Mentalization and Psychosis: A Rationale for the Use of Mentalization Theory to Understand and Treat Non-affective Psychotic Disorder

This paper considers whether the psychotic illness of a mother impacts on the development of the mentalizing capacity of her offspring and the consequences this may have for clinical practice as a child psychotherapist. It focuses on the current theoretical understanding that the secure state of mind of a mother with respect to attachment, as well as her mentalizing ability, influences the development of the child's mentalizing skills. After summarizing and evaluating evidence associated with the attachment behaviour and mentalizing capacity of a psychotic mother, the paper gives evidence that there is a strong association between mothers on the psychotic continuum and insecure-avoidant or disorganized attachment behaviour and impairment of the reflective function. This puts the infant at elevated risk of not fully developing mentalizing abilities. The issue of acquiring hypermentalization or undermentalization patterns is highlighted. In clinical practice, marked mirroring and transparency about the therapist's mental state allow the client to feel seen and to discover his or her own inner experiences in relation to external reality.

Research using the integrated model of metacognition has suggested that the construct of metacognition could quantify the spectrum of activities that, if impaired, might cause many of the subjective disturbances found in psychosis. Research on social cognition and mentalizing in psychosis, however, has also pointed to underlying deficits in how persons make sense of their experience of themselves and others. To explore the question of whether metacognitive research in psychosis offers unique insight in the midst of these other two emerging fields, we have offered a review of the constructs and research from each field. Following that summary, we discuss ways in which research on metacognition may be distinguished from research on social cognition and mentalizing in three broad categories: (1) experimental procedures, (2) theoretical advances, and (3) clinical applications or indicated interventions. In terms of its research methods, we will describe how metacognition makes a unique contribution to understanding disturbances in how persons make sense of and interpret their own experiences within the flow of life. We will next discuss how metacognitive research in psychosis uniquely describes an architecture which when compromised – as often occurs in psychosis – results in the loss of persons’ sense of purpose, possibilities, place in the world and cohesiveness of self. Turning to clinical issues, we explore how metacognitive research offers an operational model of the architecture which if repaired or restored should promote the recovery of a coherent sense of self and others in psychosis. Finally, we discuss the concrete implications of this for recovery-oriented treatment for psychosis as well as the need for further research on the commonalities of these approaches.

W ostatnich latach wzrasta świadomość, jak ważne są wczesne rozpoczęcie leczenia psychozy i podejmowanie interwencji prewencyjnych, w których coraz większą rolę odgrywa psychoterapia. Skuteczność psychoterapii w zapobieganiu progresji choroby od prodromu do pierwszego epizodu jest podobna do skuteczności farmakoterapii. Najwięcej danych otrzymano w odniesieniu do terapii poznawczo-behawioralnej, chociaż w psychoterapii zaburzeń z kręgu schizofrenii znajdują zastosowanie również inne, coraz liczniejsze podejścia terapeutyczne. Istotnym elementem prewencji jest też zajmowanie się objawami i trudnościami związanymi z doświadczeniami urazowymi, przykładowo użycie metod terapii skoncentrowanych na traumie. Pierwszy epizod psychozy to czas, kiedy intensywne programy wczesnej interwencji przynoszą najwięcej korzyści. Programy te obejmują różne formy oddziaływań terapeutycznych, a farmakoterapia nie zawsze jest niezbędna. Pojawiają się coraz to nowe doniesienia na temat stosowania w pierwszym epizodzie psychozy terapii indywidualnej różnych modalności: terapii poznawczo-behawioralnej, terapii "trzeciej fali"-terapii opartej na uważności (mindfulness-based therapy for psychosis, MBT) oraz terapii akceptacji i zaangażowania (acceptance and commitment therapy, ACT), a także terapii bazujących na koncepcji metapoznania. Według licznych doniesień interwencje rodzinne wyraźnie zmniejszają ryzyko nawrotów i ponownej hospitalizacji we wczesnej psychozie. Istotnym i rozwijającym się obecnie obszarem badań jest znaczenie traumy-również traumy związanej z samą chorobą i leczeniem-w pierwszym epizodzie psychozy. Rozpoznawanie i leczenie objawów traumy nastręcza profesjonalistom trudności, co wynika z niewystarczającego szkolenia i braku zaleceń klinicznych. Słowa kluczowe: wczesna psychoza, ryzyko zachorowania, schizofrenia, trauma, psychoterapia Recent years have witnessed a growing awareness of the importance of early treatment of psychosis and preventive interventions, in which psychotherapy plays an increasing role. The effectiveness of psychotherapy in preventing disease progression from prodromes to the first episode is similar to that of pharmacotherapy. The majority of collected data refer to cognitive behavioural therapy, although other, increasingly numerous therapeutic approaches are also used in the treatment of schizophrenic disorders. Dealing with the symptoms and difficulties associated with traumatic experiences, e.g. by using trauma-focused therapeutic methods, is also an important element of prevention. The first episode of psychosis is the time when intensive programs of early intervention bring the most benefit. These programs encompass various forms of therapeutic interventions, and pharmacotherapy is not always necessary. There is a growing number of reports on the use of different modalities of individualised therapy, such as cognitive behavioural therapy, "third wave therapy"-mindfulnessbased therapy for psychosis (MBT), acceptance and commitment therapy (ACT), as well as metacognitive therapies, in the first...