Mapping pretend mode across developmental and clinical contexts: A scoping review

Pretend mode is a widely used but conceptually unstable term in mentalization theory, applied to developmental, therapeutic and clinical phenomena that are not consistently differentiated. This scoping review mapped how pretend mode has been described, labelled, operationalized and clinically applied across developmental stages and clinical and non-clinical contexts.

Following PRISMA-ScR guidance, five databases were searched for peer-reviewed papers published between 1995 and 2025 that explicitly used the term pretend mode. A total of 148 papers met inclusion criteria and were charted and synthesized thematically.

Pretend mode was rarely examined as a primary construct. The literature showed substantial conceptual and terminological variability, with 87 labels and descriptors identified. Childhood papers largely reiterated foundational developmental formulations, adolescence was sparsely represented and adult clinical papers predominated. Pretend mode was variously linked to developmental pretence, therapeutic 'as-if' work, defensive detachment, pseudomentalizing, hypermentalizing and mentalizing breakdown. Only three studies attempted systematic operationalization. Clinical recommendations were common but largely theoretical or case-based.

Pretend mode remains clinically important but insufficiently developed. The review identifies a boundary problem: the term is used across partly overlapping contexts, from developmental pretence, pretend play and therapeutic 'as-if' processes to defensive retreat, mentalizing breakdown and detached or pseudo-reflective discourse. These uses are rarely differentiated, making reliable identification, operationalization and clinical guidance difficult. Future work should clarify which use or function of 'pretend' is being described and how it relates to affective, relational and reality-based experience.