Interpersonal rejection, ostracism, and mentalisation in women’s friendships: Clinical implications for rumination

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Deborah J. Oehlman Forbes


Interpersonal rejection is a distressing and painful event that compromises quality of life and instigates feelings of loss, disaffection, and isolation (Leary, 2015). Friendship termination, romantic and familial rejection, and being ostracised (shunned, excluded, and ignored) are examples of interpersonal rejection, all of which share psychological and physiological consequences (Williams & Nida, 2017). Why a person is ostracised, rejected, or abandoned by their peers and friends is a difficult question to answer. While many adults can bounce back, rejection and ostracism are antecedent to unexpected neurological and physiological responses wherein resolution, forgiveness, or restorative effort is deficient or denied (Hirst et al., 2020; Williams & Nida, 2017).

Relational-cultural theory (RCT) was originally developed to improve understanding of women’s psychological experiences and has played a role in women’s mental health counselling. RCT focuses on social and cultural responses to a range of health issues, such as chronic illness, depression, addictions, eating disorders, and problems in mother–daughter relationships. By recognising the diversity of interpersonal relationships RCT has extended beyond traditional human development theories (individuation and autonomy), identifying that connection to other is relationally complex (Duffey & Somody, 2011). While RCT has evolved beyond theories of the self, this theory suggests that through interpersonal connection we foster psychological growth, and we do so through healing connections. Conversely, disconnection creates significant pain, and this argument has been inextricably linked to divergent social identities and women with individual differences (Comstock et al., 2011).

Empirical research conducted by Nolen-Hoeksema et al. (2008) on rumination (repetitive thinking on unresolved situations) found temporal rumination moderates affect and is useful for goal achievement. However, prolonged rumination inhibits psycho-social wellbeing and self-management of negative abstract thoughts and is a maladaptive strategy for emotion regulation; this plays a critical role in a myriad of unwanted mental health problems. Cognitive confusion, a response to inexplicable interpersonal rejection and a contributor to rumination, centres on unresolved and ambiguous information (Koch, 2020). In terms of response-coping styles, rumination is found in acute presentations of atypical depression, as well as physiological pain found in reports of leaden paralysis (limbs feeling weighed down), a feature of atypical depression. Other responses to interpersonal rejection and ostracism may also affect sleep patterns, appetite, and attachment orientation, and lead to rejection sensitivity (Lyndon et al., 2017; Nolen-Hoeksema et al., 2008).

Liotti and Gilbert (2010) has suggested psychotherapists pay attention to mental state processes, in which not only is reflective functioning critical for cognitive processing but also the client’s capacity for mentalisation is an important feature in the maintenance of interpersonal relationships. From a lifespan perspective, early childhood abandonment, parental rejection, and adult attachment insecurity are associated with increased sensitivity to rejection, which has been shown to cause disruption to mentalising capacity (Allen & Fonagy, 2006). Therefore, the empirical evidence on mentalisation provides critical answers for the counsellor or psychotherapist helping clients restore the psychological resilience and physiological changes discussed herein.

By examining these perspectives, the author finds the antecedents and consequences of interpersonal rejection and ostracism are psychologically dynamic and clinically implicated in the context of women’s friendships with one another. This article seeks to inform psychotherapy practice by providing historical, sociological, and psychological perspectives on the social and interpersonal value of women’s friendships. In terms of gender, this paper focuses on women presenting with prolonged rumination, but would be relevant to a wide range of populations. This article is consistent with reporting standards for qualitative secondary research which aims to elaborate on relevant mixed findings, rather than a single account to explain phenomena. This is a useful method for providing sets of knowledge for mental health clinicians and researchers alike, since the approach informs intended research (American Psychological Association, 2020, pp. 93–105). The terms “interpersonal rejection” and “ostracism” are used throughout the article interchangeably since ostracism is a variant of interpersonal rejection.

Definitions and Functionality of Women’s Friendships

Philosophical perspectives on friendship are well established in the literature and are grounded in the theories of Plato and Aristotle and in the discourse of other noteworthy philosophers, such as Frederick Nietzsche and Michael Foucault, all of which have described the notion of reciprocal goodwill, similarity of character, and commonality of virtue (Kivle, 2018; Vernon, 2010). People tend to assign meaning to their friendships, adding certain terms, such as “best”, “close”, “casual”, or “old”, to define the types of bonds they share with friends (Vernon, 2010). While history has focused primarily on the masculinity of friendship, women’s friendships are also gifted by the same virtues (i.e., mutuality, goodwill, integrity, and honesty). These virtues complement the three unique types of friendship that Aristotle was said to be most interested in: with people with whom we work, socialise, and are closest.

To elaborate, the first friendship type explores goals to achieve a common purpose, insomuch as “friendliness” develops between a worker and a supervisor. The second type may provide pleasurable experiences, such as casual dining, holidaying, or casual sex insofar as these activities remain beneficial to one another. The third is a friendship of love and acceptance involving depth of mutual character admiration, which has the greatest meaning and is the closest of the friendship types, often lasting a lifetime (Vernon, 2010). Modern scholars also point to an ethical concept of “character friendship” which maintains a disposition to act in good faith, be motivated by the right reasons, and express genuine emotions by cultivating a virtuous friendship. Moreover, Kivle (2018) advocated for adult friendship to be true, valued for its moral excellence, permit fragility, and to exchange empathy, fairness, and equality, thereby apportioning a mutual responsibility to the relationship.

Friendship between women goes hand in hand with the desire for love (or care and attachment), belonging, and acceptance, while such virtues are similarly found in intellectually passionate and romantic relationships and long-term partnerships (O’Connor, 1992). Although somewhat elusive and functionally ambivalent, friendship between women has been conceived as mutually beneficial, a safe refuge offering stable companionship, and facilitating intimate exchanges akin to a faithful partnership (Hirst et al., 2020; O’Connor, 1992). Women’s friendships in the Victorian (i.e., platonic romantic friendships), suffragette, and feminist eras have provided models for meaningful social advancement; however, they have also been regarded as disruptive in terms of threating male-dominated discourse. Women friends were often described as “interrupters” in the early 20th century (Vernon, 2010).

Martinussen (2019) outlined the functionality of friendship in the workplace, whereby formal friendliness helps remodel the professional and personal self, supports self-management practices, and aids in the development of knowledge. For example, a same-sex friendship develops in the context of ascension towards self-actualisation and is often supported by a workplace mentor. While there can be positive outcomes arising from this relationship type, breaches of propriety or taking advantage of another’s intellectual resources tend to diminish relational value, and so the general rules of friendship fade in one or both parties (Leary, 2015). Moreover, the utility of professional colleagues, as Aristotle suggested, is not often about liking the other person for who they are in themselves but about liking or valuing what is more or less “useful” for a temporary period of time (Vernon, 2010).

Recent studies in the fields of sociology and personal relationships are demonstrating how emotional closeness, attachment support, and navigating women’s friendships contrast with a perceived higher value of heteronormativity, particularly in the context of hierarchical ordering (Martinussen, 2019). For example, women in their early to later midlife phase tend to apportion their female friendships as supplementary to an opposite-sex partnership. Women’s intimate relationships primarily with adult males have been configured as the only “locus of intimacy”, with marriage, intimate partner, or de facto status stationed higher on the relational value system (Martinussen, 2019; O’Connor, 1992). Furthermore, many studies on the ordering of relationship conventionality, for example, matrimonial couple, monogamy, partnering, and parenting, have focused on interpersonal functioning, intimacy, and adult attachment patterns across these relationship types (Bretherton & Munhollend, 2008).

On the other hand, women’s friendships offer a range of social health imperatives that not only accentuate themes of cultural productivity, creativity, and ingenuity but also lay across the schematics of adult attachment, emotional affect, social integration, and the nurturance of self-worth (Mikulincer & Shaver, 2016; O’Connor, 1992). Welch and Houser (2010) suggested the functionality of a valued same-sex friendship has a certain centrality, which forms a basis for emotional and attachment security. However, it is difficult to discern what makes women’s friendships conducive to positive mental health when there appears to be a lesser focus in the literature on same-sex interpersonal relating styles, individual differences, and friendship attachment. More concerning, if women’s friendships are seen as “supplemental relationships”, then friendship dissolution, rejection, and ostracism experiences disrupting emotional security render it probable that women’s friendships are not adequately attended to in the mental health setting. Furthermore, individual differences in the dissolution phase (e.g., attachment style and emotional affect) may be overlooked by clinicians.

Interpersonal Rejection and Friendship Appraisal

Rejection is a general term used to describe what is no longer needed or desired. However, interpersonal rejection (IR) is a universal experience very few people can avoid across the lifespan (Leary et al., 2001). It may be perceived, anticipated, or real, and even though rejecting someone is not always a malicious act, it has been characterised for its relational devaluation, reflecting a failure to value one’s relationship with another. Devaluation in the eyes of others extends to the notion that no person enjoys the emotional consequences associated with IR because IR comprises hurt feelings: sadness, guilt, shame, anger, and even jealousy. Hurt feelings in response to relational devaluation may be heightened or suppressed if attachment patterning has been activated (Koch, 2020).

Responses to IR may reactivate early memories of caregiver attachment, rejection, and abandonment and include adverse mental representations of attachment figures (Salter Ainsworth et al., 1978/2015). Cognitive-affective representations described as “mental scripts” determine how our interpersonal bonds are formed with others. More importantly, a desire to belong, be accepted, and seek secure attachment requires an appraisal phase, which also includes what we do to prevent rejection and ostracism (Mikulincer & Shaver, 2016; Williams & Nida, 2017). Human beings appraise each other in dynamic ways, often via their attachment profiles. Beyond the observable level, some may experience anxiety or hypervigilance at the first sign of personal threat (i.e., within a burgeoning friendship), while others may be more interpersonally dismissive (detach quickly), display inflated self-conception (i.e., deny hurt feelings), or suppress and deactivate their emotions (Sheinbaum et al., 2015).

An appraisal of friendship also necessitates some emotional risk-taking, such that self-disclosure helps to achieve a sense of belonging to and acceptance by those with whom we seek friendship. Self-disclosure intertwines hope and reciprocation of emotional safeness, as well as the desire to be in a secure relationship with at least one other (Allen & Fonagy, 2006). However, women who may be anxious and preoccupied that a friendship could potentially end are more likely to have developed a higher capacity for what Leary (2001) described as the “sociometer”. The sociometer is characterised by a delicate internal appraisal system that helps monitor whether one is accepted—or even, at lower points of acceptance, likely to be rejected at a critical point in time.

Adult Friendship Attachment

A starting point for working therapeutically with hurt feelings arising from IR and relational devaluation is adult attachment theory. This framework helps clinicians understand individual attachment differences, emotional and relational patterns, and disrupted attachment security (Hirst et al., 2020; Mikulincer & Shaver, 2016). Welch and Houser (2010) developed a friendship attachment model examining four friendship categories: self-disclosure, trust, hope, and relationship satisfaction. In relation to the category of self-disclosure, Guerrero et al. (2009) had previously pointed out that self-disclosure had been found to mitigate negative emotional responses to unsatisfying relational patterns. However, while Guerrero et al.’s (2009) study only focused on intimate partners, it is worth noting the insecure attachment styles still tended to feature fear of self-disclosure, thereby adding to existing research findings noting that insecure attachment produces psychological distance, reduces self and other appraisal processes, and thwarts mutual trust (Mikulincer & Shaver, 2016; Welch & Houser, 2010).

In a recent Australian study of psycho-social outcomes and psychological effects on emotion regulation in close friendships, Cronin et al. (2018) found anxious or ambivalent attachment to friends had direct significance for anxiety and interpersonal distress. The authors suggested that clinicians may benefit from assessing friendship attachment orientations, given those with high anxious attachment showed significant direct effects for depression, anxiety, stress, and interpersonal distress. There appeared no mediating effect for emotion dysregulation in the avoidant attachment friend profile. While avoidant attachment to friends directly predicted depression and interpersonal distress, it appears avoidant attachment is moderated by mental state processes that cushion interpersonal distress, thus pointing to differences in psycho-social outcomes. These findings are consistent with avoidant attachment findings concerning romantic and intimate partner attachment relations (Mikulincer & Shaver, 2016).

Arguably, not all IR and social ostracism experiences are contingent on attachment theory and adult friendship attachment differences. Studies focusing on emotional contagion have suggested people tend to withdraw from those who self-disclose excessive negative emotional content, as well as negative content about others. They withdraw in an effort to fortify and preserve the self from perceived threats to their own social health and wellbeing (Bloom, 2019). This need for self-fortification against others who disclose disproportionate emotional content has implications for intentional ostracism. That is to say, ignoring and excluding someone who regularly discloses negative emotions and content increases hurt feelings, elicits trauma-like responses, and threatens the need for meaningful existence (Bloom, 2019; Williams & Nida, 2011).

Ostracism as an Antecedent to Rumination

Ostracism is a pervasive form of IR and involves the use of ignoring, shunning, and excluding others. Punitive forms of ostracism significantly disrupt a person’s fundamental need for belonging, self-esteem, control over their own life, and a meaningful existence (Williams & Nida, 2011; Zadro & Gonsalkorale, 2014). While ostracism is associated with threats to temporal needs and elicits immediate responses (hurt feelings, confusion, embarrassment), experiences of being ignored and excluded are said to delay responses in the reflective functioning state (i.e., increased helplessness), particularly if a person is unable to work towards re-inclusion (Koch, 2020). Compelling reports from sources of ostracism (Zadro & Gonsalkorale, 2014), namely, those who used ostracism to exclude and ignore, have shown that motives for ostracising are often unstated to those who are ostracised. This type of relational disconnection tends to thwart opportunities for psychological growth for all involved and denies the opportunity not only for healing and forgiveness but also, where possible, restoration through mutually empathic exchange.

As briefly mentioned in the introduction, rumination in the adult population is defined by repetitive thoughts directing attention to internal symptoms and the meaning and consequences of those symptoms. The onset of a rumination disorder may occur in infancy, late childhood, or well into adulthood (American Psychiatric Association, 2013). Rumination disorder is transdiagnostic and a contributor in the maintenance of severe psychopathology, and has been found to lower capacity for regulation of intense emotional experiences (Trincas et al., 2018). The long-term health consequences of repeated ostracism, much like IR, are implicated in mood, emotional disorders, episodic distress, and physiological pain (Koch, 2020; Leary, 2001; Williams & Nida, 2011). Studies on depressive rumination have also revealed that vulnerability increased in adult females, for whom rumination predicted episodic depressive illness, even when depressive symptomology was not present at rumination onset (McBride & Bagby, 2006). This is important for psychotherapists to observe in terms of atypical depression, immediate responses to friendship dissolution, and intense feelings of devaluation. A more recent study on self-referential processing and meta-cognitive processing in the depressed state found distinct changes had occurred in the brain’s default mode network during rumination, and in relation to perceptions of self and other mentation (Zhou et al., 2020).

Response Styles and Rumination: The Emotional Dimension

Response styles theory posits a person is not only impaired cognitively by prolonged rumination but also has a pervasive tendency to focus on the emotions of a problematic situation rather than just the content of their own thoughts (Nolen-Hoeksema et al., 2008). In terms of interpersonal style, longitudinal studies examining the aetiology of depressive rumination have suggested people who are overly accommodating, submissive, self-sacrificing, and non-assertive in their communication are prone to depressive rumination when interpersonal situations are marked by considerable ambiguity (Pearson et al., 2012). These studies have helped inform psychological intervention with those presenting with high rumination by introducing an adaptive role to reduce negative emotions, for example, engaging in positive distraction activities. However, distracting activity has demonstrated no increase in insight into self and other relations, self-appraisal, or reflective functioning. Therefore, the use of distraction activities may result in prolonging symptomology as one flits between behavioural activities searching for relief from hyper-focusing on context-specific negative emotions (Nolen-Hoeksema et al., 2008). As previously intimated by Leary (2001), these findings are significant in relation to how a person responds emotionally to another person who, or group which, ostracises while seeking to understand and clarify relational dissolution ambiguities to reduce negative emotions (Watkins & Roberts, 2020).

In the relationship between rumination and depression, adult females have demonstrated more tendency to ruminate in response to depressive symptoms or dysphoric moods in order to cope. In contrast, adult males have tended to use more distraction activities as a coping strategy (McBride & Bagby, 2006; Nolen-Hoeksema et al., 2008). When Nolen-Hoeksema et al. (2008) isolated rumination from depression, they found a significant relationship between rumination and emotion-inducing anxiety resulting in reports of broad maladaptive responses and coping strategies, for example, overuse of alcohol, binge eating, and self-harm. Furthermore, Nolen-Hoeksema’s work pointed to emotion regulation strategies for avoidance, reappraisal, self-criticism, and suppression of experiences across all interpersonal and non-interpersonal unpleasant situations.


Some of the most outstanding research findings in the fields of psychological science and neurobiology are the transdiagnostic risk factors for rumination, an emotion regulation coping style (Nolen-Hoeksema et al., 2008). A significant aspect of emotion regulation falls under the umbrella of mentalisation, which theorises a mutable human capacity to understand, interpret, and reflect on the mental and emotional states of self and other. Interpretations and reflections of self and other mental states generally pertain to needs, intentions, perceptions, feelings, thoughts, and memories (Allen & Fonagy, 2006). To elaborate, Bateman and Fonagy (2016) provided a definitive statement regarding mentalisation: “Without mentalising there can be no robust sense of self, no constructive social interaction, no mutuality in relationships, and no sense of personal security” (p. 4).

Mentalisation has clinical implications across a wide range of psychological and neurobiological difficulties, from psychosis, autism, and attachment disturbance, to entrenched conflict in social and interpersonal relationships (Luyten & Fonagy, 2015). Mentalisation-based therapy is effective in the treatment of borderline personality disorder (Bateman et al., 2016) and childhood interpersonal trauma (Midgley et al., 2017), and it improves mentalisation capacity in families engaged with foster care systems (Midgley et al., 2017). Mentalising, or reflective functioning, begins early via the parent–infant or parent–caregiver dyad, later assuming a dynamic and non-static psychological mindedness. For instance, mentalising is frequently implicit in relation to the other; the mind is interested, curious to learn more, and seeks to create resonance. By developing mental processes such as insight and intuition, the mind also learns to see beyond the outward appearance of potential threat (Allen & Fonagy, 2006).

The theory of mentalisation was originally conceived by an integration of psychoanalysis, developmental psychology, and cognitive neuroscience. Theories conveyed in the psychoanalytic and psychodynamic literature have been considerably advanced by the development of an evidence base for which mentalisation is highly regarded in the context of child, youth, and adult psychotherapeutic practice (Jurist, 2018). Liotti and Gilbert (2010) reviewed social and interpersonal patterns that suggest people with higher mentalising capacity tend to be more proficient in interpreting and attending to the mind of another, for example, a child, close partner, or family member. However, in social contexts such as the workplace, academic, or other social settings (i.e., online), the same level of mentalising proficiency may be somewhat lower.

In the treatment of prolonged rumination as well as increased vulnerability to depression and anxiety, cognitive and behavioural therapies have not demonstrated effectiveness over time intervals because of the complex association rumination has with learned response styles, adverse childhood experiences, environment, socio-cultural expectancies, biological characteristics, and possibly hormonal variations (Watkins & Roberts, 2020). Emotion-oriented communication, therefore, is an important paradigm operationalised in mentalisation-based treatment, whereby learning to identify, describe, and label emotions is a core focus in the treatment setting, including conversations (mental state talk) targeting regulation of emotion (Jurist, 2018).

It is well known that psychotherapists play a unique role in the “attachment walk” by helping people regain a sense of self, observing incongruities in mental state functioning, and communicating through symbolic meaning (i.e., self, and other mental representations) so that these come to the attention of the client (Allen & Fonagy, 2006; Jurist, 2018). The mentalising stance, better known as the “mentalising therapist”, upholds a principle that communicating an interest in understanding the client’s mental states is paramount. Equally important, mentalising evokes a sense of curiosity in the unknown, for instance the client’s perceptions, memories, thoughts, feelings, and intentionality. Psychotherapeutic intervention that is underpinned by the theory of mentalisation is also arguably a strong indicator in the mediation of epistemic trust between psychotherapist and client, working together to develop insight into the client’s self and attachment relationships (Jurist, 2020) This notion acknowledges that others in the purview of the client (i.e., close friends) may have been perceived to lack trustworthiness, authenticity, and emotional safeness, and that the absence of these qualities are not simply isolated to the self (Fonagy & Allison, 2014).

The following brief statements provide examples of mentalising revealed in the narratives of school-aged children, young people, and adults reflecting on friendship attachment, trust, and self-disclosure: “I like my friend because she is kind”, or “my friend is trustworthy, she plays safe with me”, or “I feel safe with her when I feel sad and hurt”, or “our friendship means so much to me, because you accept me for who I am. I can be my real self with you”.

Social environments produce complex systems mediated by diverse interpersonal relations that align with the social-affiliative system. This social system is defined by collaboration, friendliness, and seeking peace and harmony, including altruistic acts and empathic behaviour (Allen & Fonagy, 2006). Mentalisation, therefore, is an important internal construct for navigating the social-affiliative system and fostering mutual growth and is a crucial self-protective capacity intended to moderate moral risk. Mentalisation ought to be normalised in the context of the psychotherapeutic setting so that clients may seek relief from interpersonal difficulties, and social and emotional pain, and reduction in ruminative thinking, mood affect vulnerability, and adult attachment difficulties (Jurist, 2018).

Individual Differences

Relational Transgression

Having considered the virtues of women’s friendships, and the emphasis on mutuality and empathic responsiveness, this paper now turns to individual differences. Friendships can have a dark side, and friends are not always as virtuous as we would like. To achieve goal objectives, there is a drive to preserve one’s own welfare and to serve others while serving the self. Psychological egoism is an interpersonal style often seen in women with a dominance of ego-centric traits, such as those high in narcissism and Machiavellianism. These darker traits share a tendency to transgress, exploit, and misuse others (such as friends) to achieve “welfare” or personal gain (Muris et al., 2017). In contrast to altruism (acts of freely giving to others), psychological egosim is not entirely swayed by altruistic motivation, nor is it motivated by thoughts of duty towards others. Altruistic behaviour, or helping others to achieve personal or professional gain, still seems to be viewed as a self-interested means to an end (Shaver, 2021).

The literature so far confirms relational devaluation is a major cause of friendship dissolution. Therefore, interpersonal transgression plays a distinct role in friendship bonding and attachment relationships, with interpersonal transgressions occurring in the violation of implicit and explicit social and relational rules (Kowalski, 2003). These violations, as they occur in women’s friendships, may range from deception, emotional manipulation, and rumour spreading, to increasing personal or professional opportunities, betrayal of trust, intentional social exclusion, obsessional intrusion (asking too many questions), through to more subtle or direct forms of relational aggression, such as emotional and physical hostility (Sinclair et al., 2011). In cases where one’s mental health has been adversely affected by relational transgression, again, introducing adult attachment theory into the therapeutic setting can improve understanding of how women, through their interpersonal attachment style, respond to friendship dissolution (Mikulincer & Shaver, 2016).

In a recent meta-analysis of attachment dimensions, Hirst et al. (2020) examined interpersonal transgression and the restorative effect of forgiveness. These types of studies help explain why women who are interpersonally rejected or ostracised find themselves plagued by rumination and cognitive dissonance regarding sources of ostracism, because of their individual differences in bonding and attachment style. Adult attachment was included in this extensive analysis, since the authors confirmed adult attachment theory yields a coherent theoretical model to understanding individual differences. The authors found that individual differences in attachment style centred on recall of negative relational experiences; moreover, individuals with high anxious-ambivalent attachment styles tended to ruminate longer on interpersonal transgressions, with the length of time inhibiting restorative efforts towards forgiveness, particularly in the high ambivalent dimension. However, those with avoidant attachment styles were less likely to ruminate, less likely to repair and restore disrupted relationships, and, consequently, less likely to focus on forgiveness. These findings align with the ambivalent relational dimension examined by Mikulincer and Shaver (2016) and in research on personality and individual differences in women’s friendships (Abell et al., 2016).

In the mental health counselling and psychotherapeutic setting, presentations of friendship transgression may be rather ambiguous and complex. Relational transgression is likely aggravated by more than a single phenomenon and can include one’s self-interest, individual differences in interpersonal style, attachment orientation, and socio-relational-cultural expectations of autonomy and individuation (Duffey & Somody, 2011). Such relationship disturbances need not be relegated to “some problem between two women”, but rather present an opportunity to explore further individual differences in same-sex pairing. This opportunity for exploration may depend upon how the client seeks to engage in prosocial or restorative behaviour consistent with healing connections. For example, there may be a willingness to deconstruct attachment style, explore how one’s individual differences interact with another’s, and remove obstacles that prevent growth-fostering relationships through regaining trust in others (Comstock et al., 2011; Mikulincer & Shaver, 2016).

Limits placed on self-disclosure are often influenced by having an avoidant-dismissing attachment profile (Mikulincer & Shaver, 2016). This challenge is particularly reinforced in the higher avoidant dimension and evident in expressions of high autonomous responses and lower capacity to identify and name emotions—a feature of alexithymia or agnosia (Lane et al., 2015). Alexithymia is conceived as a personality trait, a difficulty in identifying and differentiating one’s emotions. Any person regardless of gender or pathology can experience challenges in identifying and naming their feelings and emotions, not discounting developmental and neurobiological links (i.e., autism spectrum conditions, schizophrenia)  (Jurist, 2018). While alexithymia has been linked to both avoidant and anxious attachment styles, a vast number of empirical studies have focused on the avoidant-dismissive attachment profile (Mikulincer & Shaver, 2016, p. 223). Women with avoidant attachment tend to experience difficulty with emotion-oriented communication and are less likely to engage in discussing resolution and healing connections if the nature of the problem is emotion oriented and attachment based (Mikulincer & Shaver, 2016).

Friendship and Sexual Orientation

While positive mental health is associated with experiencing meaningful and mutually beneficial friendships, minimal psychotherapy frameworks and guidance exist regarding how sensitivity to IR and ostracism affects women with individual differences, specifically sexual orientation (Feinstein, 2020). For instance, women with the same or similar sexual orientation identities tend to foster their friendship attachments using unique bonding and attachment patterns (Galupo, 2006). Attachment patterns may also develop either positive salient or negative response styles to a range of social and relational structures. These may include socio-political structures, lifestyle, domestic preferences, and communication patterns such as narrating and sharing personal stories of “coming out” (Galupo, 2006; Martinussen, 2019).

One theory relevant to sexual orientation differences associated with the antecedents of IR and ostracism is minority stress theory (Feinstein, 2020). This theory explains the need for social and self-protective behaviours that prevent health disparities and decrease distress. Feinstein (2020) suggested sexism, biphobia, and homophobia have clinical implications regarding how stigmatised persons respond to and limit self-disclosure. Protective behaviour also tends to act as a mediator to interpersonal rejection sensitivity (IRS; Feinstein, 2020). Therefore, concealing parts of the self to avoid aversive, rejecting, and hostile behaviour by a recurrent use of socially protective behaviours is strongly linked to health disparities. Furthermore, where there is an increase in social and interpersonal protective behaviour, women in this group have had to find exhaustive coping strategies to avoid rejection, victimisation, vilification, and ostracism.

In the avoidance of IR experiences, protective behaviour is psychologically adaptive rather than static. Leary (2001) suggested adaptive behaviour begins to take place in the perceiving, anticipating, or experiencing of rejection associated with the social acceptance evaluation system. Subtle expressions of social or interpersonal disinterest elicit emotional warning signals from feeling less valued, included, or appreciated. To explore why same-sex friendship and sexual orientation differences have social, interpersonal, and clinical implications, sexual orientation and ethnic differences have been compared in the adult friendship inter-group domain (Cook et al., 2012). This study found those with inter-group ethnic profiles are substantially less rejected than interacting with group-connected friends with sexual orientation differences. Friendship partners with sexual orientation differences reported feeling more inhibited and constrained by the barrier of discomfort, and that interactive group outcomes also pointed to lower levels of friendship satisfaction. As mentioned previously regarding the need to withdraw from others who disclose too much emotional content, withdrawal strategies for self-protection are not always direct indicators of an avoidant attachment style. Furthermore, disclosure of one’s sexual orientation across heteronormative settings suggests this is a risk factor in the development of IRS (Butler et al., 2007; Feinstein, 2020; Galupo, 2006; Hall, 2018).

Interpersonal Rejection Sensitivity

IRS is an established feature of atypical depression, and researchers agree that atypical depression has a predominance of anxiety symptoms. Women with adverse childhood or developmental histories are more likely to present atypical features of depressive rumination which comprise intense negative emotions that are intrapersonal (Pearson et al., 2012). High ambiguity in relational attachment (i.e., low responsiveness, disinterest by other), accompanied by past rejection experiences, and a submissive interpersonal style (i.e., overly accommodating, self-sacrificing), tend toward predicting IRS (Pearson et al., 2012). Research on health consequences related to IR have found people with accumulated rejection experiences exhibit disproportionate responses in rumination style, hypervigilance, and increased reassurance seeking, along with physiological responses such as burnout, emotional exhaustion, lowered academic performance, and depersonalisation (Lyndon et al., 2017). However, symptoms comprising leaden paralysis (feeling weighed down, often in the limbs) have been difficult to delineate from other forms of depressive illness. Altered eating patterns and a strong desire to eat—often referred to as hyperphagia—are viewed as compensatory. These compensations seem to be related to that which precedes the course and development of personality characteristics which influence social behaviour. For instance, IRS is associated with childhood teasing and bullying, along with occurrences of low peer acceptance inhibiting the ability to develop new relationships (Butler et al., 2007; Lyndon et al., 2017).

Coupled with the body of evidence on IR, ostracism, and rejection, sensitivity correlations demonstrate a broad range of symptomology in response to prolonged rumination and appear strongly linked to women who have individual differences beyond the typical. These links may be observed in the clinical setting when presenting atypical symptoms are associated with inexplicable friendship dissolution. Relational dissolution that is inexplicable (i.e., sudden, unexplained), where restorative effort is denied and concerns left unresolved, will generally include cognitive ambiguity, a sense of uncertainty, and frustration at not knowing why. Women may also present social, emotional, and physiological pain extending into or exacerbating existing psychopathology, or a sudden onset of emotional pain where there had been no previous symptoms of depression.


The literature suggests women’s friendships are generally consigned to a neglected private topic and are considered “supplemental” relationships. Interpersonal relationship studies have tended to provide mental health clinicians with knowledge on other relationship variables, such as marriage, money, sex, parenting, post-separation, and raising children. Although it may be exceptional that women explicitly seek psychotherapy on friendship dissolution as opposed to family, marital, or intimate partnership dissolution, clinical indicators of direct and indirect consequences of rejection and ostracism in the context of women’s friendships deserve further investigation. There is a need for explorative research in real-world settings specific to women’s friendships that focuses more on bonding styles and friendship attachment, as well as studies on same-sex differences. Individual differences may also be apparent in women with neurodivergent profiles such as autism spectrum conditions when engaging in friendships with neuro-typical adult females.

Psychotherapy case studies would provide meaning and exemplars to the literature by examining the interchange between psychological vulnerabilities and prolonged rumination as well as how mentalisation-based treatment has intervened in ruminative functioning pertaining to improvement in emotion regulation. A limitation of this review is that there exist no specific process or outcome studies in the psychotherapy literature to help mental health clinicians draw upon psychotherapeutic models aimed at women’s friendships. RCT, while suited to women’s mental health counselling, could be extended to elaborate on same-sex friendship and interpersonal attachment styles, as well as a wider range of individual differences. Contemporary mentalisation-based models draw on childhood attachment theory but also focus on adult emotion regulation for which this paper indicates significant implication for prolonged rumination associated with women’s friendships. Therefore, RCT accompanied by mentalisation-based therapy could prove a useful approach when working with women’s friendship dissolution precipitating acute and chronic rumination.


Abell, L., Brewer, G., Qualter, P., & Austin, E. (2016). Machiavellianism, emotional manipulation, and friendship functions in women’s friendships. Personality and Individual Differences, 88, 108–113. https://doi.org/10.1016/j.paid.2015.09.001

Allen, G., & Fonagy, P. (2006). Handbook of mentalization based treatment. John Wiley & Sons. https://doi.org/10.1002/9780470712986

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

American Psychological Association. (2020). Publication manual of the American Psychological Association (7th ed.). https://doi.org/10.1037/0000165-000

Bateman, A., & Fonagy, P. (2016). Mentalization-based treatment for personality disorders: A practical guide (1st ed.). Oxford University Press. https://doi.org/10.1093/med:psych/9780199680375.001.0001

Bateman, A., O’Connell, J., Lorenzini, N., Gardner, T., & Fonagy, P. (2016). A randomised controlled trial of mentalization-based treatment versus structured clinical management for patients with comorbid borderline personality disorder and antisocial personality disorder [RCT]. BMC Psychiatry, 16, Article 304. https://doi.org/10.1186/s12888-016-1000-9

Bloom, S. L. (2019). Trauma theory. In R. Benjamin, J. Haliburn, & S. King (Eds.), Humanising mental health care in Australia (Vol. 1, pp. 1–30). Routledge. https://doi.org/10.4324/9780429021923-1

Bretherton, I., & Munhollend, K. A. (2008). Internal working models in attachment relationships: Elaborating a central construct in attachment theory. In J. Cassidy & P. R. Shaver (Eds.), Handbook of attachment: Theory, research, and clinical applications. (2nd ed., pp. 102–127). The Guilford Press.

Butler, C. J., Doherty, M. S., & Potter, R. M. (2007). Social antecedents and consequences of interpersonal rejection sensitivity. Personality and Individual Differences, 27(7), 1376–1385. https://doi.org/0.1016/j.paid.2007.04.006

Comstock, D. L., Hammer, T. R., Strentzsch, J., Cannon, K., Parsons, J., & Salazar, G., II. (2008). Relational-cultural theory: A framework for bridging relational, multicultural, and social justice competencies. Journal of Counselling and Development, 86(3), 279–287. https://doi.org/10.1002/j.1556-6678.2008.tb00510.x

Cook, J. E., Calcagno, J. E., Arrow, H., & Malle, B. F. (2012). Friendship trumps ethnicity (but not sexual orientation): Comfort and discomfort in inter-group interactions. British Journal of Social Psychology, 51(2), 273–289. https://doi.org/10.1111/j.2044-8309.2011.02051.x

Cronin, T. J., Pepping, C. A., & O’Donovan, A. (2018). Attachment to friends and psychosocial well‐being: The role of emotion regulation. Clinical Psychologist, 22(2), 158–167. https://doi.org/10.1111/cp.12159

Duffey, T., & Somody, C. (2011). The role of relational-cultural theory in mental health counseling. Journal of Mental Health Counseling, 33(3), 223–242. https://doi.org/10.17744/mehc.33.3.c10410226u275647

Feinstein, B. A. (2020). The rejection sensitivity model as a framework for understanding sexual minority mental health. Archives of Sexual Behavior, 49(7), 2247–2258. https://doi.org/10.1007/s10508-019-1428-3

Fonagy, P., & Allison, E. (2014). The role of mentalizing and epistemic trust in the therapeutic relationship. Psychotherapy, 51(3), 372–380. https://doi.org/10.1037/a0036505

Galupo, M. P. (2006). Sexism, heterosexism, and biphobia: The framing of bisexual women’s friendships. Journal of Bisexuality, 6(3), 35–45. https://doi.org/10.1300/J159v06n03_03

Guerrero, L. K., Farinelli, L., & McEwan, B. (2009). Attachment and relational satisfaction: The mediating effect of emotional communication. Communication Monographs, 76(4), 487–514. https://doi.org/10.1080/03637750903300254

Hall, W. J. (2018). Psychosocial risk and protective factors for depression among lesbian, gay, bisexual, and queer youth: A systematic review. Journal of Homosexuality, 65(3), 263–316. https://doi.org/10.1080/00918369.2017.1317467

Hirst, S. L., Hepper, R. G., & Tenenbaum, H. R. (2020). Attachment dimensions and forgiveness of others: A meta-analysis. Journal of Social and Personal Relationships, 36, 3960–3985. https://doi.org/10.1177/0265407519841716

Jurist, E. (2018). Minding emotions: Cultivating mentalization in psychotherapy (Vol. 1). The Guilford Press.

Kivle, I. (2018). Aristotle’s concept of friendship and Plato’s structure of human soul. In K. Bourdouris & M. Veneti (Eds.), Studies in Greek philosophy: Ethics, politics, and the origins of philosophy on Rhodes (pp. 133–138). University of Latvia.

Koch, E. J. (2020). Remembering that “everybody hurts”: The role of self-compassion in responses to rejection. Basic and Applied Social Psychology, 42(3), 167–175. https://doi.org/10.1080/01973533.2020.1726748

Kowalski, R. M. (2003). Lying, cheating, complaining, and other aversive interpersonal behaviors: A narrative examination of the darker side of relationships. Journal of Social and Personal Relationships, 20(4), 471–490. https://doi.org/10.1177/02654075030204003

Lane, R. D., Weihs, K. L., Herring, A., Hishaw, A., & Smith, R. (2015). Affective agnosia: Expansion of the alexithymia construct and a new opportunity to integrate and extend Freud’s legacy. Neuroscience and Biobehavioral Reviews, 55, 594–611. https://doi.org/10.1016/j.neubiorev.2015.06.007

Leary, M. R. (2001). Interpersonal rejection. Oxford University Press.

Leary, M. R. (2015). Emotional responses to interpersonal rejection. Dialogues in Clinical Neuroscience, 17(4), 435–441. https://doi.org/10.31887/DCNS.2015.17.4/mleary

Liotti, G., & Gilbert, P. (2010). Mentalizing, motivation, and social mentalities: Theoretical considerations and implications for psychotherapy. Psychology and Psychotherapy, 84(1), 9–25; discussion 98–110. https://doi.org/10.1348/147608310X520094

Luyten, P., & Fonagy, P. (2015). The neurobiology of mentalizing. Personality Disorders, 6(4), 366–379. https://doi.org/10.1037/per0000117

Lyndon, B., Parker, G., Morris, G., Das, P., Outhred, T., Hamilton, A., Bassett, D., Baune, B. T., Berk, M., Boyce, P., Mulder, R., Singh, A. B., & Malhi, G. S. (2017). Is atypical depression simply a typical depression with unusual symptoms? Australian & New Zealand Journal of Psychiatry, 51(9), 868–871. https://doi.org/10.1177/0004867417721020

Martinussen, M. (2019). Reason, season, or life? Heterorelationality and the limits of intimacy between women friends. Sociological Research Online, 24(3), 297–313. https://doi.org/10.1177/1360780418816334

McBride, C., & Bagby, R. M. (2006). Rumination and interpersonal dependency: Explaining women’s vulnerability to depression. Canadian Psychology/Psychologie canadienne, 47(3), 184–194. https://doi.org/10.1037/cp2006008

Midgley, N., O’Keefe, S., French, L., & Kennedy, E. (2017). Psychodynamic psychotherapy for children and adolescents: An updated narrative review of the evidence base. Journal of Child Psychotherapy, 43(3), 307–329. https://doi.org/10.1080/0075417X.2017.1323945

Mikulincer, M., & Shaver, P. R. (2016). Attachment in adulthood (2nd ed., Vol. 2). The Guilford Press.

Muris, P., Merckelbach, H., Otgaar, H., & Meijer, E. (2017). The malevolent side of human nature: A meta-analysis and critical review of the literature on the dark triad (narcissism, Machiavellianism, and psychopathy). Perspectives on Psychological Science, 12(2), 183–204. https://doi.org/10.1177/1745691616666070

Nolen-Hoeksema, S., Wisco, B. E., & Lyubomirsky, S. (2008). Rethinking rumination. Perspectives on Psychological Science, 3(5), 1–25. https://doi.org/10.1111/j.1745-6924.2008.00088.x

O’Connor, P. (1992). Friendships between women: A critical review. Harvester Wheatsheaf: Simon and Schuster International Group.

Pearson, K. A., Watkins, E. R., & Mullan, E. G. (2012). Rejection sensitivity prospectively predicts increased rumination. Behaviour Research and Therapy, 49(10), 597–605. https://doi.org/10.1016/j.brat.2011.06.004

Salter Ainsworth, M. D., Blehar, M. C., Waters, E., & Wall, S. N. (2015). Patterns of attachment (Vol. 1). Routledge. https://doi.org/10.4324/9780203758045 (Original work published 1978)

Shaver, R. (2021). Egoism. The Stanford Encyclopedia of Philosophy. https://plato.stanford.edu/archives/win2021/entries/egoism/

Sheinbaum, T., Kwapil, T. R., Ballespi, S., Mitjavila, M., Chun, C. A., Silvia, P. J., & Barrantes-Vidal, N. (2015). Attachment style predicts affect, cognitive appraisals, and social functioning in daily life. Frontiers in Psychology, 6, Article 296. https://doi.org/10.3389/fpsyg.2015.00296

Sinclair, H. C., Ladny, R. T., & Lyndon, A. E. (2011). Adding insult to injury: Effects of interpersonal rejection types, rejection sensitivity, and self-regulation on obsessive relational intrusion. Aggressive Behavior, 37(6), 503–520. https://doi.org/10.1002/ab.20412

Trincas, R., Schepisi, C., Leombruni, E., Di Mauro, V. E., & Mancini, F. (2018). Goals and functions of rumination. Clinical Neuropsychiatry, 15(6), 360–372.

Vernon, M. (2010). The meaning of friendship (2nd ed., Vol. 2). Palgrave Macmillan. https://doi.org/10.1007/978-0-230-27535-5

Watkins, E. R., & Roberts, H. (2020). Reflecting on rumination: Consequences, causes, mechanisms and treatment of rumination. Behaviour Research and Therapy, 127, 1–‍28. https://doi.org/10.1016/j.brat.2020.103573

Welch, R. D., & Houser, M. E. (2010). Extending the four-category model of adult attachment: An interpersonal model of friendship attachment. Journal of Social and Personal Relationships, 27(3), 351–366. https://doi.org/10.1177/0265407509349632

Williams, K. D., & Nida, S. A. (2011). Ostracism: Consequences and coping. Current Directions in Psychological Science, 20(2), 71–75. https://doi.org/10.1177/0963721411402480

Williams, K. D., & Nida, S. A. (2017). Ostracism, exclusion and rejection. Routledge. https://doi.org/10.4324/9781315308470

Zadro, L., & Gonsalkorale, K. (2014). Sources of ostracism: The nature and consequences of excluding and ignoring others. Current Directions in Psychological Science, 23(2), 93–97. https://doi.org/10.1177/0963721413520321

Zhou, H.-X., Chen, X., Shen, Y.-Q., Li, L., Chen, N. X., Zhu, Z.-C., Castellanos, F. X., & Yan, C.-G. (2020). Rumination and the default mode network: Meta-analysis of brain imaging studies and implications for depression. NeuroImage, 206, 1–9. https://doi.org/10.1016/j.neuroimage.2019.116287


Deborah J. Oehlman Forbes is a psychotherapist specialising in child and adult mentalisation-based treatment, including dynamic interpersonal therapy highlighting attachment sensitivity. An accredited family mediator, she has close to three decades working in child and women’s mental health and family counselling. Deborah’s work led to clinical leadership positions at the local and national level, later working in forensic and community mental health. Deborah is neurodivergent (Asperger’s) and is interested in the qualitative social and relational profiles of women with late diagnoses of autism. 



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