A Mentalization‐Based Approach to the Development of the Therapeutic Alliance in the Treatment of Schizophrenia

This article presents a clinical illustration of a mentalization‐based approach to the development of a therapeutic alliance in the treatment of schizophrenia. A clinically focused overview of the attachment‐based understanding of mentalization central to the mentalization‐based treatment model is first provided. This is followed by a brief summary of the theory and evidence supporting the possible link between attachment disturbances and deficits of mental state understanding in schizophrenia. A case presentation then illustrates the application of core mentalization‐based principles and interventions to enhance the therapeutic alliance by addressing disruptions of mentalization and reducing paranoia in the treatment of a patient with early course schizophrenia.     

Patterns of inner change and their relation with patient characteristics and outcome in a psychoanalytic hospitalization‐based treatment for personality disordered patients

This study investigated whether different clusters of patients with personality disorders in a psychoanalytic hospitalization‐based treatment were associated with: (a) different changes in personality organization (PO); (b) different pre‐treatment variables; and (c) different associations between changes in PO and outcome. K‐means clustering analysis identified two clusters of patients, which showed different changes in PO and mainly differed in terms of levels of anaclitic and introjective personality features, respectively. Both clusters showed a significant decrease in symptoms and an improvement in personality functioning during treatment and at 3‐month follow‐up. Clinical implications of these findings are discussed. Copyright © 2010 John Wiley & Sons, Ltd. Key Practitioner Message: ? Psychoanalytic hospitalization‐based treatment for patients with personality disorders is associated with changes in different aspects of personality organization such as representations of self and others, mentalization and felt safety. ? Patients show different trajectories of change in personality organization, which are associated with patient characteristics such as introjective and anaclitic personality dimensions as defined by Blatt (2004). ? Two identified trajectories of change during psychoanalytic hospitalization‐based treatment lead to improvement in outcome, i.e., symptom reduction and improvement in personality functioning. ? Therapists should tailor treatment to individual patient characteristics in treating personality disorders.     

What is Mentalizing? An Overview

This paper attempts to summarize the evolution of interest in the concept of mentalization which has been researched and enriched by the linking of many disciplines alongside that of psychoanalysis and attachment theory. Taking into account the work of Professors Fonagy and Target and many others, the paper describes factors that enable the development of the capacity to mentalize and those that interfere. It will consider how the quality of attachment affects the transformation of pre‐mentalized modes of experience to the recognition of psychic reality of self and other. While mentalizing is part and parcel of all therapies, a mentalization‐based therapy was developed in the context of treatment of borderline personality disorder patients by Professors Bateman and Fonagy. The paper will illustrate key concepts in the theory of mentalization with the vignette taken from clinical practice.     

EXTREME RISK SEEKING ADDICTION: THEORY AND TREATMENT

Extreme Risk Seeking Addiction (ERSA) is a behavioural addiction manifested as a repeated voluntary search for risk. This article introduces some theoretical reference points to discuss a clinical case study, a once‐weekly psychotherapy which extended over more than ten years. The model followed assumes that ERSA is due to the feelings of excitement and ‘narrow escape’ which, if reiterated, bring about the construction of a pathological organization, a psychic retreat in Steiner's terms. This organization is a part of the self which is tyrannical and falsely protective, and is able to create illusory feelings of invulnerability and all‐powerfulness. Psychotherapy can offer a benevolent interaction which is sufficiently in tune with the ERSA‐affected person to be able to favour self‐reflective experiences promoting the mentalization of affect and, more generally, the skills which make it possible to recognize emotions in the self and in others, and to manage emotional states within relationships effectively and competently.     

Well‐being therapy for generalized anxiety disorder

Well‐being therapy (WBT) aims to enhance psychological well‐being based on Ryff's (1989) six dimensions: autonomy, personal growth, environmental mastery, purpose in life, positive relations, and self‐acceptance. Previous studies have documented the efficacy of this psychotherapy in treating patients with mood and anxiety disorders and in preventing relapse in recurrent depression. We discuss and illustrate the use of WBT in generalized anxiety disorder. We present a case of a patient suffering from generalized anxiety disorder treated with cognitive‐behavioral therapy followed by WBT. © 2009 Wiley Periodicals, Inc. J Clin Psychol: In Session 65: 1–10, 2009.     

Examining the relationship between object relations and interpersonal distress in a clinical sample

The goal of the present study was to explore the relationship between patients' object relational functioning (Social Cognition and Object Relations Scale‐Global Ratings) as rated by clinicians during the course of outpatient psychodynamic psychotherapy in a university‐based clinic and patient self‐reported interpersonal vulnerabilities (Inventory of Interpersonal Problems‐64). Participants (n = 112) were outpatients entering treatment at a university‐based psychotherapy clinic and were diagnosed primarily with mood disorders as well as Axis II relational problems and features. Participants completed the IIP‐64 prior to receiving therapy, and SCORS‐G ratings were based on patients' level of relational functioning during the evaluation process (i.e., the semistructured interview, follow‐up and feedback) and across the first two psychotherapy sessions. Results showed a significant relationship between the IIP‐64 Total score with SCORS‐GSelf‐Esteem (r = ?.21, p < .05) and Affective Quality of Representations (r = ?.20, p < .05), wherein self‐reported interpersonal dysfunction was greater among patients who had lower self‐worth and perceived others as more malevolent. These findings suggest that patients who rated themselves as having more significant interpersonal difficulty reported more negative expectations and experiences of relationships in their psychotherapy narratives. The utility of the SCORS‐G and the IIP‐64 as two different avenues of assessing patient relational functioning is explored.     

Interpersonal profiles in eating disorders: Ratings of SASB self‐image

Introduction: Although evidence suggests that interpersonal psychotherapy may be an efficacious treatment for eating disorders, there is surprisingly little systematic knowledge about the interpersonal world of these patients. Method: SASB self‐image ratings were used to explore interpersonal profiles in a large heterogeneous sample of eating disorders (N = 830), matched normal controls (N = 105) and a small group of controls with subclinical depression (N = 26). Results: Eating disorder patients clearly presented with significantly more negative interpersonal profiles compared to controls. Within the eating disorder group, anorexics were characterized by high self‐control, self‐blame and self‐attack. Patients with binge eating disorder expressed the least negative self‐image, and were significantly more self‐affirming than bulimics and less self‐controlling than patients with atypical eating disorders. Conclusions: Eating disorder patients may have distinct interpersonal profiles that increase the risk of negative therapeutic reaction. Better knowledge of interpersonal processes in eating disorders may help to improve both diagnostic assessment and treatment.     

Exploring identity and personal meanings in psychosis using the repertory grid technique: A systematic review

Current research and clinical practice in person‐centred approaches highlight the importance of self, identity, and personal meanings in psychosis. Previous research has focused on dimensions of self, but less attention has been paid to the personal meanings involved in identity. The personal construct theory framework and the repertory grid technique (RGT) allow the study of identity and personal meanings within person‐centred approaches of psychopathology and treatment in psychosis, as suggested by studies that began more than 40 years ago. However, their contributions have not yet been reviewed. We aimed to systematically review the evidence for the role of identity and personal meanings in psychotic disorders. We performed a systematic search using personal construct and RGT terms in PsycINFO, Web of Science, PubMed, EBSCO, Scopus, and Google Scholar. After identifying 2,574 articles, 15 were included. Nine studies followed an idiographic assessment, and six were nomothetic. Patients reported their subjective experience of isolation in terms of high self‐ideal discrepancy and high perceived discrepancy with their significant others, which some studies associated with a lower degree of recovery or with the way in which positive symptoms were construed. Self‐fragmentation either decreased with interventions or was associated with recovery. Evidence regarding interpersonal construing was less consistent, but there was a tendency for patients to show a more rigid cognitive structure than controls. To conclude, we found some evidence that self‐discrepancies, fragmentation of self, and interpersonal construing are affected in psychosis and potentially modifiable through psychotherapy.     

Culture analysis and metaphor psychotherapy with Arab‐Muslim clients

Attempting to reveal unconscious content and promoting self‐actualization may be counterproductive for clients who come from collectivistic cultures. Such treatment goals may expose clients to harsh confrontations with the family. Clients with dependency traits, low ego‐strength, and strict families may be helped through metaphor psychotherapy or culture analysis. Metaphor therapy makes it possible to deal symbolically and indirectly with unconscious content; culture analysis can pave the way to reveal unconscious needs and enable clients to establish a new order within their belief systems and within their families. The present article describes these two therapy methods and illustrates their clinical use with an Arab‐Muslim suffering from depression. Through such therapy anchored in his own culture and religion, the client altered his beliefs, became satisfied with himself, and found successful ways to adapt to his family. © 2009 Wiley Periodicals, Inc. J Clin Psychol: In Session 65:1–11, 2009.     

Positive interventions in clinical practice

Mainstream psychotherapy has made huge strides in treating symptoms and disorders, but it has largely overlooked happiness as a therapeutic goal despite frequently hearing from clients, “Doctor, I want to be happy.” This issue of Journal of Clinical Psychology: In Session describes a number of positive interventions for specific clinical problems, such as depression, anxiety, schizophrenia, loss, grief, and relationship distress. Although the name may suggest it, positive interventions do not imply that rest of psychotherapies are negative. Neither are negatives denied nor minimized. Distinct from self‐help recipes proffering instant changes, positive psychology interventions refer to systematic approaches to overcome challenges by using clients' strengths and assets. A hybrid psychotherapy‐coaching model and strength‐based assessment can ask a client “What is right with you?” All articles are supplemented with rich case illustrations. © 2009 Wiley Periodicals, Inc. J Clin Psychol: In Session 65: 1–6, 2009.     

Cognitive‐behavioral therapy of delusions: mental imagery within a goal‐directed framework

Central to psychotic disorders, delusions are associated with disability and often respond inadequately to pharmacotherapy. Cognitive‐behavioral treatments have been developed over the last 20 years that successfully address delusions. However, meta‐analyses suggest only a modest improvement in psychotic symptoms. Because delusions share considerable overlap with anxiety, adapting principles and techniques that have demonstrated efficacy in the treatment of anxiety disorders might improve the impact of cognitive‐behavioral treatment of delusions. We report a case illustrating a cognitive‐behavioral approach to delusions with an emphasis on mental imagery techniques. A 25‐year‐old male diagnosed with paranoid schizophrenia whose clinical presentation was dominated by paranoid delusions received 6 months of treatment. At the end of the follow‐up period, the patient's delusions were minimal and his negative symptoms had significantly improved. Mental imagery may be an important treatment tool for delusions. © 2009 Wiley Periodicals, Inc. J Clin Psychol: In Session 65:1–12, 2009.     

Attachment and Object Relations in Patients With Narcissistic Personality Disorder: Implications for Therapeutic Process and Outcome

This article presents a therapeutic approach for patients with severe personality disorders, transference‐focused psychotherapy (TFP), a manualized evidence‐based treatment, which integrates contemporary object relations theory with attachment theory and research. Case material is presented from a narcissistic personality disorder (NPD) patient in TFP whose primary presenting problems were in the arena of sexuality and love relations, and whose attachment state of mind showed evidence of oscillation between dismissing and preoccupied mechanisms. Clinical process material is presented to illustrate the tactics and techniques of TFP and how they have been refined for treatment of individuals with NPD. The ways in which conflicts around sexuality and love relations were lived out in the transference is delineated with a focus on the interpretation of devalued and idealized representations of self and others, both of which are key components of the compensatory grandiose self that defensively protects the individual from an underlying sense of vulnerability and imperfection.     

An Integrative Psychotherapy Approach to Foster Community Engagement and Rehabilitation in Schizophrenia: A Case Study Illustration

This case study illustrates the use of a long‐term integrative psychotherapy approach with a middle‐ aged man with chronic schizophrenia and a mood disorder. The case of “Holst” describes a man with a history of insecure attachment and trauma who later went on to contract a serious chronic illness, precipitating the onset of psychotic symptoms, depression, and chronic suicidal ideation, resulting in multiple hospitalizations. Combining metacognition‐oriented therapy with elements of cognitive behavioral therapy and psychiatric rehabilitation, this approach fostered significantly improved community functioning and attainment of personal goals over time. Through the journey of therapy, the patient also developed a more coherent narrative about his life, established a stable sense of self, and became an active agent in the world. This case illustration demonstrates that these three different approaches can be used in a sequential and complementary fashion to foster recovery in the midst of serious physical and mental illness.     

The role of stigma during the course of inpatient psychotherapeutic treatment in a German sample

The current study intends to investigate whether the therapeutic process is impeded by stigma and how stigma develops over the course of cognitive behavioural psychotherapy treatment. Sixty German psychotherapy inpatients were asked on a weekly basis about two facets of stigma: self‐stigma and perceived public stigma. That information was linked to additional process as well as outcome variables (therapeutic engagement, working alliance, depressive, and general psychological symptoms). Both facets of stigma decreased over the course of psychotherapy, but only the decrease in self‐stigma was significant. In a weekly interval, low (high) self‐stigma predicted high (low) levels of working alliance and therapeutic engagement and vice versa. The current study shows that self‐stigma is especially subject to change during the course of an inpatient psychotherapeutic treatment. In addition, our results point to the interrelation between self‐stigma and other process variables contributing to the effectiveness and success of psychotherapy.     

How does the general practitioner understand the patient? A qualitative study about psychological interventions in general practice

Objectives General practitioners (GPs) treat more than 90% of common mental disorders. However, the content of their interventions remains undefined. The present study aimed to explore GPs' processes of understanding the patients with emotional problems. Design The study was qualitative using semi‐structured interviews with 14 general practitioners sampled purposively. Observation was done in the surgeries of four of the GPs. Methods Analysis of the interviews was made by Interpretative Phenomenological Analysis (IPA). Observation notes were analysed from a hermeneutic‐phenomenological perspective, inspired by IPA. Results GPs had very different approaches to patients with emotional problems. Physical symptoms were the usual reason for consulting the GP. Understanding patients' perception of the meaning of their bodily symptoms in their complex life‐situation was considered important by some of the participants. Arriving at this understanding often occurred through the narrative delivered in different narrative styles mirroring the patients' mental state. Awareness of relational factors and self‐awareness and self‐reflexivity on the part of the GP influenced this process. Other participants did not enter this process of understanding patients' emotional problems. Conclusions The concept of mentalization could be used to describe GPs' processes of understanding their patients when making psychosocial interventions and could form an important ingredient in a general practice theory in this field. Only some participants had a mentalizing approach. The study calls attention to the advantage of training this capacity for promoting professional treatment of patients and a professional dialogue across sector borders.     

Mentalizing countertransference? A model for research on the elaboration of countertransference experience in psychotherapy

As a construct, the elaboration of countertransference experience (ECE) is intended to depict the implicit and explicit psychological work to which therapists submit their experiences with clients. Through ECE, defined as a mentalizing process of a particular kind, therapists' experiences are presumed to acquire and increase in mental quality and become available for meaning‐making and judicious clinical use. In this paper, we claim that such an ongoing process facilitates engagement with common therapeutic factors, such as the therapeutic alliance and countertransference management, enhancing therapist responsiveness in psychotherapy. We synthesize relevant literature on countertransference, mentalization, and, in particular, therapists' mentalization, informed by a systematic literature review. As a result, we propose a model for assessing ECE in psychotherapy, comprising 6 diversely mentalized countertransference positions (factual‐concrete, abstract‐rational, projective‐impulsive, argumentative, contemplative‐mindful, and mentalizing), 2 underlying primary dimensions (experiencing, reflective elaboration), and 5 complementary dimensions of elaboration. Strengths and limitations of the model are discussed.     

The relationship between body dysmorphic disorder symptoms and self‐construals

Background: Cognitive models of body dysmorphic disorder (BDD) suggest that beliefs and evaluations related to self‐concept are central to the maintenance of the disorder, but such beliefs have received little empirical attention. This study examined the relative importance of contingent self‐worth and self‐ambivalence to BDD symptoms in comparison to their importance to obsessive–compulsive disorder and social phobia symptoms. Method: The sample comprised 194 non‐clinical participants (female, N = 148; males, N = 46) with a mean age of 24.70 years (standard deviation = 9.34). Participants were asked to complete a battery of self‐report questionnaires. Results: While significant relationships were found between the self‐beliefs and symptoms of all three disorders, some specificity was found in the relationships. Conclusions: Self‐worth based upon appearance was most important in BDD, while contingent self‐worth based on the approval of others was important in social phobia. Self‐ambivalence was associated with each disorder. Implications and limitations are discussed.