Despite years of training in clinical psychology students, no significant differences were found in self-reported mentalization capacity between first and last year students

Does clinical training improve mentalization skills in future therapists? A comparison of first and last year students of clinical psychology and of engineering. Steffen André Fagerbakk, Silje Helen Sørhøy, Torbjørn Nilsen and Nina Jakhelln Laugen. Front. Psychol., January 23 2023. https://doi.org/10.3389/fpsyg.2023.1066154

Objective: Mentalization has been suggested as a therapist skill that might be important for therapeutic success. The aim of this study was to explore whether the mentalization capacity of students of clinical psychology differs from other students, and whether last-year students differ from first-year students.

Method: A total of 297 students participated in this study, recruited from first and last years of psychology and engineering study programs. All participants filled out the MentS, a self-report measure of mentalization capacity.

Results: No significant differences were found in self-reported mentalization capacity between first and last year students of clinical psychology. The results did however show that first year students of psychology had significantly higher self-reported mentalization skills compared to students of engineering, and higher MentS-scores were associated with gender (female) and higher age.

Conclusion: The finding that students of clinical psychology rate themselves as having a higher capacity to mentalize compared to students of engineering might suggest that individuals with a higher capacity to mentalize are more likely to engage in clinical psychology and become therapists. However, the lack of significant difference in self-reported mentalization capacity in last year students of clinical psychology compared to first year students might indicate that the Norwegian education in clinical psychology does not succeed in enhancing mentalization in future therapists. Clinical psychology study programs might benefit from targeted mentalization training.

Discussion

This study aimed to contribute to the line of research that has identified mentalization as a potentially important therapist skill, by exploring the mentalization abilities among students of clinical psychology at the beginning and the end of their education, compared to students of engineering. The first hypothesis was that last year students of clinical psychology would have a higher self-reported capacity to mentalize compared to first year students. However, this hypothesis was not supported as the results showed no significant difference between these groups. The second hypothesis was that first year psychology students would have a higher self-reported capacity to mentalize compared to first year engineering students. The results showed that psychology students scored significantly higher on the total MentS and its three subscales compared to engineering students, thus confirming the second hypothesis.

The Norwegian version of the MentS indicated satisfactory internal consistency. Moreover, females scored significantly higher than males and higher age predicted higher MentS scores. These results are in line with expectations based on previous research (Anderson et al., 2009; Abu-Akel and Bo, 2013; Dimitrijević et al., 2018).

Differences between first year students and last year students

Our study found no significant differences in self-reported mentalization capacity between first and last year students, neither among students of clinical psychology nor students of engineering. The assumption was that years of clinical training contributes to enhancement of mentalization capacity, and an improvement among students of clinical psychology was therefore expected.

It is reasonable to expect that students of clinical psychology would have a good basis for improving their mentalization capacity considering that they have high self-reported mentalization capacity at the beginning of their education. Previous studies have found that mentalization capacity can be improved through therapy (Fonagy and Bateman, 2019, pp. 103, 323; Luyten et al., 2020) and Ensink et al. (2013) found that psychology students significantly improved their mentalization capacity after attending a mentalization course. Their findings show that specific training in mentalization skills can make positive change in a relative short time span. They also observed a decrease in mentalization skills for a control group who only had didactic training and no training in mentalization. This indicates that the capacity for mentalization does not develop spontaneously through clinical training but must be targeted specifically. These results may also render the possibility that a narrow focus on diagnostic criteria and formulations of treatment plans might cause a decline in mentalization capacity. Although knowledge about diagnostic criteria and treatment plans are essential in clinical practice, one should be aware of the potential downfalls with excluding targeted mentalization training in the curriculum.

Another possible explanation for our results is that self-report measures might not successfully measure actual mentalization due to response bias. Self-report measures are based on participants self-evaluation, and not objective observations of actual behavior in interpersonal interactions (e.g., Murphy and Lilienfeld, 2019). Thus, participants might not have an accurate experience of their own mentalization capacity, it can be distorted by characteristics in the person such as self-confidence. Also, clinical education and training might provide students of clinical psychology with more insight about what it is possible to know about themselves and others. The clinical program does include both self-reflection and training in critical thinking about science. Therefore, students of psychology might become more critical about their own knowledge and about what they can know about themselves and others. Thus, the effect of growing critical thinking might confound the effect of growing mentalization skills in psychology students. Furthermore, social desirability might be a confounder of the student’s responses as mentalization is viewed as a desirable quality for a psychologist. This might lead to systematic bias in the students’ responses to the MentS. Also, it might be possible that students who are admitted to the clinical program gain a new perspective on themselves and view themselves as future psychologist. This new perspective might make them overconfident about their mentalization skills, leading them to report mentalization capacity in an overconfident way. Moreover, it is reasonable to assume that low mentalization skills involves less precise evaluation of these skills in the self, considering that these individuals often have a lack of interest in the mental world of themselves and others (Fonagy and Target, 2008; Luyten et al., 2019, pp. 39–43). This might lead to systematic bias in self-reporting by individuals with low mentalization skills.

The regression analysis showed a positive relationship between MentS-scores and age, but not with years of study. This differs from the findings of Dimitrijević et al. (2018), who found that higher education, and not age, was related to higher score on the MentS. Considering the hypothesis that capacity for mentalization improves simply by mentalizing (Allen et al., 2008, p. 320), especially in interpersonal contexts with individuals that possesses high mentalization skills, the capacity for mentalization should improve with age (Luyten et al., 2020). If this is true, then older people would have better mentalization skills simply because they have had more time practicing the skill. There are however few known studies that investigates the nature of age-related changes in mentalization skills. Conclusions regarding this are therefore yet to be made.

Differences between first year students of psychology and engineering

First year students of clinical psychology scored significantly higher than engineering students on both the total MentS and each of the three subscales. Interestingly, students of clinical psychology also scored significantly higher than students of fundamental psychology for both the total MentS and the Self-and Motivation-subscales, but not for the Other-subscale. These results suggest that students of clinical psychology have a high self-reported capacity to mentalize already at the beginning of their education.

The preliminary hypothesis was that first year students of psychology would have a higher capacity to mentalize compared to engineering students. The assumption was that individuals with an motivation and skill to mentalize, would be more likely to select psychology as their major. Thus, differences in mentalization abilities should be evident even at the beginning of the course, and before students receive any therapist training. The field of psychology involves attempts to understand the interactions between the human mind and behavior, and the contextual environment in which it takes place, whereas mentalization broadly refers to the ability to understand mental states that underlies behavior in oneself and others (Fonagy, 2008, p. 3). It can be assumed that individuals who have a lower innate motivation and skill to engage in such activities should thus be less likely to engage in the field of psychology if choices are influenced by their levels of interests in the human mind and behavior.

The findings that first year students of psychology rate themselves as having higher capacity to mentalize compared to first year students of engineering support the assumption that mentalization capacity may predict student’s selection of study major to some extent. These results correspond with Focquaert et al. (2007) who found that students of humanities (e.g., social science, medicine, and biology) had a more empathizing cognitive style than students of science (e.g., mathematics, engineering, physics, and chemistry).

The significant differences between students of clinical psychology and fundamental psychology were not expected. The preliminary assumption was that students selecting any psychology program would possess similar levels of mentalization by the beginning of their studies. The admission process is based on high-school grades and does not involve any screening of their therapeutic abilities, such as the capacity to mentalize. Whereas fundamental psychology is concerned with the theoretical and empirical study of the human mind and behavior, clinical psychology also involves implementing this knowledge into direct interpersonal interactions with patients in therapy. This difference in course curriculum thus renders the possibility that students with a higher motivation and skill to mentalize, might be more likely to select the clinical perspective.

Among the psychology students in our study, there was an overrepresentation of female students. This rendered the possibility that the group differences in mentalization capacity were due to gender rather than study program. However, the regression analysis confirmed that study program significantly predicted total MentS scores even when accounting for the significant effects of gender. These findings strengthen the conclusion that students of psychology had a significantly higher self-reported capacity to mentalize than students of engineering, regardless of their gender. Why women seem to have better mentalization skills than males are not fully understood. A common stereotype is that women generally talk more about thoughts and feelings (i.e., mental states) than males do. This stereotype is supported by studies indicating that women are more emotional and emotionally expressive than are men (Brody and Hall, 2008). It also might be supported by research showing gender differences in constructs closely related to mentalization and attentiveness toward mental states. Evidence in current literature suggests that females have higher emotional intelligence compared to males, and that females generally have a more empathizing cognitive style (Brackett et al., 2004; Focquaert et al., 2007). Also, some studies have found that parents have more emotional content in their talk with daughters than with sons (Fivush et al., 2000; Aznar and Tenenbaum, 2015), and it is suggested that children are shaped into this gender difference in emotion expression by their parents and by their particular social environment (Chaplin, 2015). Luyten et al. (2020) argues that the capacity to mentalize is relationship-and context dependent, as mentalization develops in the context of interpersonal interactions and is continuously influenced by the mentalizing capacity of those who partake in these interactions. If females in fact do engage in more talk about mental states, and thus practice their mentalizing skills more than males, then this might be a possible reason why females have a higher capacity to mentalize. However, considering the common view that women are more emotional and emotionally expressive than men (Brody and Hall, 2008), it might be the case that women have an advantage in interview-based measures of mentalization because of their superior ability to express emotions. This view is supported by studies showing that women are more elaborate when depicting internal states (e.g., Fivush and Haden, 2003; Fivush et al., 2012; Grysman, 2018).

Limitations and future research

This study presents new and interesting findings about the mentalization capacity among students of clinical psychology. However, some limitations of this study need to be addressed. The study uses a cross-sectional design, which may not be suitable to evaluate actual changes in mentalization capacity. Longitudinal designs represent a better basis for evaluating the development of individual mentalization skills, and may allow for within-subject comparisons of mentalization skills development in addition to between-subject comparisons. However, longitudinal designs are both time and resource demanding and were therefore beyond the scope of this study. Also, this study used voluntary response sampling and there is no information on those that were invited to participate but did not respond. This might be an issue in terms of representativeness, as the respondents might for example be those who were most interested in the field of study, leading to sampling bias. Moreover, there is need for more understanding of how mentalization develops in training programs as we currently do not know exactly what promotes mentalization and what does not.

As described throughout this discussion, there are some obvious limitations with the use of self-report measures. However, self-report measures are less time and resource demanding, and thus more suitable for use in larger samples. Future research should include additional measures for evaluation and assessment of the psychometric properties of the MentS. Assessments of the MentS reliability should include comparisons with established measures of mentalization, such as questionnaires (e.g., RFQ: Fonagy et al., 2016) and interviews (e.g., AAI: George et al., 1996). Because self-evaluations of one’s own mentalization capacity might be inaccurate and biased by individual characteristics, it could be advantageous to collect information from family, significant others, peers, and co-workers. Thus, it might be of interest to develop a version of the MentS for other-evaluation of mentalization capacity. Comparisons of self-evaluations vs. other-evaluations might contribute to more accurate assessment of mentalization. Other-evaluations of participants mentalization capacity might provide researchers with information about how individuals mentalization is experienced by others in interpersonal interactions. This would make sense considering that mentalization is a relational concept, and measurement should capture relational contexts.

The validity of self-report measures of mentalization is challenging to assess due to the complexity of the construct. Mentalization overlaps with other constructs that are different, but closely related to mentalization (e.g., empathy, theory of mind, and emotional intelligence). It can be challenging to determine if a self-report really measures mentalization and not related constructs. Because mentalization is a complex construct that involves several aspects of human behavior and mental states, self-report measures might not be sufficient for measuring all of these aspects.

The distribution of MentS-scores showed a lower spread among psychology students compared to students of engineering. This could suggest a ceiling effect, meaning that the MentS might not be sensitive enough for groups who have high mentalization skills. The assessment of mentalization in homogenous groups such as therapists might require different methods of measures than groups that are more heterogenous in terms of mentalization capacity. Furthermore, the MentS does not measure mentalization in terms of context or interpersonal relationships which rises some uncertainty about whether or not it can capture the “state” aspects of mentalization, considering it is assumed to be invariant across different relationships and contexts (Fonagy and Luyten, 2009). Other measures, such as the Reflective Functioning Scale as scored on the Adult Attachment Interview, involve the aggregation of mentalization across a number of attachment relationships.