Mentalisation is the cognitive ability to interpret behaviours as arising from intentional mental states (Gorgellino et al., 2025), or to put it another way: our ability to make sense of what’s going on in someone’s mind, and in our own. Mentalisation has been found crucial for understanding thoughts, feelings, and intentions in social interactions (Gergely et al., 2002).
Past research indicated that mentalisation deficits, particularly in people with a diagnosis of borderline personality disorder (BPD) or psychosis, could lead to emotional dysregulation and interpersonal dysfunction (e.g., Bateman & Fonagy, 2008). These deficits contribute to social withdrawal and are linked to various psychiatric disorders, suggesting they may be a transdiagnostic risk factor for broader psychopathology (Bateman, 2012; Luyten et al., 2020).
Significant childhood trauma, neglect and abuse, particularly, are prevalent in psychiatric populations, affecting social cognition and mentalisation abilities (McKay et al., 2021). While 70% to 85% of individuals in these populations report traumatic experiences (Battle et al., 2004), compared to about 30% in the general population (Whitten et al., 2024), the mechanisms are not well understood. Only a few studies have explored the link between childhood trauma and mentalisation; highlighting the need for more research to inform prevention and treatment strategies for mental illness.
The present study sought to address a gap in existing literature by incorporating a transdiagnostic approach in exploring the relationships between childhood trauma, mentalisation, and later psychopathology (Gorgellino et al., 2025).
Understanding how childhood trauma disrupts mentalisation offers crucial insight into the shared roots of diverse psychiatric disorders.
Methods
Search strategy
A systematic search was conducted in Ovid (Medline, Embase, PsycINFO) for studies from database inception to December 2022, focusing on psychiatric populations, childhood trauma (CT), and mentalisation domains. The keywords included the following terms ‘Theory of Mind’, ‘metacognition’, and ‘mindfulness’ to ensure a comprehensive search, reducing the risk of overlooking relevant papers. Filters were applied to exclude duplicates and non-English studies. Two researchers (GK & YP) independently screened titles and abstracts, achieving 92% agreement, with discrepancies resolved by senior researchers (LA & MA). Full-text eligibility was assessed similarly, with any differences addressed in group discussions.
Inclusion and exclusion criteria
Using the PICO(S) framework, studies needed to include psychiatric diagnoses based on established manuals, measure CT before age 18, compare with individuals without CT, assess mentalisation outcomes with validated tools, report quantitative results, and be published in peer-reviewed journals. Exclusions included reviews, case studies, or participants over 65.
Data extraction and quality assessment
Data was extracted into a Microsoft Excel database (GK & YP), and cross-checked by a third researcher (MG). The review process utilised the modified Newcastle–Ottawa Scale (Wells et al., 2014) to evaluate study quality and bias, which was also verified by a third reviewer (LA). More details on quality assessment are provided in the supplementary material.
Results
Summary of search results
Out of 3,018 eligible articles, 179 were screened in full text, and 29 were included in the qualitative synthesis, with 22 published between 2016 and 2020. All studies employed a cross-sectional design, recruiting clinical populations from inpatient and outpatient mental health services, and diagnoses were based on ICD-10 or DSM-IV/V criteria.
Sample sizes ranged from 19 to 757 patients, with 19 studies including healthy control groups. Most studies (76%) assessed childhood trauma (CT) using established measures like the Childhood Trauma Questionnaire (CTQ) and the Childhood Experience of Care and Abuse (CECA) Scale. Nine studies employed a composite measure of CT, while 20 differentiated between subtypes such as physical and emotional abuse.
Mentalisation abilities were assessed with various tests, notably the Reading the Mind in the Eyes Test (RMET) and the Hinting Task (HT), each used in six studies. Only six studies conducted mediation analyses, finding that mentalisation impairments partially mediated the relationship between CT and psychiatric disorders. However, the study by Mansueto et al. (2019) was the only one to probe moderation effects, revealing no moderating influence of mentalisation in individuals with psychotic disorders.
Study quality assessment
Most of the 29 studies scored between 5 and 7 on the Newcastle–Ottawa Scale (NOS). Among these, nine studies were rated as good (31%), 14 as fair (48%), and six as poor (21%). The studies generally performed well in the “Selection” category (e.g., trauma ascertainment, representativeness). However, many studies lacked comparability; they often failed to control for key confounders such as IQ, medication, and comorbidity, or did not justify their sample sizes through power analysis. Additionally, since all studies were cross-sectional, none included follow-up assessments, which limited inferences about causality or changes over time.
Transdiagnostic association between childhood trauma and mentalisation capacity
Among clinical samples, 20 out of the 29 studies (approximately 69%) reported at least one negative association between childhood trauma (CT), whether composite or subtype, and measures of mentalisation. Only one study, conducted by Trauelsen et al. (2019) showed a paradoxical positive association, while eight studies (about 28%) found no association at all. When examining CT subtypes, neglect (both physical and emotional) was most consistently linked to impaired mentalisation in approximately 59% of the studies. In contrast, the evidence for abuse (emotional, physical, or sexual) was weaker, with associations found in only 22-35% of the studies, and associations with composite childhood trauma were moderate, around 44%.
Diagnostic-specific associations between childhood trauma and mentalisation capacity
In the context of schizophrenia and psychosis, fourteen studies examined the relationship between childhood trauma and mentalisation in psychotic or clinically high-risk populations. Nine of these studies found significant negative correlations, particularly related to neglect (noted in six studies), and, to a lesser extent, sexual or emotional abuse. None of the studies found a specific link to physical abuse. Four studies reported no association, some using composite measures of childhood trauma or focusing only on abuse.
Metacognition, social cognition, and cognitive empathy
Five studies (17%) focused on metacognition, often using the Metacognitive Assessment Scale for Adults (MAS-A), and four of these found negative associations between childhood trauma and metacognition. Eight studies (28%) explored social cognition, generating mixed findings; half reported associations while the other half did not, utilising various tools such as the Mayer-Salovey-Caruso Emotional Intelligence Test (MSCEIT). Lastly, two studies (7%) investigated cognitive empathy and found no significant associations.
Findings suggest a consistent link between childhood neglect and impaired mentalisation, especially in psychotic disorders, though results vary across diagnoses and measures.
Conclusions
The systematic review by Gorgellino et al. (2025) sheds light on the subtle but significant role of mentalisation in the long-term effects of childhood trauma across psychiatric diagnoses. By synthesising findings from diverse clinical populations, the authors highlight a consistent association, particularly between neglect and impaired mentalisation, while also acknowledging the complexity of measuring such constructs.
Targeting impaired mentalisation may offer a promising pathway for trauma-informed care across psychiatric settings.
Strengths and limitations
The authors of the review examine a range of disorders, including psychosis, depression, personality disorders, PTSD, addiction, and more. This wide scope suggests a potential common mechanism, specifically mentalisation that underlies various psychopathologies.
The review was registered in PROSPERO and adheres to PRISMA guidelines, which enhances transparency and methodological rigour. Due to the variability in measures and methods, the authors avoid overgeneralising their findings. They carefully outline where results are consistent, such as in psychosis and neglect, and where findings are more mixed, like in PTSD and abuse.
In their analyses, the authors distinguish between neglect and abuse, emphasising that there are stronger links between neglect and deficits in mentalisation. They also address the diversity of mentalisation measures and the confounding factors present in the existing literature.
However, all 29 studies included in the review are cross-sectional, which means that causation cannot be established. It remains unclear whether childhood trauma (CT) impairs mentalisation or if deficits in mentalisation predispose individuals to both trauma and psychopathology.
The review grapples with considerable conceptual confusion, as terms such as “mentalisation,” “metacognition,” “theory of mind,” “reflective functioning,” and “social cognition” are used inconsistently across studies. This inconsistency, combined with the varied tasks and instruments used, prevents drawing direct conclusions.
Moreover, many studies depend on retrospective self-report measures, like the Childhood Trauma Questionnaire (CTQ) and the Child Experiences of Care and Abuse (CECA), which are prone to recall bias. Additionally, the timing, chronicity, and age at exposure to trauma are rarely examined, which limits the depth of interpretation. Finally, while nearly half of the studies focus on psychotic populations, there is an underrepresentation of other diagnoses, such as bipolar disorder.
A comprehensive yet cautious review linking childhood trauma to impaired mentalisation across mental health conditions, highlighting both clinical relevance and research gaps.
Implications for practice
Assessing both trauma history and difficulties with mentalisation on a routine basis can help guide more targeted interventions. Tools such as the Childhood Trauma Questionnaire (CTQ) and structured interviews that evaluate reflective functioning or theory of mind can provide a deeper understanding of a patient’s developmental vulnerabilities.
Second, interventions designed specifically to enhance mentalising, like Mentalization-Based Treatment (MBT), may be especially beneficial for individuals with trauma histories, not solely for those diagnosed with borderline personality disorder. The transdiagnostic relevance noted in the review suggests that the principles of MBT could be adapted for various settings, including psychosis services, youth mental health, and trauma recovery programs.
Third, clinicians should be careful not to label all trauma-related difficulties as “mentalisation deficits” without considering the context. The varied findings across different diagnostic groups indicate that mentalisation can be disrupted in different ways, depending on the nature and timing of the trauma, co-occurring symptoms, and current relational environments.
Finally, establishing a therapeutic relationship that models curiosity, empathy, and a non-judgmental attitude may aid in restoring mentalising in clients. When clinicians actively demonstrate mentalisation by recognising multiple perspectives and validating emotional experiences, they create an environment that supports recovery from trauma-related disruptions in interpersonal understanding.
Enhancing mentalisation in trauma-exposed individuals offers a promising, transdiagnostic path to more personalised and effective care.
Statement of interests
No conflicting interests to declare. I acknowledge the use of AI in assisting with the revision of the text to enhance clarity and correctness. This tool has helped with grammar checks and rewriting long sentences to increase the overall quality of the blog.
Links
Primary paper
Gorgellino, M., Kumar, G., Parkar, Y., Catalan, A., Fares-Otero, N., Debbané, M., … & Alameda, L. (2025). The shadow of trauma: impaired mentalization in clinical populations–a systematic review. Psychological medicine, 55, e186.
Other references
Bateman, A. W., & Fonagy, P. (Eds.). (2012). Handbook of mentalizing in mental health practice. American Psychiatric Publishing, Inc.
Bateman, A., & Fonagy, P. (2008). 8-year follow-up of patients treated for borderline personality disorder: mentalization-based treatment versus treatment as usual. American Journal of Psychiatry, 165(5), 631-638.
Battle, C. L., Shea, M. T., Johnson, D. M., Yen, S., Zlotnick, C., Zanarini, M. C., … & Morey, L. C. (2004). Childhood maltreatment associated with adult personality disorders: findings from the Collaborative Longitudinal Personality Disorders Study. Journal of personality Disorders, 18(2), 193-211.
Gergely, G., Fonagy, P., Jurist, E., & Target, M. (2002). Affect regulation, mentalization, and the development of the self. International Journal of Psychoanalysis, 77, 217-234. Luyten, P., Campbell, C., Allison, E., & Fonagy, P. (2020). The mentalizing approach to psychopathology: State of the art and future directions. Annual review of clinical psychology, 16(1), 297-325.
McKay, M. T., Cannon, M., Chambers, D., Conroy, R. M., Coughlan, H., Dodd, P., … & Clarke, M. C. (2021). Childhood trauma and adult mental disorder: A systematic review and meta‐analysis of longitudinal cohort studies. Acta Psychiatrica Scandinavica, 143(3), 189-205.
Trauelsen, A. M., Gumley, A., Jansen, J. E., Pedersen, M. B., Nielsen, H. G. L., Haahr, U. H., & Simonsen, E. (2019). Does childhood trauma predict poorer metacognitive abilities in people with first-episode psychosis?. Psychiatry research, 273, 163-170.
Wells, G., Shea, B., O’connell, D., Peterson, J., Welch, V., Losos, M., & Tugwell, P. (2014). Newcastle-Ottawa quality assessment scale cohort studies. University of Ottawa, B-10.
Whitten, T., Tzoumakis, S., Green, M. J., & Dean, K. (2024). Global prevalence of childhood exposure to physical violence within domestic and family relationships in the general population: A systematic review and proportional meta-analysis. Trauma, Violence, & Abuse, 25(2), 1411-1430.
