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Mentalisation has been considered to be the common characteristic, either explicitly or implicitly of effective psychological therapies (Allen et al., 2008) including art psychotherapy (Taylor Buck and Havsteen-Franklin, 2013); and

metaphor has been considered as being inextricably linked to the mentalising process (Barnett, 2008; Long and Lepper 2011). Allen ( 2008, p. 6) describes mentalising as,

“Interacting in the mentalizing mode, we aspire to understand each other as autonomous persons and to influence each other on the basis of our

understanding. In the non-mentalizing mode, we can dehumanize and treat each other as objects, becoming coercive and controlling.”

According to Meissner (2008) a critical stage in the development of

mentalisation can be seen in the process of acquiring a linguistic and cognitive model of communication that belongs to the infant. The infant develops a sense of agency

through a range of interactions and particularly the marked mirroring responses from the carer (Gergely and Watson, 1996). Where this begins to break down and there is insufficient care, attention and mirroring, the experience of self-autonomy can be compromised (Tronick, 2007).

Stanford et al (Stanford et al., 2011) suggest that there is evidence that there is a relationship between mentalising and metaphor comprehension. This is based on the speakers intended meaning of metaphor being within an interpersonal context. It is worth highlighting the psycholinguistic structure of metaphor here. The idea that another has a mind that is differentiated from one’s own is reflected in the form of metaphor comparing asymmetrical elements, which is the basic structure of metaphor. The cognitive function involved in metaphor formation is a mapping process; a source domain is mapped onto a target domain (Fludernik, 2012). Modell has argued that the same mechanism involved in metaphor formation is evident in early infancy. Modell (1997, p. 108) states,

“Although we cannot know the nature of the infant's first thoughts, it is not unreasonable to suppose that the capacity for symbolic representation in the form of proto-metaphors appears early in development.”

Nemiah (1978) also states that the structure of metaphor is comparable to the quality of relating in normal functioning with an infant and that comparing two different forms, particularly with a visual basis, produces an experience that provides the possibility of a novel, co-elaborated perspective. According to Nemiah (1978, p. 29) feelings are evoked in relation to the environment and the functioning of the body,

which provides a context for associations to become spatially localised. Similarly, Bollas (1980, p. 119) stated that metaphor formation expresses ‘…how the logic of metaphor suggests a self and an other’. In other words, the capacity to maintain this differentiation between dissimilar objects compared in metaphor is akin to the infant being engaged in an interpersonal, asymmetrical, relational process that is structurally similar to metaphor through the mother’s marked mirroring (Gergely and Watson, 1996). In fact Barnett goes so far to say that the developmentally early process of metaphorisation is the fundamental function required that precedes mentalising,

“Since mentalizing may be defined as the capacity to be attentive to

similarities and differences in the perspectives of self and others, there appears to be some conceptual overlap in the imaginative capacities for metaphor and mentalization, and in their functional impairments. However since metaphoric thought is intrinsic to the corporeal imagination (e.g., in synesthesia, and in affect conflations, described earlier), and allows comparisons of similarity and difference across temporal domains as well, it is most likely the broader and more fundamental of these capacities.” [italics mine] (Barnett, 2008)

This is a bold claim, given the limitations of research in the area of metaphor formation compared to mentalisation (see Fonagy et al., 2003). However, the study conducted by Long and Lepper (2008) confirms that mentalisation and

metaphorisation are intimately dependent upon one another. They clearly link the development of metaphor with the patient’s capacity to form a representation of another person’s internal states of mind. Long and Lepper (2008) propose,

“That metaphor also appears to play a crucial role in mentalizing exchanges within the therapy adds further weight to the idea that metaphor is an indispensable aspect of thought and of creativity and change.”

The study conducted by Long and Lepper suggested that metaphor coincided with mentalising, with a state of being attuned, empathic, psychologically minded and demonstrating a reflexive capacity. This follows Rizzuto’s important observation that through the metaphor it is the patient’s ‘…complex interweaving of affect, history, and story that unifies a multitude of compelling self-other perceptions’. (Rizzuto 2001, pp. 565–566). This echoes the definition of successful mentalising described by Choi-Kain and Gunderson, (2008) as a combination of cognitive and affective

engagement with imagining self and other states of mind, based on exploring an sense of interpersonal narrative.

According to Rizzuto (2001) the production of metaphor in a therapeutic context draws together autobiography, cognition and affect, which are essential categorical features of the creative metaphor and mentalising. In research on psychotic disorders (de Bonis et al., 1997; Brüne, 2005; Kay, 1991; Kettle et al., 2008; Kircher et al., 2007; Langdon et al., 2002) and depression (Kerr et al., 2003; Wolf et al., 2010) theory of mind, has been shown to be significantly impaired.

Further evidence of the link between mentalisation and metaphorisation can be seen with SMI research. The research provides a significant body of evidence to suggest that there is a reduced capacity to infer other people’s intentions and states of mind. It is therefore highly likely that the concepts of metaphorisation and

mentalisation are linked. Ibáñez and Albea recently conducted a review of empirical research for patients diagnosed with schizophrenia and conclude,

“In other words, in patients with schizophrenia, mentalizing anomalies contribute negatively to understanding the figurative aspects of language, beyond impairment to general intelligence.” (Ibáñez and Albea, 2013)

Their review was based on the conclusions from a diverse range of studies inferring significant links across clinical groups (Camp, 2006; Frith and Frith, 2003; Happé, 1995; Pálinkás, 2014). This suggests that in conditions where there is a severe mental health disorder, there is also likely to be a deficit in metaphor comprehension and mentalisation.

In summary, it is possible to see that there are indications of a significant overlap between problems of mentalising, problems with metaphor comprehension and SMI (Fig. 13). However, more importantly, the development of the capacity to form metaphors can be traced to interactions in early development between the carer and infant.

Figure 13 – The overlap between the diagnosis,

reduced metaphor comprehension and non- mentalising represents the conditions relevant to this study and severe mental illness. This is rather than moderate or mild conditions of mental illness where there may not be a convergence of all three areas.