15 - 28.15 Mentalization Based Therapy and Mindful

28.15 Mentalization-Based Therapy and Mindfulness

Goldman JS, Hahn SE, Catania JW, Larusse-Eckert S, Butson MB, Rumbaugh M, Strecker MN, Roberts JS, Burke W, Mayeux R, Bird T. Genetic counseling and testing for Alzheimer disease: Joint practice guidelines of the American College of Medical Genetics and the National Society of Genetic Counselors. Genet Med. 2011;13:597. Hodgson J, Gaff C. Enhancing family communication about genetics: Ethical and professional dilemmas. J Genet Couns. 2013;22(1):16–21. Klitzman R, Chung W, Marder K, Shanmugham A, Chin LJ, Stark M, Leu CS, Appelbaum PS. Attitudes and practices among internists concerning genetic testing. J Genet Couns. 2013;22:90. Lawrence RE, Appelbaum PS. Genetic testing in psychiatry: A review of attitudes and beliefs. Psychiatry. 2011;74:315. Mitchell PB, Meiser B, Wilde A, Fullerton J, Donald J, Wilhelm K, Schofield PR. Predictive and diagnostic genetic testing in psychiatry. Psych Clin North Am. 2010;33:225. Monaco LC, Conway L, Valverde K, Austin JC. Exploring genetic counselors’ perceptions of and attitudes towards schizophrenia. Public Health Genomics. 2010;13(1):21–26. Moseley KL, Nasr SZ, Schuette JL, Campbell AD. Who counsels parents of newborns who are carriers of sickle cell anemia or cystic fibrosis? J Genet Couns. 2013;22(2):218–225. Peay HL, Hadley DW. Genetic counseling for psychiatric disorders. In: Sadock BJ, Sadock VA, Ruiz P, eds. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. 9th ed. Philadelphia: Lippincott Williams & Wilkins; 2009:2562. Potokar DN, Stein CH, Darrah OA, Taylor BC, Sponheim SR. Knowledge and attitudes about personalized mental health genomics: Narratives from individuals coping with serious mental illness. Comm Ment Health J. 2012;48:584. 28.15 Mentalization-Based Therapy and Mindfulness Mentalization is a relatively new term that has been defined as the process of thinking and feeling about oneself and others. Mindfulness is somewhat similar except that it applies only to oneself. In both modalities the person attempts to stay aware of thoughts, feelings, affects, moods, and somatic sensations; but in mentalization that exercise extends to another person as well. It is an interpersonal transaction. The origins of mentalization-based therapy (MBT) have been attributed to two psychologists, Jon Allen and Peter Fonagy, and one psychiatrist, Anthony Batemen, who described the process in their book Mentalizing in Clinical Practice, much of which formed the basis for this section. From a theoretical perspective, MBT is eclectic in that it combines theories from a number of analytic and nonanalytic schools of thought: Sigmund Freud and psychoanalysis; John Bowlby and attachment theory; Aaron Beck and cognitive therapy; Carl Rogers and client-centered therapy; and Gerald Klerman and interpersonal therapy. The amalgam of these techniques developed into the unique method of treatment known as mentalization. Mindfulness has its origins in Buddhist philosophy and the term was used in the 19th century to refer to a meditative technique in which the person stayed in the moment focusing on innermost feelings and states of mind. Mindfulness and mentalization rely on the same process; the person focuses on being in the “here and now.” Some have described the differences between MBT and mindfulness by stating that in MBT one is “mindful of mindfulness.”

The novel focus of a mindfulness approach is on present-moment, nonjudgmental awareness of consciousness, that is, noticing one’s thoughts and feelings in the moment and accepting them without judging or trying to change them. In many ways, mindfulness is a variation of self-monitoring in which patients attend to and increase awareness of thoughts, feelings, and behaviors. However, increased awareness of these phenomena from a mindfulness perspective does not involve analyzing them to determine how best to modify them. Instead, patients might be asked to imagine their thoughts and feelings as if they were written on cards carried by marchers in a parade or as if they were pieces of luggage on a conveyor belt. They are asked to observe internal phenomena without reaction. THERAPEUTIC APPROACHES Freud believed that all action was preceded by thought (conscious or unconscious), and in mentalization the therapist helps the patient “capture” the thought so that actions are understood more fully. Bowlby saw attachment of the infant to the mother or to the primary caregiver as the basis for a sense of security later in life. In mentalization, the therapist relies on a secure attachment with the patient to enable him or her to explore the inner world of emotions and the outer world of action, both of which elicit anxiety. Beck proposed that cognitive distortions of the self (e.g., “She doesn’t like me”) could be reversed by positive cognitions (e.g., “I don’t know if she likes me; many people do”). The mentalization therapist corrects distortions through interpretation and helps the patient test the validity of negative thoughts. The patient is encouraged to use the mechanism of empathy to step into the shoes of the other and to experience what that person may be thinking or feeling. It is the antithesis of self-centeredness. Klerman emphasized transferential distortions—a Freudian concept—that interfere with interpersonal relationships. The mentalization therapist attempts to strengthen the patient’s capacity to see the other as he or she really is by not “mind reading” or fantasizing about what the other person thinks. Rogers emphasized the autonomy of the patient vis-à-vis the therapist who was not to be seen as all knowing and omnipotent. The mentalization therapist relies on a certain degree of self-disclosure to reinforce that concept. In that sense, the therapist serves as a role model for coping with the anxieties of daily living and the vicissitudes of life. The task of the therapist is neither to judge nor advise. He or she takes a “mentalizing stance,” which is neutral and allows the patient to resolve conflict using innate resources that were previously unrecognized. MBT also allows the patient to mentalize the future by anticipating events and his or her reactions to them. In MBT emotion is experienced in a controlled and modulated manner, which can be a valuable therapeutic experience for persons whose affect is restricted because of fear. Fonagy has described what he calls the mentalizing stance as “an attitude of openness, inquisitiveness and curiosity about what’s going on in the others’ mind and in your own.” In that sense, the use and development of empathy is a core component of the process. Mindfulness is the practice of paying attention in a particular way—on purpose, in

the present moment, and without judgment. Mindfulness skills include the ability to observe, describe, and participate fully in one’s actions in a nonjudgmental, mindful, and effective manner. Some of the work in mindfulness-based approaches centers on decreasing what is known as experiential avoidance or the unwillingness to experience negative feelings, thoughts, and sensations. Persons who are skilled and well practiced in mindfulness are more adept at taking their automatic thoughts “with a grain of salt.” Upset by a series of interpersonal disappointments, a person may think “I am never going to let myself care about people ever again.” However, as he or she takes stock of this thought, the individual quickly concludes that this self-statement is neither realistic nor constructive. Instead, the person recognizes that the emotional pain of the moment is tied up in biased thinking, and that the solution to recovering from negative life events requires learning from the difficult situations and moving on. Mindfulness approaches are aimed at improving patients’ abilities to regulate their emotions and tolerating distress may then be considered, in effect, exposure exercises. Although techniques that increase patients’ nonjudgmental awareness of internal sensations may be considered at odds with attempts to change thoughts in a way that is typical within cognitive therapy, the techniques may be considered comparable to exposure-based procedures that help patients to reduce anxiety and distress associated with certain types of thoughts and images through repeated exposure to those thoughts and images. The overlap between cognitive-behavioral treatments and mindfulnessbased approaches continues to be hotly debated. INDICATIONS Mentalization has been applied to a number of clinical disorders, one of which is autism. In autism, both child and adult are impaired socially because they are less sensitive to emotional cues given by others. They have difficulty empathizing, which makes their social interactions awkward and stilted. Mentalization focuses on teaching empathy and improving social engagement with others. Patients with antisocial personality disorder may also benefit from MBT. Such patients are manipulative, give no thought to the results of their actions, lack the capacity for loyalty, and are unable or unwilling to empathize with others. MBT focuses on the core issues of their psychopathology. If a secure attachment can be made between patient and therapist the basic trust that is lacking in the antisocial person may be developed for the first time. MBT has also been of use in patients with borderline personality disorder. Mindfulness-based treatments have been demonstrated to be effective for a wide range of psychological problems, including borderline personality disorder, anxiety, chronic pain, depression, and stress. The approaches also have been used to reduce dysfunction in patients with medical conditions (e.g., cancer, multiple sclerosis) and to increase general well-being. Patients also learn to develop a greater tolerance for feelings of anxiety or depression and recognize that those states are often transitory, which may enable them to deal with conflict with greater confidence.

REFERENCES Allen JG, Fonagy P, Bateman AW. Mentalizing in Clinical Practice. Arlington: American Psychiatric Pub; 2008. Asen E, Fonagy P. Mentalization-based therapeutic interventions for families. J Fam Ther. 2012;34(4):347–370. Bateman AW, Fonagy P. 8-Year follow-up of patients treated for borderline personality disorder: mentalization-based treatment versus treatment as usual. FOCUS. 2013;11(2):261–268. Bateman AW, Fonagy P. Mentalization-based treatment of BPD. J Person Disord. 2004;18(1):36–51. Brüne M, Dimaggio G, Edel MA. Mentalization-based group therapy for inpatients with borderline personality disorder: Preliminary findings. Clin Neuropsychiatry. 2013;10:196–201. Davis TS. A literature review exploring the potential of mindfulness as a tool to develop skills and qualities for effective consultation. Mindfulness. 2013;1–13. Hoffman CJ, Ersser SJ, Hopkinson JB Nicholls PJ, Harrington JE, Thomas PW. Effectiveness of mindfulness-based stress reduction in mood, breast-and endocrine-related quality of life, and well-being in stage 0 to III breast cancer: A randomized, controlled trial. J Clin Oncol. 2012;30(12):1335–1342. Kabat-Zinn J. Mindfulness-based interventions in context: Past, present, and future. Clin Psychol. 2013;10(2):144–156. Luyten P, Van Houdenhove B, Lemma A, Target M, Fonagy P. A mentalization-based approach to the understanding and treatment of functional somatic disorders. Psychoanal Psychother. 2012;26(2):121–140. Miller JJ, Fletcher K, Kabat-Zinn J. Three-year follow-up and clinical implications of a mindfulness meditation-based stress reduction intervention in the treatment of anxiety disorders. Gen Hospital Psychiatry. 1995;17(3):192–200. Newman CF, Beck AT. Cognitive therapy. In: Sadock BJ, Sadock VA, Ruiz P, eds. Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. 9th ed. Vol. 2. Philadelphia: Lippincott Williams & Wilkins; 2009:2857. Paulson S, Davidson R, Jha A, Kabat-Zinn J. Becoming conscious: the science of mindfulness. Ann N Y Acad Sci. 2013;1303(1):87–104. Shaheen L. Mindfulness-based therapies in the treatment of somatization disorders: A meta-analysis (P7. 305). Neurology . 2014;82(10 Supplement):P7–305. Slater P. Minding the child: Mentalization-based interventions with children, young people and their families. J Child Psychother. 2013;39(1):126–129.