Academic journal article American Journal of Psychotherapy

Mentalization and Dialectical Behavior Therapy

Academic journal article American Journal of Psychotherapy

Mentalization and Dialectical Behavior Therapy

Article excerpt

INTRODUCTION

Mentalization-based treatment (MBT) is a psychosocial treatment for borderline personality disorder (BPD) that has gathered significant support both in controlled research trials (Bateman & Fonagy, 1999, 2001, 2003, 2008, 2009) and in increasingly widespread application (Bateman & Fonagy, 2012). While MBT structures treatment around goals, agreements between therapist and patient, and crisis planning protocols, the defining feature and purported active ingredient in MBT is mentalization. Therapists adopt a curious, not-knowing stance, monitor attachment and mentalizing capacity, and use interventions aimed to restore or maintain the capacity of patients to mentalize. The MBT therapist shares a written case formulation with the patient that highlights the way in which problems with mentalizing were influenced by early attachments, have played a role in relationship patterns, and are likely to manifest in psychotherapy. Alongside the individual therapy, patients are provided psycho-education and structured exercises to bolster comprehension about mentalizing. Patients participate in group therapy during which they mentalize in order to to generalize their capacity.

Allen, Fonagy, & Bateman (2008) have claimed:

.. . we believe that therapists of all persuasions can benefit from a solid understanding of mentalizing and, furthermore, that patients also can benefit from this understanding-regardless of the type of treatment in which they are engaged. (p. 20; italics from the original)

Given that MBT is supported in controlled research trials, that it was originally designed for treating borderline personality disorder, and that the focus of MBT is the strengthening of capacities in the patient-all of which are features of dialectical behavior therapy (Linehan, 1993)- mentalizing may be of interest to DBT therapists.

Both MBT and DBT share some proximal aims: establish a secure attachment relationship in therapy, use empathy and validation in a reciprocal relationship, strengthen patient capacities to reduce emotional dysregulation and impulsive behaviors, and enhance self-awareness, attentional control, and flexible thinking in the contexts of emotions and relationships.

All of this is especially interesting given that MBT and DBT are derived from such different foundations. Mentalization-based treatment comes from psychoanalysis, attachment theory and research, and developmental psychopathology. Dialectical behavior therapy synthesizes acceptancebased approaches, behavioral science, and dialectical philosophy. Mentalization-based treatment has a more unitary focus than DBT, with MBT centering on an instability in mentalizing as the underlying problem in borderline personality. Dialectical behavior therapy does not posit an "underlying problem," but focuses on changing targeted behaviors with a range of strategies to address a range of controlling variables (Linehan, 1993). In this review we will define mentalizing and specify some of its essential facets, consider how the conceptual underpinnings of MBT might influence the importation of mentalizing into DBT, scan the packages of DBT strategies to see if mentalizing already exists in DBT and whether it would be compatible with DBT, and consider whether and how the DBT therapist and patient may benefit from a mentalizing focus.

WHAT IS MENTALIZING?

Mentalizing is surprisingly difficult to grasp, perhaps because it is so ordinary and ubiquitous-"the capacity that makes us human" (Allen, Fonagy, & Bateman, 2008)-yet named by an unfamiliar term. Further, a behaviorist might at first recoil from the frequent use of the term "mental states" since it sounds imprecise and as if it refers to hypothetical "mentalistic" entities. In fact it simply refers to constellations of cognitions, emotions, perceptions, and sensations that are activated in concert with one another. For instance, desires and intentions are "mental states. …

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