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Improving Client Mentalizing as a Crisis Intervention Strategy
Who are "professionals in crisis," and how do they come to treatment?
The prototypical patient of the Professionals in Crisis program is a high-achieving individual who has attained significant educational and professional success as reflected in Global Assessment of Functioning (GAF) scores prior to the crisis that precipitated the admission. This prototypical patient is in his or her late 20s to mid-late 50s and presents a characteristic constellation of mutually reinforcing problems. Most typically, this constellation includes various combinations of the following psychiatric disorders: depression; bipolar disorder; anxiety disorder, including posttraumatic stress disorder; substance abuse and dependence; and personality disorders. Personality disorders in particular include narcissistic, histrionic, and compulsive personality, or personality disorder NOS with borderline, histrionic, narcissistic, paranoid, and/or compulsive features.
The treatment process
Enhancing mentalizing: How does one go about enhancing patients' capacity to mentalize? A critical precondition is establishing an environment where it is safe--and expected--to observe, label, and communicate internal states, including the associated physiological reactions, thus introducing a mentalizing perspective that links behavior to underlying mental states. The focus of interventions is generally on simple mental states, such as belief and desire, rather than making explicit links of feelings to dissociated or repressed experiences or to past events. Staff members invite patients to consider current, moment-to-moment changes in the person's mental states as they occur during rounds with the team, during group sessions with other peers, or during individual encounters with staff - including individual psychotherapy sessions. It is possible, for example, to focus the patients' attention on the circumstances that lead to aggression; on situations in which they feel misunderstood, blocked, or ignored by others; or those in which they are made to feel vulnerable. At the same time, staff members convey the perspective that gaining control over automatic reactions-including, in particular, automatic reactions that provide a momentary sense of safety and control--may actually help patients feel more in charge of their own lives and behavior. In this respect, the overall approach pursued in the program is a reversal of the classic psychoanalytic interventions. Psychoanalysis opens paths to the experiences of repudiated affect. In contrast, helping patients who are prone to inhibiting mentalizing in the face of threatening internal cues requires that they learn to use their ideational capacity to modulate their emotional experience. In individual and group interventions, patients are helped to understand which thoughts, interactions, and circumstances--both internal and environmental--result in their feeling certain affective states. Likewise, they receive help in learning to recognize what they say to themselves and the choices they make in terms of ignoring or approaching, communicating or concealing different aspects of their experience. During rounds, for example, a patient was helped to recognize that when she felt that her psychiatrist was dismissive of her concerns and so rushed that he hardly allowed her to finish her statements, she flew into a rage and thought about leaving the program instead of revealing how hurt and humiliated she felt by the perceived slight. Her choice was to conceal her hurt feelings and avoid her experience of vulnerability. The result of such choices is to put in jeopardy the possibility of her receiving help and to perpetuate the view of others as insensitive and indifferent.
Strengthening impulse control and enhancing self-regulation: Closely linked to the enhancement of a mentalizing perspective are the efforts to curb the impulsive, automatic, and/or addictive responses triggered by internal or interpersonal cues. A critical perspective conveyed through individual and group interventions--and explicitly discussed in the psychoeducational module--is the appreciation of the adaptive function of impulsive, automatic, and addictive patterns: These behavioral patterns indeed provide relief and a sense of control and safety. The choice to relinquish them is naturally fraught with uncertainty and anxiety and is difficult to entertain, particularly for people who have predicated much of their identity and adaptive success on their capacity to selectively disown vulnerability. Staff members thus seek to help patients give meaning to their understandable reluctance to give up patterns of coping and relating that cause pain and maladaptation, yet are the most effective mechanisms available to them to gain a sense of safety, control, and human connection. Such a perspective frees patients to examine the price they pay for relying on maladaptive patterns of coping and experiencing and coercive modes of relating. These examinations help undercover the therapeutic bargain at the heart of the treatment process: The patients' choice of relinquishing maladaptive, addictive, and coercive patterns of coping and relating--and the illusory sense of control, safety, and connection they derive from them--exposes them to unfamiliar dangers and vulnerabilities and requires a laborious and painful process of replacing illusory control and coercive relatedness with real mastery and meaningful attachments--a choice that calls for tremendous courage. An explicit recognition of their dilemma--the choices between unfamiliar, frightening, but potentially more adaptive responses--can actually exacerbate impulsive, addictive, coercive patterns by increasing the sense of vulnerability that triggers a retreat from mentalizing. In the throes of nonmentalizing functioning, patients require help to manage suicidal, parasuicidal, and other harmful or impulsive behaviors such as substance abuse or binge eating. It is crucial to appreciate the procedural nature of these addictive or otherwise nonmentalizing patterns, because procedural patterns can be modified only by procedural rather than by verbal-symbolic strategies. Thus patients are assisted in recognizing that they need to first "walk the walk" implied in a willingness to accept a structure designed to stop impulsive, addictive behavior, and only afterwards "talk the talk" involved in finding meaning and giving narrative coherence in their life story. Recognizing the need for procedural strategies to interrupt addictive, procedural patterns resolves an apparent paradox: A treatment program meant to support a sense of agency and self-regulation expects patients to accept the constraints of a structure that "bans" addictive behaviors and encourages attendance in 12-step support groups. The 12-step model calls for an acceptance of one's helplessness to control addictive patterns--as the first step to achieve sobriety--and real mastery. Enhanced impulse and symptom control can be promoted with psychoeducational interventions that communicate the procedural nature of eating disordered behavior, addictive patterns, posttraumatic reactions or overwhelming anxiety, all responses triggered by specific internal states or interpersonal cues. Crisis and relapse-prevention plans help define the triggers of procedural, impulsive, addictive, and coercive patterns and delineate steps that patients can take to curb such responses, enabling them to avoid "losing" the capacity to mentalize.
Promoting awareness of others' mental states
Through individual and group interventions, patients are encouraged to become aware of the mental states of others. The first aim is to show that all may not be as it seems to them, particularly under conditions when they feel vulnerable or threatened. Typically, however, patients actively resist such awareness, because it challenges their habitual patterns of experiencing and relating and threatens to expose them to feelings they find unbearable. Awareness of others' mental states is often promoted synergistically with the enhancement of mentalizing. Patients are encouraged to consider what it would be like if they were to report their own experience in a particular interaction and hear other persons share their perspective and explain where they are coming from. Individual psychotherapy sessions are particularly conducive to helping patients understand how therapists think about the internal states underlying behavior and the ways such understanding paves the way for reciprocal relationships--in treatment and beyond--particularly in the face of threatening internal and interpersonal cues. And "practicing" awareness of the mental states of staff and peers facilitates engaging in mentalizing exchanges within their families. The opportunities in treatment to take a playful, humorous, or "as if" stance are important steps in promoting mentalizing and the awareness of others' mental states. Play, humor, and pretend require holding in mind simultaneously two realities, the pretend and the actual, in synchronicity with a moment-to-moment reading of the other person's state of mind. Role-playing offers a way to "step back" from overwhelming, threatening, or unmanageable interpersonal exchanges and help pare them down into more manageable bits. But the key to ultimately setting up virtuous cycles that promote mentalizing is the capacity to align the individual's changes in mentalizing capacities with synergistic changes in his or her family context. The first step in helping families often involves exploring the stressors impinging on family members and the interactive patterns associated with inhibition of mentalization and triggering of coercive pattern of interaction. Reviewing interactions around specific core issues in marital or family sessions allows for the planning of new modes of interaction designed to break coercive cycles and promote mentalization. The patient and other family members often need individual coaching before they can engage in mentalizing interactions involving emotionally loaded or conflictual issues. The coaching is carried out in sessions designed to help family members with "the content and style of what is to be said, prepare for potential reactions by other participants, and solidify a mini-contract that challenges the participants to follow through as planned once the interaction begins" (Liddle & Hogue, 2000, p. 274). The preparatory coaching focuses on enabling family members to appreciate others' point of view and to become clear about their own perspective and motivation, which encourages less extreme and rigid positions. By processing in advance interactions that habitually result in the loss of mentalizing, family members can take a first step toward restoring it.
Using attachments to move toward integration
Meaningful attachments between patients and staff members develop in the context of intensive work designed to help patients mentalize, achieve more effective means for self-regulation, and become aware of others. The stirrings of a growing attachment serve to rekindle hope that help and support can be derived from human connections. These stirrings also trigger increased anxiety and defensiveness as internal states associated with attachment, such as dependency and vulnerability, also signal danger (Allen, 2001; Bleiberg, 2001; Fonagy et al., 2002). Relationships within the treatment program thus become a crucial arena in which dysfunctional patterns of experiencing, coping, and relating come to life in full force. Yet staff members do not seek to interpret the patient's transference in the classic sense of exploring how specific thoughts, feelings, wishes, fantasies, fears, and conflicts are "transferred" from important figures in the patient's past to the contemporary relationships. Instead, the relationships with staff members are central because they provide a relatively controlled route to initiating the development of the capacity to sustain mentalizing functioning in the context of a significant attachment relationship.
- Bleiberg E,Treating professionals in crisis: a framework focused on promoting mentalizing; Bulletin Of The Menninger Clinic, 2003 Summer, Vol. 67, Issue 3
Reflection Exercise #11
The preceding section contained information about improving client mentalizing as a crisis intervention strategy. Write three
case study examples regarding how you might use the content of this section in
What are the four steps in the Professionals in Crisis program? To select and enter your answer go to .