Mentalization Psychotherapy for Patients Presenting with a Psychotic Personality Structure: A Contemporary Approach

Overt psychotic symptoms, currently understood as resulting from both neurobiological and developmental etiological factors, are also associated with deficits in mentalization in a subgroup of patients presenting with psychotic personality structure. Neurodevelopmental and traumatic impairments seen in this subtype of psychotic disorders create a pressure or need for what has been called a transformational mentalizing process. This specific form of mental elaboration focuses explicitly on finding words and images that help patients to grasp their emotional and mental states. It thus differs from mainstream mentalization treatment, which puts a greater emphasis on reflective functioning. A psychodynamically informed mentalization-based individual and group psychotherapy for this subgroup of patients was developed, aiming at augmenting the patient's psychological resources through explicit transformational mentalization, rather than primarily targeting symptom reduction. This program stimulates curiosity about one's mental states, progressively aiming to give shape to and explore affectively charged mental states, and is integrated with other treatment modalities. This article presents a psychological model of psychotic personality structure and its psychotherapeutic implications, as well as clinical illustrations. Preliminary findings from a pilot study provide encouraging support for the model, including emerging reflective capacities and symptom reduction, as well as overall improvement of social and occupational functioning.