What follows is fictionalized. It is based on real events. Welcome to the Frontier Psychiatrists Newsletter. The footnotes in this article are being used to explain, as “meta-data,” the Mentalization-Based Treatment techniques used, so they are not trivial in this piece; they are the whole point. Names have been changed, and the de-identified and hybridized patients involved consented to their mashed-up and de-identified stories used in this manner.
“Do you wanna have a milkshake?1”
Maggie wore a polka-dot dress with an additional purple polka-dot bow in her hair. She stood awkwardly, unsteadily, in her patent leather shoes on top of the couch in my office. The awkwardness in her balance was exacerbated by the fact that she was trying to push herself upward to grasp the other end of the electrical cable that was wrapped around her neck as she flung it up over an exposed pipe.
Maggie was trying to hang herself.2
“Wait, what?” said Maggie, with her eyes locked onto mine, momentarily distracted from the effort she had been making to end her life in my doctor’s office.
“Do… you… want… to have a milkshake?”3
“Like, a milkshake milkshake?”
“Yeah, a milkshake place makes milkshakes with cold brew; it’s just a couple blocks away. Oddfellows. Ice cream. Cold brew. Coffee milkshake?”4
Maggie slowly let the electrical cord wrapped around her neck fall away5. Her heels dropped down to the pillow of the couch. Much less precarious. Good.
“I have a question. Do they have other ice cream flavors? Other than coffee?” Maggie was in her late 20s— she looked younger. “Could pass for 16” younger.
“They have a variety of ice cream flavors. It’s an ice cream shop. It’s right down the street, do you want to go?”
“You mean and not call the police because I’m trying to kill myself again?”
“That is my plan, yes.”6
“I have to see a musical with my dad tonight. And I was going to do it after I kill myself here7, but I guess I could just go to the musical. I don’t want to go to the hospital.”
“I know you don’t want to go to the hospital8. Besides, I have a headache9. The coffee will help. Come on.”
Maggie stepped down from the sofa and tossed the electrical cable-turned-noose to the side10. There, it resumed its electrical cable identity, and she followed me out the office door and onto the Brooklyn sidewalk.
Yes, I’m a psychiatrist. Yes, some version of that happened.
I convinced someone not to end their life by offering them an alternative they didn’t expect—that’s a superpower. It’s about understanding a person’s emotional state and helping them shift from that state to something more beneficial to them and you. You do this first by gaining their trust and then getting them curious. No matter how upset they are, no matter how certain about the path they’re on, you engage their curiosity. This superpower is what I teach in my one academic book on mentalizing.
You don’t have to be a doctor to use it. You don’t have to be a serious danger to yourself for it to help you. You have to understand some basic information, get a little bit of practice, and you can use it in your day. You can be the Jedi master of your own life. It’s called mentalizing.
Cool, right?
Like, ice cream headache cool. It’s so cool it’ll make your head hurt. That’s how cool we’re talking.
I did not invent mentalizing. I am an official supervisor in the technique through the Anna Freud Centre in London. It was the course content for my teaching at the Mayo Clinic, Menninger, Harvard, Academic Conferences (Myriad), and even prisons and schools. I even worked with major tech companies to help their teams feel seen and heard.
The theory came about in the 1960s. It wasn’t turned into a treatment until the 1990s in England by Hungarian psychologist Peter Fonagy, Ph.D., and British psychiatrist Anthony Bateman, FRCP Psych. A definition: The process by which we understand our own—or someone else’s—mental state and how that state is connected to behavior. Until now, only therapists, physicians, and scientists have had access to these awesome tools. I want it to get out to the rest of the world.
I use mentalizing to treat people whose brains are doing things that most people’s brains aren’t doing. Sometimes, that means treating people in extreme situations like Maggie. Sometimes it means helping patients who suffer from crippling depression or OCD (which, surprisingly, contributes to more suicides than depression). But it almost always revolves around people who are worried and stressed out. And right now, we have a lot to worry about. Journalists have written about it as a second pandemic of loneliness and disconnection. They aren’t wrong. We can’t connect. We’re more short-tempered and distrustful around others. We’re social creatures, but we’ve become more isolated from friends and strangers. These missed connections are leading to a lot of heightened agita. People’s wavelengths aren’t in sync.
At the beginning of the Internet, computer scientists had a similar problem. Computers can’t assume that they are speaking the same language, or they won’t connect. The computer’s solution is to negotiate at the beginning of every conversation to ensure that both computers speak the same digital language. This goes something like: “1 means 1, and 0 means 0, right buddy?” On the internet, they call this TCP/IP protocol, and for those of us who are old enough, we remember the sounds of our modems, working this out with other computers. We would hear:
Computer 1: “Ccchhhhkkk sphhh chuuuuck spppphhhh chuk chuk beep beep beeeeeeep.”
Computer 2: “Ccchhhhkkk sphhh chuuuuck spppphhhh chuk sphleewwwww beep beep beeeeeeep”.
Computer 1: [Thank god.]
Computer 2: [I know, right?]
This was the sound of computers establishing their connection. In humans, there are similar prerequisites to forming connections. If we try communicating without them, we usually fail. The emotional WiFi (modems don't use WiFi) goes down. We’re pissed off and hurt and can’t figure out how to get it back up and running. We may also be resentful that we have to work so hard to reestablish the connection again. So we call a therapist, just like we have to call Verizon to get online again. It’s a connection we take for granted—until it’s not there anymore. No one taught us the building blocks of connection or the emotional code that produces human WiFi for feelings. We think of it as a mysterious vibe arising from the ether. But we’ve gotten worse at it because we’ve become so detached from one another, physically and emotionally, over the last ten years.
Connection should be anything but mysterious. There are tangible, learnable skills to get connections going between humans, just like there are to get WiFi going between computers. In this book, we’ll learn them.
These methods are for everybody. You don’t have to be in the midst of a life-threatening crisis. You can do this to prevent a crisis from occurring. You can use it to help a loved one in need. If you’re having a serious problem, these lessons are potentially very helpful (but you should still find someone to talk to, especially with those waitlists). Antecedent? The ability to look at things in a way that is just a little bit different than you’re used to or to get your loved one to look at things differently breaks the chain of worrying and opens up the door of possibility. You can get what you want out of your life. I’ve spent years learning how to do this, and it will be a much quicker journey for you. Because I already made the mistakes, and I share those regularly.
But now—back to a sidewalk in Brooklyn, New York, on a late fall morning, and a walk to an ice cream shop:
“That wasn’t very therapeutic,” Maggie said matter-of-factly as we stepped out of my office.
“I mean, you’re not wrong11. It would be hard to argue that anything in that session was therapeutic12 except this part. Ice cream doesn’t have to be therapy. Ice cream has to be good. I was trying to ignore you because you’re right, I didn’t want to reinforce your behavior when you were to kill yourself again, or at least try.”
“You know that never works, Dr. Muir.”
Maggie made a really good point. When she was as upset as she was in my office and didn’t feel connected, nothing I said had… relevance. Like, I may have had good ideas, but it didn’t matter; she didn’t want to hear them. It wasn’t going to change anything.
This is true for so many of us so much of the time. We can know the right answer. We can be in the right. Other people’s points of view can be completely wrong. But we can’t convince them. And sometimes, we try to push, convince, and control, which doesn’t work. We can’t get other people to change their minds. Sometimes, it’s like that with our own minds, too. Because essentially, we’re not listening to what we should be listening to in our own mind. It’s not working.
At this point, people usually search the self-help section, and maybe they find a useful book like Atomic Habits or The Subtle Art of Not Giving a F***. And they’ll try not giving a fuck over the things they can’t control. Because zero fucks is sometimes the right answer. But it’s not always the right answer. And when it’s not the right answer, it can go catastrophically wrong. Like what just happened in my office.
Not giving a single fuck, no fucks at all, that’s a useful strategy only some of the time. The real win in life is knowing how many fucks to give. You need to give the right amount of fucks. When it’s zero, the subtle art of not giving a fuck comes in quite handy. But so does giving enough fucks, some, not too much, not too little.
It’s like Goldilocks, except in this case, it’s Goldifucks, that subtle zone of caring just enough, giving just enough of a fuck, to be interested in the outcome, but not trying to push things too far, and not giving up on caring entirely. It’s in this golden zone that we do our most remarkable work. This is the work known as mentalizing.
Caring the right amount is where we win. Because that’s where we stay engaged and figure out what’s going on in our own minds or the minds of others, this mind radar is different from the Jedi's ability to suggest and have it be the case. When Obi-Wan Kenobi does his little hand wave, the stormtrooper lets him go because these aren’t the droids they’re looking for; it’s a cheap trick. Mind control: He could’ve gotten the same result by punching them in the face hard enough and knocking them out for a hot minute.
Obi-Wan Kenobi would be a shitty therapist. He’d wave his hand and tell you what to think, and you’d believe it in the moment. Maybe it would last forever. But the cooler version of that trick is helping someone do their own mind tricks, come to their own realizations, and not have to keep doing it all the time. Give that stormtrooper a sense of his own agency so that instead of asking if these are the droids he’s looking for, he’s asking himself if this is the identity he wants to have, as one of a million clone soldiers, toiling away on a desert planet.
That’s what the mentalizing does. Obi-Wan Kenobi offered certainty. I offer the possibility to others that we’re not quite sure, and in that uncertainty comes curiosity for what you can be more certain about. And this pursuit frees you up from all sorts of awfulness.
With the ability to mentalize, you won’t be so worried. (I’m required to remind you that this is not medical advice—and then further, remind myself—the really useful things I say aren’t remotely medical or, for that matter, advice.) The hand-wringing that gets done about the mental health crisis is not unlike a weatherman dutifully standing in the middle of a hurricane. He’s yelling about how it’s raining. He’s not wrong…but he’s not helping. We get it. He’s wet, and so are we. Has anyone seen my umbrella?
Mentalizing is an umbrella. It’s not here to get rid of the rain, it’s here to help keep you dry whenever things come down unexpectedly on your or someone you love. If that sounds good to you, then you’re reading the right Substack. If it sounds bad to you, then I’m sorry, but you spent your time on the wrong article. But you’re probably not gonna stop right here. Because people don’t do a very good job of that. But that’s a different problem.
How Mentalizing Works
Trust is the foundation for human connection, the currency that actually closes the deal. Money is great, but if you don't trust you'll get it, it doesn't conclude transactions, emotional or business. If you don’t trust information, it’s not safe learn it. It doesn’t make sense to learn new things from goddamn liars. We have a brain system for that. Our first pass in our brain is a giant filter of all of our experiences that asks the question: should I trust the source of this information?
If the answer is no, we have a series of strategies in our cognitive operating system to avoid, dodge, forget, fight back against, and generally make sure none of that information changes the way we act in the future. This is colloquially termed “bullshit detection.” Teenagers refer to this sort of information in the conflating to different ideas so as "boring.” When you ask teens what they learned at school, and you get the answer "I don't know, whatever”--you are bearing witness to a remarkable system that allows humans to sift through unbelievable amounts of information and only remember the most relevant.
When I teach mentalizing, I’ll give learners the recipe for the secret sauce that builds trust. If I do a really good job, you’ll learn how to build trust with yourself and others. The surprising part about this recipe? It doesn’t involve knowing anything specific. You need no information other than this: not knowing the answer leads to all the actual answers.
You don’t stop at not knowing. But you always start there.
Here are some quick examples to drive the point home:
Would you like someone to calm down?
Won’t work: “You need to calm down!”
Might work: “It seems like you’re really upset?”
Trying to convince someone of your conspiracy theory?
Won’t work: 9/11 was an inside job!
Might work: “On a scale of the number 9 through the number 11, can you give me a numerical rating for how confident you are that 9/11 was not an inside job?”
“Um. 10.9”
“Oh, that’s interesting. What made it 10.9 and not 11?
“Well, there’s this one little doubt I have…”
These techniques–mentalizing by both not assuming I know, and being curious about what the other person thinks– work in all kinds of situations, not just the clinic in which I work as a psychiatrist.
Most of us spend our lives trying to pretend we know what’s going on. This is a mistake—not the pretend part, but the idea that the goal in life is to know.
Most of us don’t know. How could we? That sense of obligation is a heavy burden, which is why we don’t get up to confront the stranger in the pizza shop. We are all exhausted Atlases, shrugging. We feel we don’t have the answers to his problem. But the truth is no one has the answers. We’re all winging it—and in our most important moments, no less.
“Don’t Panic” is written on the cover of the travel guide Ford Prefect hands to Arthur Dent in The Hitchhiker’s Guide to the Galaxy. Dent has just witnessed his planet get destroyed by aliens to make way for the construction of a galactic bypass. It’s the perfect message for the dystopic, out-of-sync headspace that most of us feel we’re in right now. Like the Douglas Adams book, my writing takes an absurdist mentalized approach to helping.
It's probably worth mentioning that Douglas Adams has been my favorite author since I was six years old. The reason his book works so well, to make us laugh, is the same reason I hope this book will work so well. Douglas Adams wrote in a way that was jaunty, strange, and laugh-out loud-in-public-so-others-stare-at-you funny. The content he covered was utterly dark. That book begins with the destruction of the planet Earth , and virtually everyone on it. The five book series that follows involves meeting the love of your life and then losing her inexplicably, wars that could destroy all life, a man being murdered by Dent over and over again in every incarnation. It is nihilistic at a level that, absent humor, would be utterly horrifying. Yet, I remember it as funny, and most people do too. The absurd humor helps us cope with the abyss. The “Hitchhiker’s Guide” described in the Douglas Adams books wasn't something the human public could go out and buy. It didn't exist. But that fictional book told you what to do in any situation. Mentalizing might well (No obi wan certainty) do the same, as it applies to your relationships. It’s help for your difficulties, and unlike most other self-help books, it'll also help you help others. All of us are hitchhiking in our minds, and this mentalizing is that guide.
In mentalizing treatment, comments that are “out of left field” can be used as a “challenge” to disrupt non-mentalizing modes, in which suicidal ideation can emerge.
suicide attempts, particularly those in a psychiatrists’ office, are often understood in MBT as an attempt to “pull a reaction” out of the other person. It’s referred to as “teleological mode”—the person who can’t imagine a mind at the time acts to elicit proof. In this case, trying to hang oneself is generally the kind of thing that gets a call to 911.
I’m using ellipsis here to illustrate the “slowing down” of my thinking as “marked” for the patient by slowing down, in an unexpected way, the initial “challenge”
Using the “cold” of the ice cream to “cool down” the emotional temperature was the thought, but the “clarification” is intended to “slow down” and cool down the emotions that led to an attempt at suicide.
Obviously, the thought process has changed, and the suicide attempt may have been derailed.
“clarification,” which is both validating and cools down the affective temperature further.
This is conceptually incoherent—and evidence of “pretend mode” in the MBT model—words that just don’t make any sense.
validation.
This judicious self-disclosure uses a pull from “self-to-other” polarity, which is a technique in mentalizing treatment to enhance mentalizing by creating a “hear and now with us” focus.
better than a call to 911, and screaming about how hospitals don’t help.
validation
validation