Table Of ContentMentalizing
in Clinical Practice
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Mentalizing
in Clinical Practice
Jon G. Allen, Ph.D.
Helen Malsin Palley Chair in Mental Health Research and Professor of Psychiatry,
Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of
Medicine, Houston, Texas
Peter Fonagy, Ph.D., FBA
Freud Memorial Professor of Psychoanalysis and Director of the Sub-Department of
Clinical Health Psychology, University College London; Chief Executive of the Anna
Freud Centre, London, England
Anthony W. Bateman, M.A., FRCPsych
Consultant Psychiatrist in Psychotherapy, Halliwick Unit, St. Ann’s Hospital, Barnet,
Enfield, England, and Haringey Mental Health Trust
Washington, DC
London, England
Note: The authors have worked to ensure that all information in this book
is accurate at the time of publication and consistent with general psychiatric
and medical standards. As medical research and practice continue to ad-
vance, however, therapeutic standards may change. Moreover, specific sit-
uations may require a specific therapeutic response not included in this
book. For these reasons and because human and mechanical errors some-
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Copyright © 2008 American Psychiatric Publishing, Inc.
ALL RIGHTS RESERVED
Manufactured in the United States of America on acid-free paper
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Library of Congress Cataloging-in-Publication Data
Allen, Jon G.
Mentalizing in clinical practice / Jon G. Allen, Peter Fonagy, Anthony W.
Bateman. — 1st ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-58562-306-8 (alk. paper)
1. Psychotherapy. 2. Mental healing. 3. Self-perception. I. Fonagy, Peter,
1952- II. Bateman, Anthony. III. Title.
[DNLM: 1. Awareness. 2. Psychotherapy—methods. 3. Psychoanalytic
Theory. 4. Social Behavior. 5. Social Perception. WM 420 A427m 2008]
RC480.5.A454 2008
′
616.8914—dc22
2007044458
British Library Cataloguing in Publication Data
A CIP record is available from the British Library.
Contents
About the Authors. . . . . . . . . . . . . . . . . . . . . . . . . . . .vii
Foreword
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ix
Stuart C. Yudofsky, M.D.
Preface
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xvii
1
Introduction
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1
PART I
Understanding Mentalizing
2
Mentalizing
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .25
3
Development
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .73
4
Neurobiology
. . . . . . . . . . . . . . . . . . . . . . . . . . . . .113
PART II
Practicing Mentalizing
5
The Art of Mentalizing
. . . . . . . . . . . . . . . . . . . . . . 149
6
Mentalizing Interventions
. . . . . . . . . . . . . . . . . . . . . 163
7
Treating Attachment Trauma
. . . . . . . . . . . . . . . . . . . 211
8
Parenting and Family Therapy
. . . . . . . . . . . . . . . . . . 239
9
Borderline Personality Disorder
. . . . . . . . . . . . . . . . . 259
10
Psychoeducation
. . . . . . . . . . . . . . . . . . . . . . . . . . . 293
Appendix: What Is Mentalizing and Why Do It?
. . . . 311
11
Social Systems
. . . . . . . . . . . . . . . . . . . . . . . . . . . . 323
Epilogue
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 341
John M. Oldham, M.D., M.S.
Glossary
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 347
References
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 351
Recommended Reading
. . . . . . . . . . . . . . . . . . . . . . 389
Index
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 391
About the Authors
Jon G. Allen, Ph.D., holds the positions of Helen Malsin Palley Chair in
Mental Health Research and Professor of Psychiatry in the Menninger
Department of Psychiatry and Behavioral Sciences at the Baylor College
of Medicine, and Senior Staff Psychologist in The Menninger Clinic,
Houston, Texas. He conducts psychotherapy, diagnostic consultations,
psychoeducational programs, and research, specializing in trauma-
related disorders and depression. He is past editor of the Bulletin of the
Menninger Clinic, associate editor of the Journal of Trauma and Dissocia-
tion, and a member of the editorial board of Psychiatry; he also serves as
a reviewer for several professional journals and book publishers. He
has authored and co-authored numerous professional articles and book
chapters on trauma-related problems, depression, psychotherapy, hos-
pital treatment, the therapeutic alliance, psychological testing, neuro-
psychology, and emotion. Previous books he has authored, co-authored,
or co-edited include Traumatic Relationships and Serious Mental Disorders;
Coping With Trauma: Hope Through Understanding; Coping With Depres-
sion: From Catch-22 to Hope;Diagnosis and Treatment of Dissociative Disor-
ders (with William Smith); Borderline Personality Disorder: Tailoring the
Treatment to the Patient (with Leonard Horwitz, Glen Gabbard, and col-
leagues); Restoring Hope and Trust: An Illustrated Guide to Trauma (with
Lisa Lewis and Kay Kelly); and the Handbook of Mentalization-Based
Treatment (with Peter Fonagy).
Peter Fonagy, Ph.D., FBA, is Freud Memorial Professor of Psychoanalysis
and Director of the Sub-Department of Clinical Health Psychology at
University College London; Chief Executive of the Anna Freud Centre,
vii
viii Mentalizing in Clinical Practice
London; and Consultant to the Child and Family Program at the Men-
ninger Department of Psychiatry and Behavioral Sciences at the Baylor
College of Medicine. He is Chair of the Postgraduate Education Com-
mittee of the International Psychoanalytic Association and a Fellow of
the British Academy. He is a clinical psychologist and a training and su-
pervising analyst in the British Psycho-Analytical Society in child and
adult analysis. His work integrates empirical research with psychoana-
lytic theory, and his clinical interests center around borderline psychopa-
thology, violence, and early attachment relationships. He has published
over 300 chapters and articles and has authored or edited several books.
His most recent books include Psychoanalytic Theories: Perspectives From
Developmental Psychopathology (with Mary Target); What Works for Whom?
A Critical Review of Psychotherapy Research (with Anthony Roth); Psycho-
therapy for Borderline Personality Disorder: Mentalization-Based Treatment
(with Anthony Bateman); Mentalization-Based Treatment for Borderline
Personality Disorder: A Practical Guide (also with Anthony Bateman);
Reaching the Hard to Reach: Evidence-Based Funding Priorities for Interven-
tion and Research (with Geoffrey Baruch and David Robins); and Hand-
book of Mentalization-Based Treatment (with Jon Allen).
Anthony W. Bateman, M.A., FRCPsych,is Consultant Psychiatrist in Psy-
chotherapy, Halliwick Unit, St. Ann’s Hospital, Barnet, Enfield, and
Haringey Mental Health Trust; Visiting Professor, University College
London; and Visiting Consultant, The Menninger Clinic and the Men-
ninger Department of Psychiatry and Behavioral Sciences at the Baylor
College of Medicine. In collaboration with Peter Fonagy, he has devel-
oped mentalization-based treatment for personality disorder and is
conducting clinical research trials on its effectiveness. He is an expert
member of the National Institute for Clinical Excellence (NICE) devel-
opment group for treatment guidelines for borderline personality dis-
order in the United Kingdom. He has authored numerous research
articles and book chapters on personality disorder and the use of psy-
chotherapy in psychiatric practice. His several books include Psycho-
therapy for Borderline Personality Disorder: Mentalization-Based Treatment
and Mentalization-Based Treatment for Borderline Personality Disorder: A
Practical Guide, both co-authored with Peter Fonagy.
Disclosure of Interests: The authors of this volume have no competing
interests to declare.
Foreword
The Ox Cart
An ancient philosophical riddle asks the following question: “What is
the most important part of an ox cart?” Most people answer, “The wheel.”
“The ox.” “The cart.” “The driver.” “The axles.” “The apparati connect-
ing the ox to the cart,” etc. One seasoned psychoanalyst even quipped,
partially in jest, “The whip.” The answer to this riddle that I prefer is,
“The concept of an ox cart.” I believe that this is, by far, the best answer
to the riddle, because the answer demonstrates how important and how
powerful concepts can be—even if concepts are unable to be seen, pal-
pated, or imaged with MRI.
A related question is, “What, among the vast universe of concepts,
makes a particular concept potent or valuable?” I propose that there are
four elements that measure the merit of a concept: 1) the clarity of its def-
inition; 2) its utility; 3) its longevity; and 4) its elaboration into future
concepts. Applying these four elements to the ox cart: the concept of
joining a pair of wheels to a pair of axles, fastening these to a wooden
box, and then attaching the wheeled box to an ox is clearly defined (ele-
ment #1); of obvious use for transportation of people and goods (element
#2); and after 3,000 years since its initial conceptualization, remains in
use to this very day in many parts of the world (element #3). Further, the
ox cart has evolved into more potent concepts (element #4)—such as the
automobile and truck, which, like the ox cart, are four-wheeled vehicles
for transportation of humans and material goods, with the power source
in the front and a seated human responsible for the guidance. Note that
I do not propose that “originality” and “novelty” are requisite measures
ix
