one’s own mental to determine whether one’s emotional suffering decreases after states can be operationalized either as simple attention to an intervention (Davis et al., 2019), or to understand why we one’s own emotions (that is, the degree to which individuals react the way we do toward others (Fonagy and Target, 1997; notice their feelings) or as further comprehension or emotional Frith, 1999; Brackett et al., 2006). Self-mentalizing also promotes clarity (that is, the ability to distinguish and to understand self-regulation (Fonagy et al., 2005; Heatherton, 2011), thus one’s mood; Mayer and Gaschke, 1988; Salovey et al., 1995). suggesting a role in the “digestion” of one’s own feelings. These levels of emotional awareness (e.g., attention vs. further Because internalizing problems are defined as those in which comprehension) are usually assessed in separate studies or, suffering is directed inward (e.g., anxiety, depression, and somatic more rarely, they are assessed in the same study but refer to complaints; Achenbach et al., 2016), we hypothesized that a very specific psychopathological condition (e.g., Butler et al., “self ” polarity of mentalizing would be especially associated 2018; Ballespí et al., 2019). However, no study has considered with internalizing problems. Likewise, if self-mentalizing helps these different levels of emotional awareness in the context of to manage one’s own mental states, and psychological well- general mental health, especially in a sample of non-clinical being or internal equilibrium are usually associated with mental general population. processes, we also predicted that self-mentalizing would be more Similarly, mentalization about others’ mental states can be strongly associated with measures of psychological well-being evaluated on a spectrum of profundity. Other-mentalization (i.e., happiness, self-esteem, and life-motivation) than would is measured using myriad methods that are often compared other-mentalizing. in research, in spite of the important differences existing among them (Luyten et al., 2019). Two primary groups of methods exist: Clinical interviews based on primary attachment The Hypothetical Association Between figures, and film- or picture-based measures which are non- Other-Mentalizing, Social-Functioning, specific to the individual being evaluated. When using an and Externalizing Problems attachment interview, mentalizing is evaluated with regard to The capacity to understand others’ mental states is an advantage well-known close-others such as family members and based on to navigate in the social world (Amodio and Frith, 2006). internal cues, which requires the individual to draw on complex An adequate interpretation of others’ minds is associated with representations of attachment figures (i.e., the working model; better social and role functioning (Brackett et al., 2006; Perera Fonagy and Target, 1997). In contrast, film- or picture-based and DiGiacomo, 2013; Miao et al., 2017), higher quality of measures utilize characters and stories to prompt reasoning for social interaction (Lopes et al., 2004), and sociometric status the motivations behind characters’ actions. In such a measure, (Slaughter et al., 2015; Lonigro et al., 2018), less inter-personal there is not a complex representation of a specific well- conflicts (García-Sancho et al., 2014), more secure attachment known other, but mentalizing is based on general knowledge style (Fonagy and Bateman, 2016), and higher social support (Di about social behavior and on the external cues of these Fabio, 2015). Because our social and role functioning occur in characters like facial expression, gestures, and tone of voice the social world, it was hypothesized that mentalization regarding (Frith and Frith, 2012). others’ mental states might be more associated with social and It can be argued that mentalizing activity which refers role functioning than self-mentalizing. to an “insignificant” character of a picture-based story is Psychopathological problems expressed outside the individual disparate to mentalizing activity of a real, close other. While and with a special impact in the social world are defined a story character activates general social knowledge, a specific as externalizing problems (Achenbach et al., 2016) and person, whom an individual holds an affective bond to involve symptoms with an particular impact on others (e.g., (attachment relationship) activates a unique “working model” impulsivity, aggression, oppositionism, and rule-breaking of the figure, with very concrete, complete and refined behavior; Liu, 2004). Studies of Borderline Personality knowledge about the personality and social functioning of Disorder (Fonagy and Luyten, 2009; Sharp et al., 2011) this specific close other (Collins et al., 2006). These different and aggression (Dolan and Fullam, 2004; Taubner et al., levels of mentalizing referred to others’ mental states, based 2013) show that mentalizing about others’ intentions and on a different degree of specificity or depth, should be also feelings is associated with externalizing symptoms. However, distinguished. This distinction, however, is lacking from the acting out is also associated with emotional dysregulation, literature, whereby different studies with inconsistent measures which is in turn associated with problems of self-mentalizing of mentalizing are compared. Frontiers in Psychology | www.frontiersin.org 3 February 2021 | Volume 12 | Article 566254 Ballespí et al. Mentalizing Polarities and Mental Health Consequently, the second aim of this study was to analyze Measures whether the level of self- or other- mentalizing is associated Mentalization with symptoms, functioning and well-being. Regarding the Adolescent Mentalizing Interview self- polarity, attention vs. further comprehension of one’s This is a brief, two-part, semi-structured interview (Ballespí own emotional states is distinguished in the relationship with and Pérez-Domingo, 2015) specifically designed for adolescents symptoms, functioning and well-being. Regarding the other- and originally created in Spanish and Catalan to obtain an polarity, mentalizing referred to the characters of a picture- interview-based score of mentalization in a short time (i.e., based story (i.e., unspecific others) is distinguished from 20–30 min depending on the responses of the participant). It mentalizing referred to specific and real attachment figures, consists of two guided exercises with 7 questions scored from 0 which is expected to be more refined (Fonagy and Target, 1997; to 4, for which 0 indicates that mentalization is “Absent” in the Fonagy and Bateman, 2016). individual’s response, 1 that it is “Poor,” 2 “Sufficient,” 3 “Good,” We hypothesized that deeper levels of mentalizing (that and 4 “Sophisticated.” The first part (3 items) is a story-based is, a higher relative ability to mentalize) would be more procedure used to ask the adolescent about the mental states strongly associated to mental health. Specifically, it was expected of the characters of a fictitious illustrated story. In the second that comprehension of one’s own emotional states would part, individuals are encouraged to choose two very-close-others be more strongly associated to internalizing symptoms and (i.e., two people important for them at this moment of their psychological well-being than simple attention (i.e., a less life; Bartholomew and Horowitz, 1991) and different demand profound understanding of one’s own internal mental states). questions (Fonagy et al., 1998) are made in order to explicitly Further, mentalizing about attachment figures is more specific elicit mentalizing ability (e.g., “Why do you think he reacted and refined, and it better reflects the degree of sophistication like that?”). The first part is aimed to provide a measure of that someone is able to reach when mentalizing. Therefore, we non-attachment-based mentalizing since it is referred to fictious predicted that attachment-based mentalizing, that is, mentalizing unknown characters of a story (i.e., “insignificant” others). referred to significant close others (attachment figures) might The second part is aimed to measure mentalization toward an be more strongly associated with externalizing symptoms and attachment figure, i.e., a significant close other. Reliability in the social- and role- functioning than mentalizing referred to the present sample is good both for the total scale (α = 0.91) and the characters of a story (i.e., general or ‘insignificant others). subscales (α = 0.88 and α = 0.85), respectively. Trait Meta-Mood Scale MATERIALS AND METHODS The Trait Meta-Mood Scale (TMMS-24) measures the 3 dimensions of meta-cognition defined through factor analysis Participants according to the model of Mayer and Salovey (Mayer and This study was based on a sample of adolescents from the general Gaschke, 1988): attention, comprehension (emotional clarity), population. Importantly, mentalization is quite developed at and repair (emotional regulation) toward one’s own emotional adolescence. Furthermore, both psychopathological and a wide states. The widely used 24-items version was selected (Fernandez- range of subclinical problems are quite prevalent in community Berrocal et al., 2004). All 24 items are scored from 1 (strongly adolescent samples (Merikangas et al., 2010; Muris et al., 2011). disagree) to 5 (strongly agree). The first two dimensions of Participants were recruited from schools within the context of attention and emotional clarity or comprehension were used in a broader project about psychopathology, personality, and coping the present study. The attention scale includes items such as “I skills. The inclusion criteria were: (1) to be in the eligible age pay a lot of attention to how I feel,” while the clarity scale evaluates range of the study (12–18); (2) to speak Spanish or Catalan (i.e., the understanding of one’s emotional states and includes items the languages of the questionnaires). The exclusion criteria were: like “I almost always know exactly how I am feeling,” or “I can’t (1) presence of severe mental illness such as autism spectrum make sense out of my feelings.” The internal consistency in the disorder, psychosis or intellectual disability; (2) parents, teachers current sample is excellent (α = 0.91 for the total score, α = 0.90 or adolescents failing to fill in one or more scales. Five out for attention, and α = 0.92 for comprehension). of 10 invited schools agreed to participate, thus providing an eligible sample of 1735 families. Primary participation refusal Psychopathology reasons included low interest in the project, being too busy, or Achenbach’s System for Empirically Based Assessment refusal to provide data about family’s mental health. The final Achenbach’s System for Empirically Based Assessment (ASEBA) sample consisted of 214 adolescents (53.3% of girls) aged 12 is a well-known dimensional and empirically derived system to 18 years old (M = 14.7, SD = 1.7). Approximately 87% of to classify psychopathology with good psychometric properties the participants were Caucasian (White-European), 9% Arabic, (Achenbach, 2020a). Second order scales of general, internalizing 2% Asian, and 2% Latino. Most adolescents came from families and externalizing problems reported from parents’ and teachers’ with middle socio-economic level (72%), although there was were used in the current study (Achenbach, 2020b). The Spanish a bias to medium-high and high socio-economic level (10.3% adaptation (Achenbach and Rescorla, 2001) shows excellent Low, 13.6% Medium-Low, 18.7% Medium, 39.7% Medium- internal consistency both for the Child Behavior Check-List or High, and 17.8% High) according to the Hollingshead’s index CBCL (α ranges from 0.78 to 0.97) and the Teacher’s Report Form (Hollingshead, 1975). or TRF (α ranges from 0.72 to 0.97), as well as adequate test-retest Frontiers in Psychology | www.frontiersin.org 4 February 2021 | Volume 12 | Article 566254 Ballespí et al. Mentalizing Polarities and Mental Health reliability in both cases (ICC from 0.85 to 0.90 for CBCL, and Happiness was measured through Teachers’ Report Form 0.60–0.90 for the TRF). (Achenbach, 2020a) which includes a scale of happiness based on Drawing from the complementary perspective provided teachers’ ratings to the question “How happy is he/she?” using a by parents and teachers (De Los Reyes and Kazdin, 2005), 7-point scale (from 1-Much less to 7-Much more). multi-informant indices of symptoms and functioning were Self-Esteem was assessed with the widely used Rosenberg’s developed. Using principal component analysis, the standardized Self-Esteem Scale (RSES; Rosenberg, 1965), consisting of 10 object scores in the one-factor solution were used to combine items rated with 5-point scales according to the degree of parents’ and teachers’ scores in one single measure. Thus, agreement with each statement. The Spanish adaptation shows multi-informed indexes of Total (70% of explained variance; adequate psychometric properties (Martín-Albo et al., 2007). weights = 0.84; α = 0.58), Internalizing (68% of explained The internal consistency in the current sample was excellent variance; weights = 0.82; α = 0.53), and Externalizing problems (α = 0.90). (67% of explained variance; weights = 0.82; α = 0.50) were Transcendence is a scale based on the dimensions of obtained. The psychometric properties of these indices are Spirituality, Community, and Conformity of the Aspiration adequate since they combine information from complementary Index of Kasser and Ryan (2001; see also Grouzet et al., 2005) (i.e., usually discrepant) informants (De Los Reyes et al., 2015). consisting of 12 items rated from 1 to 9 based on the importance and likelihood of different goals in the life of the participant. Psychological Functioning The Spanish adaptation show adequate psychometric properties The CBCL/6-18 (parents’ form) provides 3 indices of functioning (Romero et al., 2012). The internal consistency in the present (Activities, Social, and School) along with one summarizing sample is good (α = 0.79). all of them (the total competence scale). The TRF/6-18 (teacher’s form) provides a scale of academic performance, Procedure four dimensions of adaptive functioning (Working Hard, The study met ethical standards according to Declaration of Behaving, Learning, and Happy) and a total score based on Helsinki and the revision of the Ethics Committee of the those four (total adaptive functioning; see the profiles in Universitat Autònoma de Barcelona (CEEAH; Spain) (Ethical Achenbach, 2020b). Using the same procedure as in the case of clearance number: CEEAH 2603). Accordingly, we reported how psychopathology described above, three multi-informed general we determined and obtained our sample, all data exclusions, indices of functioning were developed combining parents’ and all manipulations, and all measures in the study. Families were teachers’ reports: Social Functioning (i.e., peer relationships, informed about the objectives, relevance, and implications of sociometric status, and involvement with family members; 55% the research by means of a letter circulated by the school. of explained variance, weights from 0.62 to 0.81, α = 0.49), Parents, teachers and children were also invited to a meeting Role Functioning (i.e., performance in academic and extra- to resolve any questions or concerns regarding the study. All academic activities like sports or chores; 56% of explained participants (i.e., parents, adolescents, and teachers) provided variance, weights from 0.24 to 0.91, α = 0.73), and General written informed consent and were offered the option of Functioning (64% of explained variance, weights = 0.80, being informed in the case of one or multiple scales reflecting α = 0.45). dysfunction of clinical significance. Data were recruited in the schools to simplify logistics. The participants (adolescents, Well-Being parents, and teachers) received the questionnaires in closed Modern conceptions of mental health agree on that it consists envelops with their identities encrypted using alphanumeric not only the absence of symptoms or disorders but a codes and were given a deadline to return them. The instructions general state of social and emotional well-being (Bertolote, highlighted the importance and reasons that each informant 2008; World Health Organization (WHO), 2018) or, in should complete his or her form in in private, and of the more refined terms of Galderisi et al. (2017), “. . .a completing the task over the course of multiple sessions to dynamic state of internal equilibrium which enables individuals buffer the effect of fatigue. All forms were reviewed and to use their abilities in harmony with universal values of returned to the informants in case it was necessary to correct society.” According to these modern notions, three construct missing or out-or-range values. The interviews were carried measures that are usually low in the absence of good mental out individually in private spaces provided by each school health were evaluated: happiness (e.g., Ho et al., 2018), (e.g., an office, and empty classroom). Data collection occurred self-esteem (Pyszczynski et al., 2004; Keane and Loades, over the course of approximately 5 weeks in all schools 2017), and transcendence (Nygren et al., 2005). As emotional included in the study. Paper responses were archived in the well-being and self-esteem, motivation is decreased in most lab with the same alphanumeric codes they were entered to psychopathological conditions (e.g., Vogel et al., 2019), while the data matrix. positive motivational states (e.g., to have aspirations or goals in life) denote healthy personality functioning (Seligman and Statistical Analysis Peterson, 2006; Zhang and Yu, 2014). Therefore, we included We conducted power analyses using Stata V. 16.1. With α = 0.05, a motivational measure based on the Aspiration index of power (1–β) = 0.8, four explanatory variables, and three control Kasser and Ryan (2001), called here “transcendence,” and variables, the sample needed to detect a minimum change of 0.05 described below. in R2 was 208. All of the analyses were performed with sample Frontiers in Psychology | www.frontiersin.org 5 February 2021 | Volume 12 | Article 566254 Ballespí et al. Mentalizing Polarities and Mental Health size of 214. Linear regressions were conducted using IBM SPSS comprehension (self) demonstrated associations in the expected Statistics v24.0 package. The results of the association between direction. Thus, deeper levels of mentalizing within each mentalizing and each measure of symptoms, functioning and polarity showed associations with the predicted aspect of mental well-being are presented as linear regression coefficients (B) for health. There were only two exceptions: (1) Attachment-based quantitative responses, reporting 95% confidence intervals (95% mentalizing was associated with general (B = 0.727, p = 0.014) CI), and P-values (p). and role functioning (B = 0.638, p = 0.027), but not with social Because sex, age, and socio-economic level are associated functioning, and (2) comprehension of one’s own mental states with both mentalization and psychopathological conditions, revealed an association with self-esteem (B = 0.267, p < 0.0005) these variables were controlled for in all analyses. Sex is closely and transcendence (B = 0.335, p = 0.043), but not with happiness. related both to psychopathology (Zahn-Waxler et al., 2008) and In fact, happiness was not associated with any dimension of mentalizing (Schulte-Rüther et al., 2008; Cheng et al., 2009). mentalization, whereas self-esteem was associated with all Mentalization is a high-order cognition that becomes more but one (i.e., in case of attachment-based others the result is complex with age (Frith and Frith, 2003; Klindt et al., 2017; suggestive but not significant: B = 0.299, p = 0.050). Poznyak et al., 2019), and socioeconomic status (SES) is a well- known general risk factor for psychopathology (Wadsworth and Achenbach, 2005) and it is also associated with mentalization DISCUSSION (Mankus et al., 2016). Self and Other Mentalization Polarities and Dimensions of Mental Health RESULTS Research suggests that the capacity of the mind to understand one’s own and others’ minds is a key factor for mental health Descriptive Statistics and Assumptions (Luyten et al., 2020). Most studies have focused on the of the Models association between global measures of mentalizing and specific Table 1 shows the descriptive statistics for the different measures disorders. In contrast, very few studies have analyzed the of mentalization, symptoms, functioning and well-being, association between specific mentalizing polarities and global along with the correlations between them. All the significant measures of mental health. The first aim of this study was correlations show the expected direction. All the regression to analyze whether self and other polarities of mentalizing models tested met the assumptions of independent errors were associated with three widely accepted elements of (Durwin–Watson test), homoscedasticity (Plot of standardized global mental health, that is: symptoms, functioning and predicted values against standardized residuals), normality of measures of psychological well-being (self-esteem, happiness, residuals (P–P plot), absence of multicollinearity (VIF and and motivation to life-goals) as an operationalization of tolerance), and of influential cases (Cook’s distance). what recent discussions define as “internal equilibrium” or internal functioning (Galderisi et al., 2015, 2017; Aim 1. Self and Other Mentalizing World Health Organization (WHO), 2018). Polarities and Dimensions of Mental In line with our predictions, the capacity to understand others’ mental states was associated with all measures of functioning, Health while the capacity to be aware of one’s own mental states was Table 2 shows that mentalization referred to others’ mental states associated with self-esteem and transcendence (i.e., capacity to was associated with all measures of functioning (B = 0.475, stablish life goals), but not with happiness. p < 0.0005 for general functioning; B = 0.380, p = 0.005 for social The hypothesized association between happiness and self- functioning; and B = 0.364, p = 0.004 for role functioning), and mentalizing was possibly not supported because the current self-mentalizing was associated with measures of psychological measure of well-being was based only on the teachers’ well-being (B = 0.076, p < 0.0005 for self-esteem; B = 0.209, reports, that is, on the observation of adolescent behavior p = 0.002 for transcendence). No mentalizing dimension was in the academic environment. In the case of well-being, associated with symptoms. Happiness was not associated with self-reports are especially important. Future studies with self-mentalizing (B = 0.002, p = 0.728), but it was associated with more comprehensive measures might shed new light on this the capacity to mentalize others (B = 0.053, p = 0.002). point. Interestingly, happiness is associated with mentalizing referred to others’ mental states. This result has two possible Aim 2. Levels of Self and Other explanations: (1) the aforementioned reason, whereby the Mentalizing and Dimensions of Mental measure of happiness is based on teachers’ observation in the Health academic context where happiness is primarily experienced Table 3 shows levels of self-mentalizing (attention vs. through social interaction; and (2) the importance of the comprehension) and other-mentalizing (non-attachment social network for emotional well-being (Chu et al., 2010). based mentalization of “insignificant” or general others, Most studies support that social relationships and the support vs. mentalizing of well-known attachment figures). Again, they provide are key factors for happiness (Cohen and Wills, symptoms were not associated with any mentalizing process, 1985; Baumeister and Leary, 1995; Garcia-Carrion et al., though the subdimensions of attachment-based (others) and 2019). Thus, if good mentalizing of others provides better Frontiers in Psychology | www.frontiersin.org 6 February 2021 | Volume 12 | Article 566254 Ballespí et al. Mentalizing Polarities and Mental Health TABLE 1 | Correlations and descriptive statistics. 1 2 3 4 5 6 7 8 9 10 11 1. Self − 2. Others 0.09 − 3. S. Total −0.12 −0.06 − 4. S. Int −0.12 −0.09 0.74** − 5. S. Ext −0.10 0.01 0.88** 0.45** − 6. F. Gen 0.15* 0.26** −0.50** −0.23** −0.41** − 7. F. Social 0.13 0.20** −0.42** −0.46** −0.23** 0.50** − 8. F. Role 0.14* 0.24** −0.48** −0.13 −0.42** 0.91** 0.30** − 9. WB SE 0.30** 0.01 −0.30** −0.34** −0.22** 0.32** 0.25** 0.22** − 10. WB Hap 0.10 0.19** −0.39** −0.36** −0.26** 0.62** 0.38** 0.59** 0.27** − 11. WB Tran 0.31** 0.16 −0.10 −0.07 −0.14 −0.02 0.08 −0.04 0.20* 0.03 − Mean 73,89 14,57 1,35 1,29 0,94 25,71 32,16 28,49 21,50 4,51 34,82 SD 15,34 4,95 1,00 1,00 1,00 9,84 10,00 9,82 5,42 1,22 12,71 *p < 0.05 and **p < 0.01. S. Total; Symptoms Total; S. Int: Symptoms Internalizing; S. Ext: Symptoms Externalizing; F. Gen: Functioning General; F. Social: Functioning Social; F. Role: Functioning Role; WB SE: Well-being Self-esteem; WB Hap: Well-being Happiness; and WB Tran: Well-being Transcendence. TABLE 2 | Association between mentalizing dimensions and different aspects of mental health (n = 214). Self Others B (p) 95% CI B (p) 95% CI Symptoms Total -0.008 (0.056) −0.017 to 0.0002 −0.003 (0.860) −0.031 to 0.026 Internalizing −0.006 (0.167) −0.014 to 0.002 −0.025 (0.067) −0.052 to 0.002 Externalizing −0.008 (0.085) −0.017 to 0.001 0.013 (0.394) −0.016 to 0.041 Functioning General 0.051 (0.189) −0.025 to 0.128 0.475 (<0.0005) 0.228 to 0.721 Social 0.040 (0.339) −0.042 to 0.123 0.380 (0.005) 0.113 to 0.646 Role 0.058 (0.132) −0.018 to 0.135 0.364 (0.004) 0.119 to 0.609 Well-being Self-esteem 0.076 (<0.0005) 0.034 to 0.117 0.117 (0.093) −0.020 to 0.253 Happiness 0.002 (0.728) −0.008 to 0.012 0.053 (0.002) 0.020 to 0.087 Transcendence 0.209 (0.002) 0.079 to 0.340 0.141 (0.534) −0.307 to 0.589 Results are adjusted for age, sex and socio-economic level in all cases. In case of functioning and well-being, results are additionally adjusted for total psychopathological symptoms. Significant B values are highlighted in bold. social relationships, then it becomes an “indirect” factor for of emotional well-being should clarify this result, along with emotional well-being. studies addressing the broader notion of “dynamic internal Further, the role of happiness in mental health has equilibrium,” represented here by the other two measures of been recently questioned (Galderisi et al., 2015), which is psychological well-being, self-esteem and transcendence, along an important consideration in light of our negative result. with happiness. While the notion of mental health has evolved across one century to reach beyond symptoms (Bertolote, 2008), the initial WHO definition of mental health including well-being The Lack of Association Between (World Health Organization (WHO), 2001) is purported to Mentalization Polarities and Internalizing be excessively organized around an hedonic and eudaimonic or Externalizing Symptoms perspective (Galderisi et al., 2017). Thus, it is possible that Regarding symptoms, it was predicted that self-mentalizing no association between self-mentalizing and happiness was should be associated with internalizing symptoms, while revealed because happiness, as a hedonic state, is not a externalizing problems might be associated with self- and also consistent dimension of the “dynamic internal equilibrium” other-mentalizing. Results did not support any association referred by Galderisi and colleagues as the foundation of between polarities and symptoms. This is an unexpected finding mental health. Future studies with more complete measures for three reasons. Firstly, literature suggests that mentalizing is Frontiers in Psychology | www.frontiersin.org 7 February 2021 | Volume 12 | Article 566254 Ballespí et al. Mentalizing Polarities and Mental Health TABLE 3 | Association between levels of self- and others- mentalizing and different aspects of mental health (n = 214). Self attention Self comprehension Others non-attachment based Others attachment based B (p) 95% CI B (p) 95% CI B (p) 95% CI B (p) 95% CI Symptoms Total 0.005 (0.609) −0.016 to 0.027 −0.017 (0.096) −0.037 to 0.003 0.047 (0.347) −0.051 to 0.144 −0.039 (0.239) −0.105 to 0.026 Internalizing 0.005 (0.624) −0.015 to 0.025 −0.015 (0.109) −0.034 to 0.003 −0.051 (0.278) −0.143 to 0.041 −0.012 (0.693) −0.074 to 0.049 Externalizing 0.003 (0.775) −0.018 to 0.025 −0.011 (0.286) −0.031 to 0.009 0.095 (0.061) −0.005 to 0.195 −0.045 (0.187) −0.112 to 0.022 Functioning General 0.039 (0.677) −0.145 to 0.223 0.094 (0.299) −0.084 to 0.273 0.100 (0.816) −0.749 to 0.949 0.727 (0.014) 0.152 to 1.302 Social 0.167 (0.107) −0.036 to 0.369 0.020 (0.838) −0.172 to 0.212 0.515 (0.282) −0.426 to 1.456 0.264 (0.409) −0.365 to 0.892 Role 0.022 (0.808) −0.159 to 0.204 0.113 (0.208) −0.063 to 0.289 −0.032 (0.940) −0.871 to 0.806 0.638 (0.027) 0.074 to 1.203 Well-being Self-esteem −0.172 (0.001) −0.268 to −0.075 0.267 (<0.005) 0.176 to 0.358 −0.054 (0.812) −0.498 to 0.391 0.299 (0.050) 0.000 to 0.598 Happiness 0.010 (0.409) −0.014 to 0.035 −0.004 (0.760) −0.027 to 0.020 0.057 (0.327) −0.057 to 0.171 0.050 (0.198) −0.026 to 0.126 Transcendence 0.173 (0.346) −0.189 to 0.535 0.335 (0.043) 0.011 to 0.658 0.036 (0.965) −1.590 to 1.663 0.234 (0.669) −0.847 to 1.316 Results are adjusted for age, sex and socio-economic level in all cases. Results are additionally adjusted for total psychopathological symptoms in case of functioning and well-being. Significant B values are highlighted in bold. a resilience factor because it lacks when mental health lacks association between symptoms and mentalization stands as an (for a review, see Sharp et al., 2008; Katznelson, 2014), and unresolved question. Secondly, it is possible that more specificity it is a common ingredient in all psychological treatments, is required not only in the multidimensional assessment of that is: to restore mental health, mentalization must be mentalizing, but also regarding psychopathology. Perhaps the improved (Allen et al., 2008). This suggests an association imbalance in mentalizing polarities is specific for different between mentalizing and mental health which should be psychopathological conditions (Luyten et al., 2020) but it fades applicable to all the three evaluated elements: functioning, away when symptoms are grouped in higher-order factors well-being, and also symptoms. Secondly, previous studies (internalizing, externalizing, and “p” factor). This new possibility utilizing global measures of mentalizing found no association deserves attention. with general psychopathology (e.g., Ballespí et al., 2018), but The aim of this study was not to analyze specific disorders it was expected that investigation with a multidimensional but general symptoms in a non-clinical sample. However, the measure of mentalizing would provide different results. Finally, lack of association between mentalizing polarities and higher- albeit limited, there is evidence supporting the association order factors of symptoms lead us to explore the clinical between the role of mentalizing in the development of dimensions of the ASEBA system. More specificity in this regard internalizing and externalizing problems (Sharp et al., 2008). did not change results. That is, when using the specific clinical Nonetheless, this evidence approaches the association from scales (e.g., anxious-depressed, anxious-withdrawn) instead of either a specific psychopathological condition (e.g., autism, the general factors (internalizing, externalizing, and general sexual abuse, complex trauma, and borderline symptoms; e.g., problems) no association between mentalizing polarities and Ensink et al., 2016) or a trans-generational point of view (i.e., the eight clinical scales of ASEBA was revealed, and very maternal reflecting function moderating children externalizing few associations appeared with the six DSM-oriented scales. difficulties; e.g., Ensink et al., 2017; Dejko–Wańczyk et al., 2020), Specifically, anxiety problems showed association with self- or comprise a longitudinal design to analyze the trajectories attention and oppositional-defiant disorders showed association of externalizing problems based on mentalizing variations with others’ mentalizing. More specificity did not change (Morosan et al., 2020). results. Of course, there is some contradiction in checking for Our study design was cross-sectional and focused on a simple clinical dimensions in a non-clinical sample, even when using intra-individual association: to what extent one’s own mentalizing a dimensional approach (Achenbach, 2020a,b). However, it is capacities are associated to one’s own symptoms. Current possible that the association between mentalizing and symptoms findings do not support the relationship between mentalizing is not dimensional or progressive but qualitatively different in polarities and symptoms in spite of using measures of higher depending on the level of psychopathology. This might explain order factors of psychopathology (internalizing, externalizing, why results are different in clinical samples, where mentalizing and total; Caspi et al., 2014). Several possibilities exist for is always impaired. Thus, it is possible that the association this lack of association. Firstly, the multi-informed measure with functioning but not with psychopathology in the current of symptoms is based on parent- and teacher-reports, but it study is due to the nature of the sample, where variability lacks adolescents’ self-evaluation. This is a limitation of this regarding functioning and well-being (usually high in non- study. However, parent and teacher assessments of functioning clinical populations) is possibly different than variability of are indeed associated with mentalizing. As such, the lack of symptoms (usually low), even when using higher-order factors Frontiers in Psychology | www.frontiersin.org 8 February 2021 | Volume 12 | Article 566254 Ballespí et al. Mentalizing Polarities and Mental Health (internalizing, externalizing, and global). Studies ranging all the one’s own emotions. This is consistent with previous findings span of severity (from non-clinical to clinical levels) might reveal and supports the idea that comprehension is more vital to self- different results. function than simple attention. Too much attention to emotions, particularly if it lacks understanding of said emotions, can be overwhelming and it is usually associated with emotional Association Between Levels of Self- and dysregulation, which blocks mentalizing (Fonagy et al., 2005). Other- Mentalizing and Level of Mental In contrast, comprehension of emotional states is a coping skill Health to deal with emotional pain (Allen et al., 2008) and also leads In contrast to symptoms, the levels of self- and other- to self-knowledge (Fonagy and Target, 1997), which is path to mentalization fit predictions regarding functioning and well- self-acceptance (Wilson, 2009). Therefore, it is reasonable that being with two exceptions. Regarding functioning, while self-esteem is associated with good understanding of one’s self. attachment-based mentalizing was found to be associated with general and role functioning, it was not associated with social functioning. This is particularly intriguing because the general Limitations and Recommendations for measure of other-mentalizing (Table 2) was indeed associated Further Research with social functioning. Given that social functioning involves This is a first study showing a specific association between self interaction with various individuals, including attachment figures and other polarities of mentalizing and aspects of self-other and insignificant others, there is an association with “global” healthy functioning. Above all, the findings reported in the other-mentalizing but not with “partial” specific measures. present study should be replicated before drawing significant This leads us to question what types of measures of other- interpretations. Further, limitations to the research do exist. mentalizing should be used to best evaluate this ability. There are First, the cross-sectional design impedes the possibility of insignificant variations in standardized image-based measures establishing causal relationships. As such, it is unknown whether such as the Movie for the Assessment of Social Cognition the imbalances in self and other polarities of mentalizing are (MASC; Dziobek et al., 2006) or the Reading the Mind in the cause or the consequence of the mental health dimensions the Eyes Test (RMET; Baron-Cohen et al., 2001) usually that were analyzed. Moreover, although a multi-informant-based measuring mentalization based on external cues, compared to method was used for most variables, adolescent self-report measures based on attachment-interviews (e.g., the Reflective was lacking for most measures. Future studies including self- Function Scale; Luyten et al., 2019), which are based on internal reports may further highlight whether no association between cues. It is possible that these variations have consequential mentalization polarities and symptoms in general population implications in the multidimensional analysis of mentalizing is indeed present. Finally, better measures of mentalization and mental health. Knowing that assessment methods differ polarities are required. The zeitgeist of the study of this in the depth of mentalizing they elicit, and that therefore higher order cognition has just begun, and the problem results may vary according to the assessment procedure, the of how measuring such a complex function still lacks a election of the procedure should be made with caution and the solution, especially regarding the self- polarity. In this sense, comparison among studies should take variation in measure the TMMS-24 is a widely used and psychometrically well- types into account. stablished measure of emotional self-awareness, but it is With regard to well-being, comprehension of one’s own a self-report, and there is currently no method by which mental states was positively associated with self-esteem and to researchers or clinicians may assess subprocesses or levels of transcendent life goals, but not with happiness. In fact, as in the self-mentalizing, with the only exception of the LEAS (i.e., case of social functioning, the association of happiness with the the Levels of Emotional Awareness Scale; Lane et al., 1990), global measure of other-mentalizing (Table 2) disappears when which was dismissed for this study because it is longer (20 analyzing the sub-scores of the factor (i.e., attachment-based social situations about which the adolescent should write with or referred to well-known others vs. non-attachment based or no limit of words) and not adapted to Spanish and Catalan referred to general others; Table 3). Again, this suggests that an population. In this sense, the importance of refining the association only exists when combining both aspects of other- multidimensional assessment of mentalizing has been already mentalizing (i.e., the general social knowledge used to solve highlighted (Luyten et al., 2020). the picture-based assessment, along with the capacity to read While some limitations of this research are present and the specific mental states of particular close-others). Since the it would benefit from replication, this study also benefits measure of well-being comes from teacher reports in the ASEBA from prominent strengths. To our knowledge, this research system, these results should be interpreted with caution. Finally, is novel in nature–no studies to date have analyzed the since the role of hedonic well-being as a dimension of mental association between self- and other- mentalization polarities health has been questioned (Galderisi et al., 2017), our different and a multidimensional measure of mental health in a non- results with happiness than with the other measures of internal clinical population. This multidimensional approach inherently well-being (i.e., self-esteem and transcendence) could be coherent considers recent developments in the approach to mental health, with this perspective. which is trans-diagnostic and trans-symptomatic [Galderisi Interestingly, self-esteem was found to be positively associated et al., 2017; World Health Organization (WHO) (2018)] with comprehension and negatively associated with attention to involving social and role functioning and measures of “internal Frontiers in Psychology | www.frontiersin.org 9 February 2021 | Volume 12 | Article 566254 Ballespí et al. Mentalizing Polarities and Mental Health equilibrium” along with different types of symptoms. Further, highlights the importance of promoting mentalization in both symptoms and functioning indicators come from multi- developmental non-clinical population, when mental health is informed measures based on Achenbach’s System for Empirical- not disrupted and learning conditions are optimal. Fostering Based Assessment (Achenbach, 2020a), which provides a mentalization across the developmental stage, in adolescence or dimensional perspective consistent with modern approaches to possibly earlier, may not only meet the standards set forth by mental health (Cuthbert, 2014). Heckman (Heckman, 2020a) and the idea to nurture a “dynamic internal equilibrium” which is the foundation of mental health (Galderisi et al., 2015). Moreover, fostering mentalization CONCLUSION AND IMPLICATIONS FOR across development: (1) might help to develop mentalizing MENTAL HEALTH in a more natural manner than the intensive treatments do once clinical threshold is met, (2) might provide resilience To our knowledge, this is the first study to show a specific throughout development as mentalizing is promoted from association between self- and other- mentalizing polarities and early stages, and (3) might help to produce an adult with better different aspects of mental health. Despite the fact that no mentalizing abilities and therefore a generation more able to mentalizing dimension was associated with symptoms, this is mentalize the subsequent one. Finally and most importantly, the first study to date to show an association between self-other fostering mentalization across development may incorporate mentalizing polarities and aspects of self-other function. This one of the UNESCO’s challenges (UNESCO, 2017, 2019) for is not only suggestive of adjusting interventions to the specific the Education of the millennium citizen: this will educate aspects of mentalization dimensions that require treatment, but individuals to properly regulate their emotions and to help it also highlights the importance of mentalizing for salutogenesis, others to do so. even in a non-clinical sample. In this sense, this novel research supporting the association between mentalization and mental health, even in a sample from non-clinical population, stresses DATA AVAILABILITY STATEMENT the importance of fostering mentalization not only in the clinical contexts, when mental health suffers because a disorder was The original contributions presented in the study are included developed, but also and very especially when the disorder still in the article/Supplementary Material further inquiries can be lacks and in order to prevent its development. directed to the corresponding author/s. Mentalization-based treatments help to restore mental health when it is lacking, and this means to work on mentalization abilities under the impairing effect of a disorder (and thus, ETHICS STATEMENT in suboptimal conditions). Why do not foster such important abilities when a disorder is not present? According to Heckman’s The studies involving human participants were reviewed and equation (Heckman, 2020b), any investment in human potential approved by Ethics Committee of the Universitat Autònoma prior to the onset of a clinical condition might provide a de Barcelona (CEEAH, Spain; CEEAH no. 2603). Written higher return the earlier is done, always higher than investing informed consent to participate in this study was provided by the the same efforts under impairing conditions. This is suggestive participants and/or their legal guardian/next of kin. of nurturing mentalization not only in clinical but also in general population, where mentalization is also associated to positive mental health, according to current results. However, AUTHOR CONTRIBUTIONS this begs the question of why our societies and educational systems invest such financial resources and attention to SB conceptualized and investigated the study and wrote the traditional literacy (reading, writing, and reasoning) while invest manuscript. SB and JV contributed to data curation and a relative absence of resources in the “emotional literacy” of the visualization, defined the methodology, and performed formal general population. The school formal curriculum is aimed at analysis. All authors acquired funding and provided resources. training children in competences of unquestionable relevance CS, LC, and NB-V validated the data. All authors critically (i.e., languages, mathematics, social and natural knowledge, reviewed the manuscript. sciences, physical education, arts, and digital learning) across a minimum of 10 years. Out of school activities are aimed at providing specialized attention to improving sports, playing FUNDING a musical instrument, speaking a new language or training other skills. Interestingly, we only seek specialized attention This work was supported by the Catalan Government (grant for our socio-emotional competences once there is a clinically number 2017 SGR 1612, Suport als Grups de Recerca), diagnosable issue. The present results support a call to by the Spanish Ministry of Economy and Competitiveness invert this situation. [grant numbers PSI2014-56303-REDT (PROMOSAM), PSI2014- Current findings support an association between 52962-P, PSI2017-88416-R, and PSI2017-87512-C2-00], and by mentalization polarities and mental health in a sample the ICREA Academia Research Award (Institució Catalana de of adolescents from general population. This association Recerca i Estudis Avançats) from the Government of Catalonia. Frontiers in Psychology | www.frontiersin.org 10 February 2021 | Volume 12 | Article 566254 Ballespí et al. Mentalizing Polarities and Mental Health ACKNOWLEDGMENTS for their contribution to data collection. Special thanks go to Jacqueline G. Nonweiler for the edition work. The authors would like to thank all families who contributed to the study, as well as the schools Escola Pia Sarrià-Calassanç, Institut Lluís Vives, Institut Besós, Institut Corbera and Institut SUPPLEMENTARY MATERIAL Angeleta Ferrer i Serrat from Barcelona, and Institut Francesc Ribalta and Escola Arrels from the center of Catalonia, for The Supplementary Material for this article can be found their collaboration. Our gratitude to Ariadna Pérez-Domingo, online at: https://www.frontiersin.org/articles/10.3389/fpsyg. Judit López-Berga, Ángel Lorite, Ruth Ocón, and Cristian Lago 2021.566254/full#supplementary-material REFERENCES anxiety disorder. J. 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Oxford: Oxford University Press. open-access article distributed under the terms of the Creative Commons Attribution doi: 10.1093/med/9780198569183.001.0001 License (CC BY). The use, distribution or reproduction in other forums is permitted, Sharp, C., Pane, H., Ha, C., Venta, A., Patel, A. B., Sturek, J., et al. (2011). Theory of provided the original author(s) and the copyright owner(s) are credited and that the mind and emotion regulation difficulties in adolescents with borderline traits. original publication in this journal is cited, in accordance with accepted academic J. Am. Acad. Child Adolesc. Psychiatry 50, 563.e–573.e. doi: 10.1016/j.jaac.2011. practice. No use, distribution or reproduction is permitted which does not comply 01.017 with these terms. Frontiers in Psychology | www.frontiersin.org 13 February 2021 | Volume 12 | Article 566254