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ABSTRACT
Disturbances of mentalization have been increasingly associated with the symptoms and functional impairment of people with psychotic disorders. It has been proposed that psychotherapy designed to foster self and other understanding such as mentalization-based treatment (MBT), may p lay an important part in facilitating recovery from psychosis. Here, we present an attachment-based understanding of mentalization impairments. We then outline a neuropsychological model that links disruptions of mentalization associated with disturbances in the caregiving environment to the pathophysiology of psychosis in genetically at-risk individuals. This is followed by an illustration of some of the core MBT techniques for the rehabilitation of the capacity to mentalize as applied to the treatment of a patient with a psychotic disorder.
INTRODUCTION
Impaired mentalization (i.e., the capacity to think about mental states in the self and others) is increasingly regarded as an important psychopathological domain in people with psychotic disorders (1-3). Because psychotic symptoms frequently involve misunderstandings of social situations (e.g., persecutory delusions and hallucinations), or of the persons self-appraisal with respect to other people (e.g., grandiose or religious delusions), it has been proposed that the disruption of the capacity for social understanding may constitute a key vulnerability to psychosis (4). This hypothesis has received support from studies showing associations between mentalization deficits (e.g., impaired theory of mind [ToM]) and core psychotic symptoms, such as delusions and hallucinations (5). Moreover, growing evidence links aberrant mentalization to the social dysfunction (e.g., inability to work, poor quality of life) that commonly accompanies psychosis (6). The strength of the relationship between impaired mentalization and the socially disabling effects of psychosis is highlighted by a recent meta-analysis that showed that ToM impairments exhibited the strongest association with social dysfunction in schizophrenia of any social or neurocognitive domain tested (7).
One question raised by these findings is whether psychotherapy focusing on deficits of social understanding, such as mentalization-based treatment (MBT), can facilitate the recovery of patients with psychosis. Closely related to MBT is metacognitive psychotherapy (8, 9), which targets deficits of "thinking about thinking" in schizophrenia. Metacognition and mentalization have been linked theoretically and empirically, as both involve meta-representational abilities (10). Typically, metacognition is closely associated with self-monitoring ones cognitive performance (e.g., evaluating how well one has learned the material for a...