Playing with Reality or Playing outside Reality: Transitional and Defensive Pretend Mode in Therapy with Children

The theory of mentalization is about development of thinking about self, others, feelings, thoughts, and intentions, and how this thinking develops in the context of attachment relationship. The model describes how mentalization develops during childhood in stages from concrete undifferentiated thinking (teleological mode and psychic equivalence mode) to phantasy, creative thinking in pretend mode before integrating into mature affective mentalization. A long linage of clinicians has worked on the premise that through children’s play a more mature way of thinking and functioning can develop. In this article, we suggest, as many others have, that the stage of pretend mode is of special interest for psychotherapists, yet it has also been presented in MBT as a defensive mode. However, as child therapists we have experienced that pretend functioning through play has the potential for development and change. We argue that a differentiation of pretend mode into a transitional pretend mode, influenced by Winnicott’s term transitional space, and a defensive pretend mode could be clinically meaningful. We think this is a differentiation that could technically aid therapists. We propose that the quality of the relationship between therapist and patient provides information to discern the sort of pretend-state the child is in during therapeutic work. A way of grasping the quality of the relationship is through focusing on if there is a joint attention, how regulated the affect in the child and therapist is, and finally the symbolic meaningfulness the play holds, and if it has the potential to be mentalized.