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Mentalization-based treatment for borderline and antisocial personality disorder
Mentalization-based treatment for borderline and antisocial personality disorder
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Anthony Bateman1 and Peter Fonagy2 1 University College London, London, United Kingdom, 2Research Department of Clinical, Educational and Health Psychology, University College London, London, United Kingdom
Mentalizing is the ability to understand actions of other people and oneself according to underlying mental states, that is, through recognizing thoughts, feelings, wishes, and desires as being intentional. It is a very human capability that underpins everyday interactions (Allen, Bleiberg, & Haslam-Hopwood, 2003; Fonagy, Gergely, Jurist, & Target, 2002). Trying to understand other people’s behavior in terms of mental states contrasts with understanding others’ and one’s own actions through their consequences in the physical world: we are what we do. For instance, I see someone drop something, so he or she meant to do so. Similarly, I did something, so I must have wanted to do it. Mentalizing is not an entirely stable, consistent, or one-dimensional process. People are not all able to mentalize to the same extent. Many of us have strengths or weaknesses in particular aspects of mentalizing, and most people are more likely to struggle to mentalize in moments of stress or anxiety. We can all act according to mistaken beliefs about others’ mental states, leading to everyday misunderstandings, difficulties, and social faux pas. In addition, problems in mentalizing are the common factor in many psychiatric disorders (Bateman & Fonagy, 2012), particularly personality disorders.
The multidimensional nature of mentalizing Mentalizing is not an all-or-nothing phenomenon. It ranges from full and effective mentalizing through ineffective mentalizing to nonmentalizing. In daily life, people’s ability to mentalize fluctuates, and people with personality disorders may show excellent mentalizing at times. The mentalizing model of borderline personality disorder (BPD) and antisocial personality disorder (ASPD) is not a deficit model. It is a model of vulnerability to imbalance and instability in mentalizing. It provides a comprehensive account of the phenomenology and origins of BPD and ASPD from a developmental perspective and informs clinicians how to target in treatment the mentalizing vulnerability that is hypothesized to be at the core of the disorders (Fonagy & Bateman, 2007, 2008). People with BPD show greater Contemporary Psychodynamic Psychotherapy. DOI: https://doi.org/10.1016/B978-0-12-813373-6.00009-X © 2019 Elsevier Inc. All rights reserved.
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propensity than others to lose mentalizing in interpersonal interactions and in a wider range of situations, they experience nonmentalizing for longer periods, and they find it more difficult to regain mentalizing once it has been lost. People with ASPD show similar mentalizing instability but also demonstrate a persistent imbalance of mentalizing in cognitive affective process, with cognitive mentalizing of both self and other dominating affective mentalizing.
Neurobiology of mentalizing Neuroscience has identified four distinct components to mentalizing (Luyten & Fonagy, 2015), which are organized into dimensions that are helpful for therapists to identify in the clinical practice of mentalization-based treatment (MBT). These dimensions are automatic versus controlled mentalizing; mentalizing the self versus others; mentalizing with regard to internal versus external features; and cognitive versus affective mentalizing. These are not dimensions in the normal understanding of the term. They link on the basis of joint function. To mentalize effectively requires an individual not only to be able to maintain a balance across the dimensions of mentalizing, but also to apply the dimensions appropriately according to context. Consistent favoring of one or other side (or pole) of a dimension leads to distorted understanding of the mental states of oneself or others, which can be associated with profound social and emotional difficulties (Fonagy, Luyten, & Bateman, 2015). Commonly, one or more of the dimensions is relatively neglected at one end, and consequently, the opposite pole comes to dominate social cognition. For example, overly emotional thinking emerges in the absence of cognitive mentalizing. Clinically, the patient seems to be dominated by affective process and emotionally driven decision making, yet the problem can be due to the loss of cognitive processing systems. As another example, if the patient’s subjective experience of selfstates is reduced, the influence of others dominates and the patient becomes vulnerable to exploitation. From this perspective, different types of psychopathology can be distinguished on the basis of different combinations of impairments on the four dimensions. In other words, personality disorders (and, to some extent, other psychiatric disorders) can be understood according to their characteristic mentalizing profiles.
Automatic versus controlled mentalizing The most fundamental dimension to mentalizing is the spectrum between automatic (or implicit) and controlled (or explicit) mentalizing. Controlled mentalizing reflects a serial and relatively slow process, which is typically verbal and demands reflection, attention, awareness, intention, and effort. The balancing pole of this dimension—automatic mentalizing—involves much faster processing, tends to be reflexive, and requires little or no attention, awareness, intention, or effort.
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Mentalizing the self versus others This mentalizing dimension involves the capacity to mentalize one’s own state— the self (including one’s own physical experiences)—and/or the state of others. The two are closely connected, and an imbalance signals vulnerability in mentalizing others and/or the self. People with mentalizing difficulties are likely to preferentially focus on one end of the spectrum. Individuals with BPD tend to be highly sensitive to others and vulnerable to others’ states of mind; individuals with ASPD show sudden switches from being more other-directed to defending the self from disorganizing shame.
Internal versus external mentalizing Mentalizing involves making inferences on the basis of the external indicators of a person’s mental states (e.g., facial expressions, tone of voice, body posture) or working out someone’s internal experience from what one knows about the other person and the situation and feeling state the other person is in. People with BPD and ASPD focus more on external than internal indicators.
Cognitive versus affective mentalizing Cognitive mentalizing involves the ability to name, recognize, and reason about mental states (in oneself and others), whereas affective mentalizing involves the ability to experience and understand associated feelings, again, in oneself or others. Both need to be integrated for any genuine experience of empathy or true sense of self-coherence.
Dimensional mentalizing profile characteristic of BPD and ASPD Individuals with BPD and ASPD easily find themselves switching to persistent automatic mentalizing. Stress and arousal, especially in an attachment context, bring automatic mentalizing to the fore and disengage the neural systems that are associated with controlled mentalizing. Under these conditions, interactions become nonquestioning precisely when they need to be more controlled and contextualized. Thinking becomes impulsive; the individual makes assumptions about others’ thoughts and feelings that are not reflected upon or tested. Logic is intuitive, unreasoned, and nonverbal. As a consequence, patients may be overly distrustful (paranoid) or, in BPD, sometimes overly trustful (naive). Patients with BPD may show excessive concern about their own internal state; that is, they hypermentalize in relation to the self without having an awareness of how others perceive them. In contrast, patients with ASPD tend to avoid selfscrutiny and hypermentalize about others. Failure to balance self-perception with
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sincere curiosity about how one is perceived by others (people with ASPD do not care how others perceive them) can lead to exaggeration of the self-image in either a positive (more common in ASPD) or a negative (more common in BPD) direction. A balanced, adaptive form of self-mentalizing conditioned by the social context is absent. Patients with BPD and ASPD pay more attention to external indicators of mental states, and their initial ideas, arising from automatic mentalizing, go unchecked by controlled, reflective mentalizing. For example, if the clinician looks out of the window, to the patient this means that the clinician is not taking the patient seriously. A focus on external features, in the absence of reflective mentalizing, renders an individual highly vulnerable in social contexts, as it generates interpersonal hypersensitivity and hypervigilance.
The reemergence of nonmentalizing modes in BPD and ASPD While the dimensions of mentalizing can reflect anomalies in terms of mechanisms, the clinician experiences the outcomes of these malfunctions as nonmentalizing modes. These are grouped into three typical modes of subjectivity: psychic equivalence mode, teleological mode, and pretend mode (Fonagy & Bateman, 2008). The nonmentalizing modes are important for the clinician to recognize and understand, as they tend to emerge in the consulting room and reflect core aspects of the patient’s experience. It is important to address them because they cause considerable interpersonal difficulties and result in destructive behaviors. In general terms, nonmentalizing modes fluctuate in BPD and are more persistent in ASPD. Newbury-Helps, Feigenbaum, and Fonagy (2017) found a range of mentalizing problems in people with ASPD, which were more pronounced in offenders than in nonoffenders.
Psychic equivalence mode In the psychic equivalence mode, thoughts and feelings become “too real” to a point at which it is extremely difficult for the patient to entertain possible alternative perspectives. What thought is experienced as being real and true, leading to concreteness of thought; that is, thoughts are treated as facts. Patients with BPD and ASPD who are in this mode describe an overriding sense of certainty about their beliefs; for example, “the therapist does not like me” or “I am a wicked person.” These thoughts and beliefs cannot be argued with.
Teleological mode In the teleological mode, states of mind are recognized and believed only if their outcomes are physically observable. Hence, the individual can recognize the
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existence and potential importance of states of mind, but this recognition is limited to physical indicators. For example, affection is perceived to be real only if it is accompanied by a touch or caress. A patient with BPD, describing a recent incident in which her partner failed to respond to a text message, may say that her partner’s nonresponse to the message “means that he does not love me.” In ASPD, teleological function is often engrained in how others’ motives are understood (you are what you do); for instance, someone who does not step aside in the street has malevolent intent with determination to dominate and challenge. The teleological mode is apparent in patients who are imbalanced toward the external pole of the internal external mentalizing dimension. They are heavily biased toward understanding how people (and they themselves) behave and what their intentions may be in terms of what they actually do.
Pretend mode In the pretend mode, thoughts and feelings become severed from reality. Taken to an extreme, this may lead to feelings of derealization and dissociation. Patients in pretend mode can discuss experiences without contextualizing them in any kind of physical or material reality, as if they were creating a pretend world. The patient may hypermentalize or pseudomentalize, a state in which the patient is overly focused on internal self-states and may say much about states of mind but with little true meaning or connection to reality. In ASPD the focus on self-states may, paradoxically, be about others’ motives, with self-serving justification of violent or threatening behavior, for example. Attempting psychotherapy with patients who are in this mode can lead to lengthy but inconsequential discussions of internal experience that have no link to genuine experience and will achieve no change. In summary, imbalances within the dimensions of mentalizing predictably generate the nonmentalizing modes. Psychic equivalence is inevitable if emotion (affect) dominates cognition. Teleological mode follows from an exclusive focus on external features to the neglect of the internal. Pretend mode thinking and hypermentalizing are unavoidable if reflective, explicit, controlled mentalizing is not well established.
Attachment It is a central tenet of the mentalization-based approach that a sense of self and the capacity to mentalize both develop in the context of attachment relationships (Fonagy & Luyten, 2018). In patients with BPD and ASPD there is a common history of early (in particular emotional) neglect, a disrupted early social environment, and abusive or even brutalized family relationships. These may contribute to undermining the ability of some individuals to develop full mentalizing capacities. Subsequent adversity or trauma may disrupt mentalizing further, in part as an adaptive maneuver on the part of the individual to limit exposure to a dehumanizing
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psychosocial environment and in part because the high level of arousal generated by attachment hyperactivation and disorganized attachment strategies serve to disrupt less well-practiced and less robustly established higher cognitive capacities. In addition, genetic influences may be expressed through the mediation of mentalizing. In summary, the mentalizing model points to a final common developmental pathway that a range of biological, family, and broader social contextual influences may take to generate the range of difficulties that are normally considered under the term personality disorder (Fonagy et al., 2015).
Epistemic trust The most recent theoretical developments in our thinking about mentalizing and therapeutic change have important implications for how we approach our clinical practice. This new thinking involves the theory of epistemic trust. In short, this theory emphasizes the social and emotional significance of the trust we place in the information about the social world that we receive from another person—that is, the extent and ways in which we are able to consider social knowledge as genuine and personally relevant to us. The development of epistemic trust goes hand in hand with attachment processes, with the bond of secure attachment opening up trust in others to facilitate learning from them, whereas the interaction in insecure and disorganized attachment reduces this capacity. Our view is that in BPD and ASPD this process has been compromised. For further discussion of this view, see Fonagy, Luyten, and Allison (2015).
The evidence base for MBT from outcome research Research has been integrated with MBT from its inception. Randomized controlled trials (RCTs) have tested the effectiveness of MBT in BPD, ASPD, eating disorders, and self-harming adolescents with borderline features. In an early RCT of MBT for BPD in a partial hospital setting in the United Kingdom (Bateman & Fonagy, 1999, 2001), an 18-month program was associated with significant and enduring improvements in self-destructive behavior, mood states, and interpersonal functioning, and reduction in service use. Treatment for BPD showed considerable cost savings after treatment (Bateman & Fonagy, 2003), and an 8-year follow-up found that patients who had received MBT remained better than the control group, who had received treatment as usual (TAU) (Bateman & Fonagy, 2008). Two well-controlled single-blind randomized trials of outpatient MBT have been conducted in the United Kingdom, with adults with BPD (Bateman & Fonagy, 2009) and adolescents presenting to clinical services with self-harm, the vast majority of whom met BPD criteria (Rossouw & Fonagy, 2012). In the latter trial the participants received a form of MBT designed for adolescents (MBT-A). In both trials
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MBT proved superior to TAU in reducing self-harm (including suicidality) and depression. Improvement was mediated by improved levels of mentalizing, reduced attachment avoidance, and reduction in features of BPD. Three more recent studies provided further support for MBT in patients with BPD. An RCT in Denmark investigated the efficacy of MBT versus a less intensive, manualized supportive group therapy, both delivered in combination with psychoeducation and medication, for patients diagnosed with BPD (Jørgensen et al., 2013). In another study in Denmark (Petersen et al., 2010) a cohort of patients treated with partial hospitalization followed by MBT group therapy showed significant improvements after 2 years on a range of measures, with further improvement at 2-year follow-up. A naturalistic study by Bales et al. (2012) in the Netherlands showed moderate to large effect sizes at the end of treatment and, when the authors used a matched control design, found that MBT had larger effect sizes than other specialized psychotherapeutic treatments (Bales et al., 2015). Another naturalistic trial in the Netherlands studied the feasibility and effectiveness of inpatient MBT-A in 11 female adolescents aged 14 18 years with borderline symptoms (Laurenssen et al., 2014). Results showed significant decreases in symptoms and improvements in personality functioning and quality of life 12 months after the start of treatment. Better outcomes for people with ASPD receiving MBT compared with TAU have led to a definitive multicenter trial in the United Kingdom (Bateman, O’Connell, Lorenzini, Gardner, & Fonagy, 2016). Finally, an RCT comparing MBT with specialist supportive clinical management in the treatment of adults with eating disorders and impulsive BPD traits has been reported in the United Kingdom (Robinson et al., 2016). Both interventions achieved reductions in eating disorder symptoms, but MBT was associated with greater reductions in shape concern and weight concern.
The clinical approach in mentalization-based treatment MBT is operationalized as combined individual and group therapy, although it is now often delivered in one mode alone. The evidence-based program for BPD was organized as weekly individual and group therapy for a period of 18 months. MBT for ASPD consists of weekly group therapy, with an individual session at the request of the clinician or patient a maximum of once a month, for a period of 1 year. MBT requires the clinician to develop a treatment frame and milieu that facilitate epistemic trust. To do so, the clinician focuses on contingent and marked mentalizing of the patient’s internal states, because feeling mentalized is the most potent ostensive cue. The patient’s interpersonal processes and current life events form the content of this process. Initially, MBT takes a directive and informative approach (Bateman & Fonagy, 2016). MBT requires the clinician and patient to do the following: 1. Collaboratively develop a formulation early in the assessment process (see later, in the section “Collaborative process and formulation”).
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2. Identify mentalizing vulnerabilities in terms of dimensional rigidity and nonmentalizing modes, using examples that are personal to the patient. Pathways to the loss of mentalizing are identified and established as vulnerability points to be monitored carefully. 3. Discuss the diagnosis in terms of the patient’s symptoms and history. The diagnosis is less important than agreeing on a lens through which the variability of symptoms can be understood. 4. Map attachment patterns and how they play out in current relationships. The identification of attachment strategies is essential if the patient and clinician are to recognize their deployment during treatment and in the patient’s interpersonal interactions. 5. Engage the patient in an introductory phase that combines psychoeducation with some interpersonal process. The MBT-Introductory group (Bateman & Fonagy, 2016) offers the patient and clinician a shared framework for understanding BPD and the whole process of therapy. 6. Establish a developmental narrative of problems. The patient’s background and context support a compassionate view of the problems. 7. Jointly agree on goals that are relevant to the patient so that therapy is about what is important to the patient. To this end, MBT for ASPD asks the patient and clinician to work together, identifying the patient’s current and hoped-for values, to ensure that the patient does not experience therapy as imposition of the therapist’s, or an establishment, value system.
In essence, we suggest that the explanations and suggestions and the process of developing a value-driven clinical agreement in the initial phase of therapy are ostensive cues that signal to the patient the relevance to them of the information that is being conveyed. These serve to trigger in the patient a feeling of being personally recognized by the clinician in the therapeutic situation. MBT is structured, organized around the development of an attachment relationship with the patient, offers a careful focus on the patient’s internal mental processes as they are experienced moment by moment, and emphasizes the therapeutic alliance, with the active repair of ruptures in the relationship between patient and clinician.
Principles The clinician follows a number of principles that are framed to increase mentalizing and to prevent iatrogenic reduction of mentalizing. These are listed in Box 9.1 and discussed in detail in Bateman and Fonagy (2016).
Collaborative process and formulation The formulation is predominantly a collaborative clinical agreement. It is written by the clinician and shared with the patient, and is regularly revised as new understandings develop. It is important that the patient recognizes himself or herself within the formulation. It is written from a positive perspective with the patient’s strengths emphasized. It includes information from some of the domains identified below, expressed in terms of developmental vulnerabilities (e.g., “It is
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Box 9.1 MBT principles 1. 2. 3. 4. 5. 6. 7. 8. 9.
10. 11.
Primary aim is to increase the patient’s capacity to mentalize self and others. Manage the patient’s arousal levels. Focus on the patient’s mind and not on his or her behaviors. Monitor the patient’s capacity to mentalize, and use interventions that are consistent with the patient’s level of mentalizing. Identify imbalances in the poles of mentalizing, and intervene to regain balance. Seek out moments of mentalizing vulnerability leading to behaviors (e.g., selfharm, violence). Address current events and immediate states of mind. Consider marking and contingency in all interventions. Use a stepwise intervention process, starting with empathic validation, moving on to exploration, clarification, and challenge, through affect identification and affect focus, to mentalizing the clinician patient relationship itself. The clinician must maintain or regain his or her own mentalizing at all times. Do not: a. Meet nonmentalizing in the patient with high-level mentalizing in the clinician. b. Elaborate on the patient’s nonmentalizing.
understandable with all these experiences that you have become sensitive and have problems with relationships, managing your emotions, and controlling your actions”). G
G
G
G
G
Risk factors, such as suicidal or violent behavior or threats to engagement with and continuity of therapy Attachment patterns, which are often insecure anxious-avoidant/anxious-preoccupied in BPD and with marked disorganization in ASPD when strategies are activated Self-identity, that is, how the patient sees himself or herself and others. In BPD the patient may show identity confusion; in ASPD the self-states may be held in pretend mode with no connection to reality; for example, a narcissistic and grandiose self is given priority, and any threat to this is treated with dismissal Mentalizing strengths and nonmentalizing vulnerabilities, such as the mentalizing and nonmentalizing loops (see later) Immediate short-term goals in therapy, placed in relation to goals in the outside world.
Identification of nonmentalizing process The MBT clinician becomes sensitive to the vicissitudes of nonmentalizing process. The three primary nonmentalizing modes discussed earlier are not mutually exclusive; in fact, they are more likely to interweave than to manifest themselves in pure form. MBT techniques target the nonmentalizing modes to help the patient manage them better while, at the same time, exploring what triggered them when they arise. Addressing nonmentalizing modes is partly embedded in the general clinical stance and partly requires specific intervention.
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Interventions for nonmentalizing modes In psychic equivalence the patient’s mind is fixed, with no capacity to recognize alternative perspectives. This means that complex statements involving interpretation or even cognitive appraisal of the validity of the patient’s belief will be outside the patient’s comprehension. Such interventions need a higher level of mentalizing if they are to be understood by the patient. Fundamentally, the patient has to be able to think about his or her current state and appraise it if such interventions are to be useful. The MBT clinician may initially probe psychic equivalence belief and question the certainty of the patient’s understanding, but arguing with psychic equivalence is contraindicated. Instead, the clinician tries to stimulate mentalizing in a linked area of mental function. If, for instance, the topic is about the patient’s partner and the rigidity of the patient’s belief is about not being loved, it is better to make a detour, for example, to ask the patient to review how his or her relationship with the partner was a few weeks ago. If this allows some reflection, the current relationship can be explored from that standpoint. The clinician engages in a similar process when the patient’s mental processes are infused with teleological process. Working with the pretend mode is somewhat different. The clinician is more likely to unwittingly join in with pretend mode—by entering into exploration of thoughts and feelings that have no grounding in reality—but must avoid doing this. More specifically, the clinician should begin to challenge pretend mode, gently at first and then more insistently.
Not-knowing stance The not-knowing stance requires the MBT clinician to work authentically from the perspective of equality and collaboration, as the clinician can never know what is really going on in his or her own or others’ mind states. The clinician has knowledge and is expert in many ways but has to respect the opacity of mental states. Both patient and clinician have to accept that experience of mental states is impressionistic. The clinician has to accept the validity of the patient’s experience even if the clinician does not understand it. The clinician does not have to understand the patient or to make sense of the seemingly incomprehensible. This means that the clinician should never be worried if he or she does not understand what the patient is talking about. If the clinician does not know what the patient is talking about, the clinician does not try to piece it together, but says, “You know, I am having a real problem here. I can’t follow this, I can’t put it together. Can we try again?” Not-knowing is a key therapeutic attitude to enhance curiosity about mental process and experience. Curiosity is modeled by the clinician through reflecting on his or her own mind states without judgment and with empathic acceptance of experience.
Mentalizing poles The MBT clinician becomes attuned to indicators of nonmentalizing in the dialog, such as the overuse of absolutes or simplistic, overdetermined explanations and the
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mental rigidity that arises when mentalizing becomes stuck at one of the poles of mentalizing. If, for example, the patient is highly other externally focused and is watching the clinician’s movements carefully, the clinician directs the dialogue toward an internal state (of either self or other) to find out whether this instills more reflection. A clinician turned around and spoke to his patient with ASPD as they walked down the corridor to the consulting room. As they sat down, the patient stated coercively that the clinician was not to turn around to look at the patient or to speak to him as they walked down the corridor. The clinician asked what his backward glance had done to the patient—an intervention to focus the patient on the “self internal”, to balance his “other external” focus. The patient kept the focus on the clinician (other), so the clinician accepted the patient’s “other external” focus by saying that he had turned around simply as a social gesture and was not aware of any wish to cause offense. Having done this, the clinician again tried to rebalance some of the focus of mentalizing by asking the patient to describe what he had experienced from the backward glance.
The same principle of intervention applies if a patient is excessively cognitive. The MBT clinician balances this by harnessing the use of affective experience while accepting that it may be important to be fixed at the cognitive pole at certain times, for example, when solving a practical problem. This move to the affective pole can be difficult without becoming formulaic, for example, by continually asking someone how he or she feels. This is irritating for patients, who may not know how they feel, and it is often a barren intervention in terms of stimulating further mentalizing. For the MBT clinician the important factor is the quality of mentalizing—that is, whether it has become fixed and rigid—rather than whether the mental processing is either cognitive or affective. MBT recommends that the clinician increases interpersonal affectivity when the patient is fixed in a cognitive rational process with limited flexibility and, conversely, increases cognitive processing when the patient is trapped in affective dysregulation. To move from the cognitive pole, the clinician increasingly uses relational interventions in the dialogue; to move the other way, the clinician reduces the relational component and increasingly becomes more practical or rational. The aim of these interventions is to make a mentalizing process more flexible, more responsive to context, and increasingly implicit.
Mentalizing and nonmentalizing loops The clinician identifies common nonmentalizing “loops” with the patient. These are common interpersonal interactions that lead to diminished mentalizing by the patient, often in a particular form—psychic equivalence, for example—which results in painful internal states in the self (e.g., shame), which in turn leads to control of the other person, coercive behavior, or violence. It is in these loops, underpinned by the dimensions of mentalizing, that mentalizing differences between
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BPD and ASPD are apparent to the clinician. People with BPD commonly show excessive affective mentalizing with low levels of cognitive mentalizing, so they become sensitive to others while having a lowered sense of self. Clinical intervention is focused on helping the patient manage emotional dysregulation through developing more robust mentalizing and increasing cognitive control of emotions, along with better self other differentiation. In ASPD, higher cognitive mentalizing of self and other is likely to be apparent, sometimes combined with exploitation or control of others. This is often linked to a lack of affective empathy for others. Clinically, the task is therefore to increase the patient’s affective mentalizing of self and the affective component of empathy for others. MBT suggests a focus on identifying this nonmentalizing loop and increasing a more mentalizing loop—of understanding one’s own emotions, recognizing the other person’s feelings, and then empathizing with the other’s experience to the extent that interpersonal behavior becomes more constructive. The aim is that the patient becomes constrained by his or her effect on others so that, for example, the patient cares if he or she makes someone upset or frightened. This is done in group therapy, in which patients are initially asked to identify their own and each other’s emotions and underlying mental states.
Trajectory of sessions Finally, MBT not only has an overall structure to the treatment program (described in detail by Bateman & Fonagy, 2016), but also suggests a trajectory for each session. In each session there is a recommended stepwise move from a supportive position toward a more relational subjective experiential process. The MBT clinician is required, as a general principle, to start from an empathic and supportive position before moving toward a more relational focus. The clinician first needs to find out the subjective truth of the patient’s experience and to demonstrate that he or she has understood it from the patient’s perspective. Only then can the clinician “sit alongside the patient” so that the clinician and patient start looking at the patient’s story and subjective experience from a shared vantage point. As soon as the clinician senses that he or she and the patient have a shared affective platform, a process of exploration and elaboration takes place with the clarification of mental states. Clarification requires a reconstruction of events but with an emphasis on the changing mental states that were experienced during the events, a tracing of process over time, and a recognition that decisions may in the end be capricious and yet of value. The judicious use of challenge is also recommended in MBT. Challenge is a very important intervention, particularly, as mentioned earlier, when the patient is in pretend mode. There are a number of indicators for challenge. First, it should be considered specifically when a patient is interminably in a nonmentalizing mode. This may be particularly the case if the patient is in prolonged pretend mode, when the patient is in danger of believing his or her own narrative without question or
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reflection. Challenge as an intervention in MBT has certain defined characteristics. It is nearly always outside the current therapy dialogue, so it “comes from left field.” The aim is for the patient to be surprised and suddenly derailed from pretend mode. Once the clinician and patient are able to maintain a mentalizing interaction, MBT suggests an increasing focus on affect and the interpersonal domain. This has the effect of increasing emotional intensity; if mentalizing is maintained under these conditions, the MBT clinician can then move to mentalizing the relationship. The purpose of this move is to recreate the core sensitivity of the patient with BPD in the session. People with BPD are highly sensitive to interpersonal process; arousal in the interpersonal domain triggers much of the emotional dysregulation that is characteristic of BPD, which in turn disrupts mental processing further. MBT for BPD focuses on this area of sensitivity to generate more robust mentalizing around interpersonal processing, that is, relational mentalizing. The aim of mentalizing the relationship is to increase the affective interpersonal experience with the patient while maintaining mentalizing, as this is the core of the interpersonal difficulty for people with BPD. If the patient says something striking in the context of the patient clinician relationship that is of significance in the patient’s external relationships, the first task for the clinician is to validate the patient’s experience. Where is the accuracy in how the patient sees the clinician; in what way was the clinician like that? A patient with BPD told her clinician that he was too modest. To validate this experience, the clinician asked the patient what he does that is “too” modest. The patient explained that the clinician does not stand up for himself at times and seems to accept her criticisms too readily, particularly when she knows she is being difficult and irritable. The clinician and patient together identified a recent example of this, and the clinician accepted his role in the patient’s experience. Importantly, he did not question it as a distortion; it was a valid experience, contributed to by the clinician’s attitude. Next, the clinician had to identify what it was like for the patient to be working with a clinician who is too modest—what did it matter that she has a clinician who she saw as too modest? It shouldn’t really matter, but it did seem to matter to her. It turned out that the patient had seen a video on the internet of the clinician speaking at a conference and experienced him as so modest that she felt that he could not stand up for himself in the face of professional criticism. This experience had led her to self-harm, indicating how serious the issue was for her.
The MBT clinician now has to explore this sensitive area to try to get to an alternative perspective or, at least, a more complex understanding of what has happened. What actually had happened in this scenario was that the patient felt that if the clinician could not be proud of his achievements, it reduced her own achievements in life to futile meaningless events, because she saw them as being minimal compared with those of the clinician. She experienced this in psychic equivalence, so her experience of her achievements as utterly useless meant that she was useless and
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meaningless, and her life was nothing. This is an alternative perspective in MBT. Mentalizing the relationship is not an interpretation in the sense of insight; it is an attempt within the relationship to generate meaningful complexity about what has happened by engaging in a slowly unfolding relational process. At all times, the clinician monitors the reaction of the patient to the alternative perspective. Mentalizing the relationship in MBT must be approached with caution. Side effects stimulated by the clinician are common. For example, the patient’s experience is seen by the clinician as a distortion and the patient is alienated; the process becomes a jointly elaborated pretend mode in which both patient and clinician believe that they are working at depth when they are, in fact, engaged in clever cognitive work but both lose contact with reality. MBT is explicit about managing and working with components of mentalizing the counterrelationship (or the countertransference). Mentalizing the counterrelationship—essentially, using the feelings evoked in the clinician by exchanges with the patient—requires self-awareness on the part of the clinician. Some clinicians default to a state of self-reference whereby they consider most of what they experience in therapy as being relevant to the patient. This default mode needs to be resisted, and clinicians need to be mindful of the fact that their own mental states might unduly color their understanding of the patient’s mental states and that they might tend to equate these mental states without adequate foundation. The clinician therefore has to “quarantine” his or her feelings. How the clinician “quarantines” informs the MBT technical approach to countertransference, which is defined as those experiences, both affective and cognitive, that the clinician has in sessions and thinks might further develop an understanding of mental processes. Feelings in the clinician are not considered initially as a result of projective processes, and the clinician must identify these experiences clearly as his or her own; that is, they are “marked.” The purpose of expressing the counterrelationship is to explore the dyadic interaction in more detail, to explore how mind states affect mind states. As an example, a patient who is intimidating in attitude will evoke a sense of wariness or fear in the clinician, and exploring this interaction in its immediacy will be important if the patient is to modify his or her relationships.
Summary MBT is rooted in a theoretical framework derived from neuroscience and attachment research. The focus of the intervention is on increasing the stability of mentalizing processes in patients with BPD and ASPD whose difficulties arise from vulnerability to losing mentalizing, particularly in relationships. Treatment is structured according to a research-based protocol and organized around identification of the triggers of episodes of nonmentalizing. A relational process is used to promote the ability of patients to maintain their affect and mentalizing within intimate relationships and during stressful interactions.
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References Allen, J. G., Bleiberg, E., & Haslam-Hopwood, T. (2003). Understanding mentalizing: Mentalizing as a compass for treatment. Houston, TX: The Menninger Clinic. Available from http://www.menningerclinic.com/education/clinical-resources/mentalizing. Bales, D., van Beek, N., Smits, M., Willemsen, S., Busschbach, J. J., Verheul, R., & Andrea, H. (2012). Treatment outcome of 18-month, day hospital mentalization-based treatment (MBT) in patients with severe borderline personality disorder in the Netherlands. Journal of Personality Disorders, 26, 568 582. Available from https://doi.org/10.1521/ pedi.2012.26.4.568. Bales, D. L., Timman, R., Andrea, H., Busschbach, J. J., Verheul, R., & Kamphuis, J. H. (2015). Effectiveness of day hospital mentalization-based treatment for patients with severe borderline personality disorder: A matched control study. Clinical Psychology & Psychotherapy, 22, 409 417. Available from https://doi.org/10.1002/cpp.1914. Bateman, A., & Fonagy, P. (1999). Effectiveness of partial hospitalization in the treatment of borderline personality disorder: A randomized controlled trial. American Journal of Psychiatry, 156, 1563 1569. Available from https://doi.org/10.1176/ajp.156.10.1563. Bateman, A., & Fonagy, P. (2001). Treatment of borderline personality disorder with psychoanalytically oriented partial hospitalization: An 18-month follow-up. American Journal of Psychiatry, 158, 36 42. Available from https://doi.org/10.1176/appi.ajp.158.1.36. Bateman, A., & Fonagy, P. (2003). Health service utilization costs for borderline personality disorder patients treated with psychoanalytically oriented partial hospitalization versus general psychiatric care. American Journal of Psychiatry, 160, 169 171. Available from https://doi.org/10.1176/appi.ajp.160.1.169. Bateman, A., & Fonagy, P. (2008). 8-year follow-up of patients treated for borderline personality disorder: Mentalization-based treatment versus treatment as usual. American Journal of Psychiatry, 165, 631 638. Available from https://doi.org/10.1176/appi. ajp.2007.07040636. Bateman, A., & Fonagy, P. (2009). Randomized controlled trial of outpatient mentalizationbased treatment versus structured clinical management for borderline personality disorder. American Journal of Psychiatry, 166, 1355 1364. Available from https://doi.org/ 10.1176/appi.ajp.2009.09040539. Bateman, A., O’Connell, J., Lorenzini, N., Gardner, T., & Fonagy, P. (2016). A randomised controlled trial of mentalization-based treatment versus structured clinical management for patients with comorbid borderline personality disorder and antisocial personality disorder. BMC Psychiatry, 16, 304. Available from https://doi.org/10.1186/s12888-0161000-9. Bateman, A. W., & Fonagy, P. (2016). Mentalization-based treatment for personality disorders: A practical guide. Oxford, UK: Oxford University Press. Bateman, A. W., & Fonagy, P. (Eds.), (2012). Handbook of mentalizing in mental health practice. Washington, DC: American Psychiatric Publishing. Fonagy, P., & Bateman, A. (2008). The development of borderline personality disorder—A mentalizing model. Journal of Personality Disorders, 22, 4 21. Available from https:// doi.org/10.1521/pedi.2008.22.1.4. Fonagy, P., & Bateman, A. W. (2007). Mentalizing and borderline personality disorder. Journal of Mental Health, 16, 83 101. Available from https://doi.org/10.1080/ 09638230601182045.
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Fonagy, P., Gergely, G., Jurist, E., & Target, M. (2002). Affect regulation, mentalization, and the development of the self. New York, NY: Other Press. Fonagy, P., & Luyten, P. (2018). Attachment, mentalization, and the self. In W.J. Livesley & R. Larstone (Eds.), Handbook of personality disorders: Theory, research, and treatment (2nd ed., pp. 123 140). New York, NY: Guilford Press. Fonagy, P., Luyten, P., & Allison, E. (2015). Epistemic petrification and the restoration of epistemic trust: A new conceptualization of borderline personality disorder and its psychosocial treatment. Journal of Personality Disorders, 29, 575 609. Available from https://doi.org/10.1521/pedi.2015.29.5.575. Fonagy, P., Luyten, P., & Bateman, A. (2015). Translation: Mentalizing as treatment target in borderline personality disorder. Personality Disorders: Theory, Research, and Treatment, 6, 380 392. Available from https://doi.org/10.1037/per0000113. Jørgensen, C. R., Freund, C., Boye, R., Jordet, H., Andersen, D., & Kjolbye, M. (2013). Outcome of mentalization-based and supportive psychotherapy in patients with borderline personality disorder: A randomized trial. Acta Psychiatrica Scandinavica, 127, 305 317. Available from https://doi.org/10.1111/j.1600-0447.2012.01923.x. Laurenssen, E. M., Hutsebaut, J., Feenstra, D. J., Bales, D. L., Noom, M. J., Busschbach, J. J. V., . . . Luyten, P. (2014). Feasibility of mentalization-based treatment for adolescents with borderline symptoms: A pilot study. Psychotherapy, 51, 159 166. Available from https://doi.org/10.1037/a0033513. Luyten, P., & Fonagy, P. (2015). The neurobiology of mentalizing. Personality Disorders: Theory, Research, and Treatment, 6, 366 379. Available from https://doi.org/10.1037/ per0000117. Newbury-Helps, J., Feigenbaum, J., & Fonagy, P. (2017). Offenders with antisocial personality disorder display more impairments in mentalizing. Journal of Personality Disorders, 31, 232 255. Available from https://doi.org/10.1521/pedi_2016_30_246. Petersen, B., Toft, J., Christensen, N. B., Foldager, L., Munk-Jorgensen, P., Windfeld, M., . . . Valbak, K. (2010). A 2-year follow-up of mentalization-oriented group therapy following day hospital treatment for patients with personality disorders. Personality and Mental Health, 4, 294 301. Available from https://doi.org/10.1002/Pmh.140. Robinson, P., Hellier, J., Barrett, B., Barzdaitiene, D., Bateman, A., Bogaardt, A., . . . Fonagy, P. (2016). The NOURISHED randomised controlled trial comparing mentalisation-based treatment for eating disorders (MBT-ED) with specialist supportive clinical management (SSCM-ED) for patients with eating disorders and symptoms of borderline personality disorder. Trials, 17, 549. Available from https://doi.org/10.1186/ s13063-016-1606-8. Rossouw, T. I., & Fonagy, P. (2012). Mentalization-based treatment for self-harm in adolescents: A randomized controlled trial. Journal of the American Academy of Child and Adolescent Psychiatry, 51, 1304 1313. Available from https://doi.org/10.1016/j. jaac.2012.09.018.
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Anthony Bateman1 and Peter Fonagy2 1 University College London, London, United Kingdom, 2Research Department of Clinical, Educational and Health Psychology, University College London, London, United Kingdom
Mentalizing is the ability to understand actions of other people and oneself according to underlying mental states, that is, through recognizing thoughts, feelings, wishes, and desires as being intentional. It is a very human capability that underpins everyday interactions (Allen, Bleiberg, & Haslam-Hopwood, 2003; Fonagy, Gergely, Jurist, & Target, 2002). Trying to understand other people’s behavior in terms of mental states contrasts with understanding others’ and one’s own actions through their consequences in the physical world: we are what we do. For instance, I see someone drop something, so he or she meant to do so. Similarly, I did something, so I must have wanted to do it. Mentalizing is not an entirely stable, consistent, or one-dimensional process. People are not all able to mentalize to the same extent. Many of us have strengths or weaknesses in particular aspects of mentalizing, and most people are more likely to struggle to mentalize in moments of stress or anxiety. We can all act according to mistaken beliefs about others’ mental states, leading to everyday misunderstandings, difficulties, and social faux pas. In addition, problems in mentalizing are the common factor in many psychiatric disorders (Bateman & Fonagy, 2012), particularly personality disorders.
The multidimensional nature of mentalizing Mentalizing is not an all-or-nothing phenomenon. It ranges from full and effective mentalizing through ineffective mentalizing to nonmentalizing. In daily life, people’s ability to mentalize fluctuates, and people with personality disorders may show excellent mentalizing at times. The mentalizing model of borderline personality disorder (BPD) and antisocial personality disorder (ASPD) is not a deficit model. It is a model of vulnerability to imbalance and instability in mentalizing. It provides a comprehensive account of the phenomenology and origins of BPD and ASPD from a developmental perspective and informs clinicians how to target in treatment the mentalizing vulnerability that is hypothesized to be at the core of the disorders (Fonagy & Bateman, 2007, 2008). People with BPD show greater Contemporary Psychodynamic Psychotherapy. DOI: https://doi.org/10.1016/B978-0-12-813373-6.00009-X © 2019 Elsevier Inc. All rights reserved.
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propensity than others to lose mentalizing in interpersonal interactions and in a wider range of situations, they experience nonmentalizing for longer periods, and they find it more difficult to regain mentalizing once it has been lost. People with ASPD show similar mentalizing instability but also demonstrate a persistent imbalance of mentalizing in cognitive affective process, with cognitive mentalizing of both self and other dominating affective mentalizing.
Neurobiology of mentalizing Neuroscience has identified four distinct components to mentalizing (Luyten & Fonagy, 2015), which are organized into dimensions that are helpful for therapists to identify in the clinical practice of mentalization-based treatment (MBT). These dimensions are automatic versus controlled mentalizing; mentalizing the self versus others; mentalizing with regard to internal versus external features; and cognitive versus affective mentalizing. These are not dimensions in the normal understanding of the term. They link on the basis of joint function. To mentalize effectively requires an individual not only to be able to maintain a balance across the dimensions of mentalizing, but also to apply the dimensions appropriately according to context. Consistent favoring of one or other side (or pole) of a dimension leads to distorted understanding of the mental states of oneself or others, which can be associated with profound social and emotional difficulties (Fonagy, Luyten, & Bateman, 2015). Commonly, one or more of the dimensions is relatively neglected at one end, and consequently, the opposite pole comes to dominate social cognition. For example, overly emotional thinking emerges in the absence of cognitive mentalizing. Clinically, the patient seems to be dominated by affective process and emotionally driven decision making, yet the problem can be due to the loss of cognitive processing systems. As another example, if the patient’s subjective experience of selfstates is reduced, the influence of others dominates and the patient becomes vulnerable to exploitation. From this perspective, different types of psychopathology can be distinguished on the basis of different combinations of impairments on the four dimensions. In other words, personality disorders (and, to some extent, other psychiatric disorders) can be understood according to their characteristic mentalizing profiles.
Automatic versus controlled mentalizing The most fundamental dimension to mentalizing is the spectrum between automatic (or implicit) and controlled (or explicit) mentalizing. Controlled mentalizing reflects a serial and relatively slow process, which is typically verbal and demands reflection, attention, awareness, intention, and effort. The balancing pole of this dimension—automatic mentalizing—involves much faster processing, tends to be reflexive, and requires little or no attention, awareness, intention, or effort.
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Mentalizing the self versus others This mentalizing dimension involves the capacity to mentalize one’s own state— the self (including one’s own physical experiences)—and/or the state of others. The two are closely connected, and an imbalance signals vulnerability in mentalizing others and/or the self. People with mentalizing difficulties are likely to preferentially focus on one end of the spectrum. Individuals with BPD tend to be highly sensitive to others and vulnerable to others’ states of mind; individuals with ASPD show sudden switches from being more other-directed to defending the self from disorganizing shame.
Internal versus external mentalizing Mentalizing involves making inferences on the basis of the external indicators of a person’s mental states (e.g., facial expressions, tone of voice, body posture) or working out someone’s internal experience from what one knows about the other person and the situation and feeling state the other person is in. People with BPD and ASPD focus more on external than internal indicators.
Cognitive versus affective mentalizing Cognitive mentalizing involves the ability to name, recognize, and reason about mental states (in oneself and others), whereas affective mentalizing involves the ability to experience and understand associated feelings, again, in oneself or others. Both need to be integrated for any genuine experience of empathy or true sense of self-coherence.
Dimensional mentalizing profile characteristic of BPD and ASPD Individuals with BPD and ASPD easily find themselves switching to persistent automatic mentalizing. Stress and arousal, especially in an attachment context, bring automatic mentalizing to the fore and disengage the neural systems that are associated with controlled mentalizing. Under these conditions, interactions become nonquestioning precisely when they need to be more controlled and contextualized. Thinking becomes impulsive; the individual makes assumptions about others’ thoughts and feelings that are not reflected upon or tested. Logic is intuitive, unreasoned, and nonverbal. As a consequence, patients may be overly distrustful (paranoid) or, in BPD, sometimes overly trustful (naive). Patients with BPD may show excessive concern about their own internal state; that is, they hypermentalize in relation to the self without having an awareness of how others perceive them. In contrast, patients with ASPD tend to avoid selfscrutiny and hypermentalize about others. Failure to balance self-perception with
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sincere curiosity about how one is perceived by others (people with ASPD do not care how others perceive them) can lead to exaggeration of the self-image in either a positive (more common in ASPD) or a negative (more common in BPD) direction. A balanced, adaptive form of self-mentalizing conditioned by the social context is absent. Patients with BPD and ASPD pay more attention to external indicators of mental states, and their initial ideas, arising from automatic mentalizing, go unchecked by controlled, reflective mentalizing. For example, if the clinician looks out of the window, to the patient this means that the clinician is not taking the patient seriously. A focus on external features, in the absence of reflective mentalizing, renders an individual highly vulnerable in social contexts, as it generates interpersonal hypersensitivity and hypervigilance.
The reemergence of nonmentalizing modes in BPD and ASPD While the dimensions of mentalizing can reflect anomalies in terms of mechanisms, the clinician experiences the outcomes of these malfunctions as nonmentalizing modes. These are grouped into three typical modes of subjectivity: psychic equivalence mode, teleological mode, and pretend mode (Fonagy & Bateman, 2008). The nonmentalizing modes are important for the clinician to recognize and understand, as they tend to emerge in the consulting room and reflect core aspects of the patient’s experience. It is important to address them because they cause considerable interpersonal difficulties and result in destructive behaviors. In general terms, nonmentalizing modes fluctuate in BPD and are more persistent in ASPD. Newbury-Helps, Feigenbaum, and Fonagy (2017) found a range of mentalizing problems in people with ASPD, which were more pronounced in offenders than in nonoffenders.
Psychic equivalence mode In the psychic equivalence mode, thoughts and feelings become “too real” to a point at which it is extremely difficult for the patient to entertain possible alternative perspectives. What thought is experienced as being real and true, leading to concreteness of thought; that is, thoughts are treated as facts. Patients with BPD and ASPD who are in this mode describe an overriding sense of certainty about their beliefs; for example, “the therapist does not like me” or “I am a wicked person.” These thoughts and beliefs cannot be argued with.
Teleological mode In the teleological mode, states of mind are recognized and believed only if their outcomes are physically observable. Hence, the individual can recognize the
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existence and potential importance of states of mind, but this recognition is limited to physical indicators. For example, affection is perceived to be real only if it is accompanied by a touch or caress. A patient with BPD, describing a recent incident in which her partner failed to respond to a text message, may say that her partner’s nonresponse to the message “means that he does not love me.” In ASPD, teleological function is often engrained in how others’ motives are understood (you are what you do); for instance, someone who does not step aside in the street has malevolent intent with determination to dominate and challenge. The teleological mode is apparent in patients who are imbalanced toward the external pole of the internal external mentalizing dimension. They are heavily biased toward understanding how people (and they themselves) behave and what their intentions may be in terms of what they actually do.
Pretend mode In the pretend mode, thoughts and feelings become severed from reality. Taken to an extreme, this may lead to feelings of derealization and dissociation. Patients in pretend mode can discuss experiences without contextualizing them in any kind of physical or material reality, as if they were creating a pretend world. The patient may hypermentalize or pseudomentalize, a state in which the patient is overly focused on internal self-states and may say much about states of mind but with little true meaning or connection to reality. In ASPD the focus on self-states may, paradoxically, be about others’ motives, with self-serving justification of violent or threatening behavior, for example. Attempting psychotherapy with patients who are in this mode can lead to lengthy but inconsequential discussions of internal experience that have no link to genuine experience and will achieve no change. In summary, imbalances within the dimensions of mentalizing predictably generate the nonmentalizing modes. Psychic equivalence is inevitable if emotion (affect) dominates cognition. Teleological mode follows from an exclusive focus on external features to the neglect of the internal. Pretend mode thinking and hypermentalizing are unavoidable if reflective, explicit, controlled mentalizing is not well established.
Attachment It is a central tenet of the mentalization-based approach that a sense of self and the capacity to mentalize both develop in the context of attachment relationships (Fonagy & Luyten, 2018). In patients with BPD and ASPD there is a common history of early (in particular emotional) neglect, a disrupted early social environment, and abusive or even brutalized family relationships. These may contribute to undermining the ability of some individuals to develop full mentalizing capacities. Subsequent adversity or trauma may disrupt mentalizing further, in part as an adaptive maneuver on the part of the individual to limit exposure to a dehumanizing
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psychosocial environment and in part because the high level of arousal generated by attachment hyperactivation and disorganized attachment strategies serve to disrupt less well-practiced and less robustly established higher cognitive capacities. In addition, genetic influences may be expressed through the mediation of mentalizing. In summary, the mentalizing model points to a final common developmental pathway that a range of biological, family, and broader social contextual influences may take to generate the range of difficulties that are normally considered under the term personality disorder (Fonagy et al., 2015).
Epistemic trust The most recent theoretical developments in our thinking about mentalizing and therapeutic change have important implications for how we approach our clinical practice. This new thinking involves the theory of epistemic trust. In short, this theory emphasizes the social and emotional significance of the trust we place in the information about the social world that we receive from another person—that is, the extent and ways in which we are able to consider social knowledge as genuine and personally relevant to us. The development of epistemic trust goes hand in hand with attachment processes, with the bond of secure attachment opening up trust in others to facilitate learning from them, whereas the interaction in insecure and disorganized attachment reduces this capacity. Our view is that in BPD and ASPD this process has been compromised. For further discussion of this view, see Fonagy, Luyten, and Allison (2015).
The evidence base for MBT from outcome research Research has been integrated with MBT from its inception. Randomized controlled trials (RCTs) have tested the effectiveness of MBT in BPD, ASPD, eating disorders, and self-harming adolescents with borderline features. In an early RCT of MBT for BPD in a partial hospital setting in the United Kingdom (Bateman & Fonagy, 1999, 2001), an 18-month program was associated with significant and enduring improvements in self-destructive behavior, mood states, and interpersonal functioning, and reduction in service use. Treatment for BPD showed considerable cost savings after treatment (Bateman & Fonagy, 2003), and an 8-year follow-up found that patients who had received MBT remained better than the control group, who had received treatment as usual (TAU) (Bateman & Fonagy, 2008). Two well-controlled single-blind randomized trials of outpatient MBT have been conducted in the United Kingdom, with adults with BPD (Bateman & Fonagy, 2009) and adolescents presenting to clinical services with self-harm, the vast majority of whom met BPD criteria (Rossouw & Fonagy, 2012). In the latter trial the participants received a form of MBT designed for adolescents (MBT-A). In both trials
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MBT proved superior to TAU in reducing self-harm (including suicidality) and depression. Improvement was mediated by improved levels of mentalizing, reduced attachment avoidance, and reduction in features of BPD. Three more recent studies provided further support for MBT in patients with BPD. An RCT in Denmark investigated the efficacy of MBT versus a less intensive, manualized supportive group therapy, both delivered in combination with psychoeducation and medication, for patients diagnosed with BPD (Jørgensen et al., 2013). In another study in Denmark (Petersen et al., 2010) a cohort of patients treated with partial hospitalization followed by MBT group therapy showed significant improvements after 2 years on a range of measures, with further improvement at 2-year follow-up. A naturalistic study by Bales et al. (2012) in the Netherlands showed moderate to large effect sizes at the end of treatment and, when the authors used a matched control design, found that MBT had larger effect sizes than other specialized psychotherapeutic treatments (Bales et al., 2015). Another naturalistic trial in the Netherlands studied the feasibility and effectiveness of inpatient MBT-A in 11 female adolescents aged 14 18 years with borderline symptoms (Laurenssen et al., 2014). Results showed significant decreases in symptoms and improvements in personality functioning and quality of life 12 months after the start of treatment. Better outcomes for people with ASPD receiving MBT compared with TAU have led to a definitive multicenter trial in the United Kingdom (Bateman, O’Connell, Lorenzini, Gardner, & Fonagy, 2016). Finally, an RCT comparing MBT with specialist supportive clinical management in the treatment of adults with eating disorders and impulsive BPD traits has been reported in the United Kingdom (Robinson et al., 2016). Both interventions achieved reductions in eating disorder symptoms, but MBT was associated with greater reductions in shape concern and weight concern.
The clinical approach in mentalization-based treatment MBT is operationalized as combined individual and group therapy, although it is now often delivered in one mode alone. The evidence-based program for BPD was organized as weekly individual and group therapy for a period of 18 months. MBT for ASPD consists of weekly group therapy, with an individual session at the request of the clinician or patient a maximum of once a month, for a period of 1 year. MBT requires the clinician to develop a treatment frame and milieu that facilitate epistemic trust. To do so, the clinician focuses on contingent and marked mentalizing of the patient’s internal states, because feeling mentalized is the most potent ostensive cue. The patient’s interpersonal processes and current life events form the content of this process. Initially, MBT takes a directive and informative approach (Bateman & Fonagy, 2016). MBT requires the clinician and patient to do the following: 1. Collaboratively develop a formulation early in the assessment process (see later, in the section “Collaborative process and formulation”).
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2. Identify mentalizing vulnerabilities in terms of dimensional rigidity and nonmentalizing modes, using examples that are personal to the patient. Pathways to the loss of mentalizing are identified and established as vulnerability points to be monitored carefully. 3. Discuss the diagnosis in terms of the patient’s symptoms and history. The diagnosis is less important than agreeing on a lens through which the variability of symptoms can be understood. 4. Map attachment patterns and how they play out in current relationships. The identification of attachment strategies is essential if the patient and clinician are to recognize their deployment during treatment and in the patient’s interpersonal interactions. 5. Engage the patient in an introductory phase that combines psychoeducation with some interpersonal process. The MBT-Introductory group (Bateman & Fonagy, 2016) offers the patient and clinician a shared framework for understanding BPD and the whole process of therapy. 6. Establish a developmental narrative of problems. The patient’s background and context support a compassionate view of the problems. 7. Jointly agree on goals that are relevant to the patient so that therapy is about what is important to the patient. To this end, MBT for ASPD asks the patient and clinician to work together, identifying the patient’s current and hoped-for values, to ensure that the patient does not experience therapy as imposition of the therapist’s, or an establishment, value system.
In essence, we suggest that the explanations and suggestions and the process of developing a value-driven clinical agreement in the initial phase of therapy are ostensive cues that signal to the patient the relevance to them of the information that is being conveyed. These serve to trigger in the patient a feeling of being personally recognized by the clinician in the therapeutic situation. MBT is structured, organized around the development of an attachment relationship with the patient, offers a careful focus on the patient’s internal mental processes as they are experienced moment by moment, and emphasizes the therapeutic alliance, with the active repair of ruptures in the relationship between patient and clinician.
Principles The clinician follows a number of principles that are framed to increase mentalizing and to prevent iatrogenic reduction of mentalizing. These are listed in Box 9.1 and discussed in detail in Bateman and Fonagy (2016).
Collaborative process and formulation The formulation is predominantly a collaborative clinical agreement. It is written by the clinician and shared with the patient, and is regularly revised as new understandings develop. It is important that the patient recognizes himself or herself within the formulation. It is written from a positive perspective with the patient’s strengths emphasized. It includes information from some of the domains identified below, expressed in terms of developmental vulnerabilities (e.g., “It is
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Box 9.1 MBT principles 1. 2. 3. 4. 5. 6. 7. 8. 9.
10. 11.
Primary aim is to increase the patient’s capacity to mentalize self and others. Manage the patient’s arousal levels. Focus on the patient’s mind and not on his or her behaviors. Monitor the patient’s capacity to mentalize, and use interventions that are consistent with the patient’s level of mentalizing. Identify imbalances in the poles of mentalizing, and intervene to regain balance. Seek out moments of mentalizing vulnerability leading to behaviors (e.g., selfharm, violence). Address current events and immediate states of mind. Consider marking and contingency in all interventions. Use a stepwise intervention process, starting with empathic validation, moving on to exploration, clarification, and challenge, through affect identification and affect focus, to mentalizing the clinician patient relationship itself. The clinician must maintain or regain his or her own mentalizing at all times. Do not: a. Meet nonmentalizing in the patient with high-level mentalizing in the clinician. b. Elaborate on the patient’s nonmentalizing.
understandable with all these experiences that you have become sensitive and have problems with relationships, managing your emotions, and controlling your actions”). G
G
G
G
G
Risk factors, such as suicidal or violent behavior or threats to engagement with and continuity of therapy Attachment patterns, which are often insecure anxious-avoidant/anxious-preoccupied in BPD and with marked disorganization in ASPD when strategies are activated Self-identity, that is, how the patient sees himself or herself and others. In BPD the patient may show identity confusion; in ASPD the self-states may be held in pretend mode with no connection to reality; for example, a narcissistic and grandiose self is given priority, and any threat to this is treated with dismissal Mentalizing strengths and nonmentalizing vulnerabilities, such as the mentalizing and nonmentalizing loops (see later) Immediate short-term goals in therapy, placed in relation to goals in the outside world.
Identification of nonmentalizing process The MBT clinician becomes sensitive to the vicissitudes of nonmentalizing process. The three primary nonmentalizing modes discussed earlier are not mutually exclusive; in fact, they are more likely to interweave than to manifest themselves in pure form. MBT techniques target the nonmentalizing modes to help the patient manage them better while, at the same time, exploring what triggered them when they arise. Addressing nonmentalizing modes is partly embedded in the general clinical stance and partly requires specific intervention.
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Interventions for nonmentalizing modes In psychic equivalence the patient’s mind is fixed, with no capacity to recognize alternative perspectives. This means that complex statements involving interpretation or even cognitive appraisal of the validity of the patient’s belief will be outside the patient’s comprehension. Such interventions need a higher level of mentalizing if they are to be understood by the patient. Fundamentally, the patient has to be able to think about his or her current state and appraise it if such interventions are to be useful. The MBT clinician may initially probe psychic equivalence belief and question the certainty of the patient’s understanding, but arguing with psychic equivalence is contraindicated. Instead, the clinician tries to stimulate mentalizing in a linked area of mental function. If, for instance, the topic is about the patient’s partner and the rigidity of the patient’s belief is about not being loved, it is better to make a detour, for example, to ask the patient to review how his or her relationship with the partner was a few weeks ago. If this allows some reflection, the current relationship can be explored from that standpoint. The clinician engages in a similar process when the patient’s mental processes are infused with teleological process. Working with the pretend mode is somewhat different. The clinician is more likely to unwittingly join in with pretend mode—by entering into exploration of thoughts and feelings that have no grounding in reality—but must avoid doing this. More specifically, the clinician should begin to challenge pretend mode, gently at first and then more insistently.
Not-knowing stance The not-knowing stance requires the MBT clinician to work authentically from the perspective of equality and collaboration, as the clinician can never know what is really going on in his or her own or others’ mind states. The clinician has knowledge and is expert in many ways but has to respect the opacity of mental states. Both patient and clinician have to accept that experience of mental states is impressionistic. The clinician has to accept the validity of the patient’s experience even if the clinician does not understand it. The clinician does not have to understand the patient or to make sense of the seemingly incomprehensible. This means that the clinician should never be worried if he or she does not understand what the patient is talking about. If the clinician does not know what the patient is talking about, the clinician does not try to piece it together, but says, “You know, I am having a real problem here. I can’t follow this, I can’t put it together. Can we try again?” Not-knowing is a key therapeutic attitude to enhance curiosity about mental process and experience. Curiosity is modeled by the clinician through reflecting on his or her own mind states without judgment and with empathic acceptance of experience.
Mentalizing poles The MBT clinician becomes attuned to indicators of nonmentalizing in the dialog, such as the overuse of absolutes or simplistic, overdetermined explanations and the
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mental rigidity that arises when mentalizing becomes stuck at one of the poles of mentalizing. If, for example, the patient is highly other externally focused and is watching the clinician’s movements carefully, the clinician directs the dialogue toward an internal state (of either self or other) to find out whether this instills more reflection. A clinician turned around and spoke to his patient with ASPD as they walked down the corridor to the consulting room. As they sat down, the patient stated coercively that the clinician was not to turn around to look at the patient or to speak to him as they walked down the corridor. The clinician asked what his backward glance had done to the patient—an intervention to focus the patient on the “self internal”, to balance his “other external” focus. The patient kept the focus on the clinician (other), so the clinician accepted the patient’s “other external” focus by saying that he had turned around simply as a social gesture and was not aware of any wish to cause offense. Having done this, the clinician again tried to rebalance some of the focus of mentalizing by asking the patient to describe what he had experienced from the backward glance.
The same principle of intervention applies if a patient is excessively cognitive. The MBT clinician balances this by harnessing the use of affective experience while accepting that it may be important to be fixed at the cognitive pole at certain times, for example, when solving a practical problem. This move to the affective pole can be difficult without becoming formulaic, for example, by continually asking someone how he or she feels. This is irritating for patients, who may not know how they feel, and it is often a barren intervention in terms of stimulating further mentalizing. For the MBT clinician the important factor is the quality of mentalizing—that is, whether it has become fixed and rigid—rather than whether the mental processing is either cognitive or affective. MBT recommends that the clinician increases interpersonal affectivity when the patient is fixed in a cognitive rational process with limited flexibility and, conversely, increases cognitive processing when the patient is trapped in affective dysregulation. To move from the cognitive pole, the clinician increasingly uses relational interventions in the dialogue; to move the other way, the clinician reduces the relational component and increasingly becomes more practical or rational. The aim of these interventions is to make a mentalizing process more flexible, more responsive to context, and increasingly implicit.
Mentalizing and nonmentalizing loops The clinician identifies common nonmentalizing “loops” with the patient. These are common interpersonal interactions that lead to diminished mentalizing by the patient, often in a particular form—psychic equivalence, for example—which results in painful internal states in the self (e.g., shame), which in turn leads to control of the other person, coercive behavior, or violence. It is in these loops, underpinned by the dimensions of mentalizing, that mentalizing differences between
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BPD and ASPD are apparent to the clinician. People with BPD commonly show excessive affective mentalizing with low levels of cognitive mentalizing, so they become sensitive to others while having a lowered sense of self. Clinical intervention is focused on helping the patient manage emotional dysregulation through developing more robust mentalizing and increasing cognitive control of emotions, along with better self other differentiation. In ASPD, higher cognitive mentalizing of self and other is likely to be apparent, sometimes combined with exploitation or control of others. This is often linked to a lack of affective empathy for others. Clinically, the task is therefore to increase the patient’s affective mentalizing of self and the affective component of empathy for others. MBT suggests a focus on identifying this nonmentalizing loop and increasing a more mentalizing loop—of understanding one’s own emotions, recognizing the other person’s feelings, and then empathizing with the other’s experience to the extent that interpersonal behavior becomes more constructive. The aim is that the patient becomes constrained by his or her effect on others so that, for example, the patient cares if he or she makes someone upset or frightened. This is done in group therapy, in which patients are initially asked to identify their own and each other’s emotions and underlying mental states.
Trajectory of sessions Finally, MBT not only has an overall structure to the treatment program (described in detail by Bateman & Fonagy, 2016), but also suggests a trajectory for each session. In each session there is a recommended stepwise move from a supportive position toward a more relational subjective experiential process. The MBT clinician is required, as a general principle, to start from an empathic and supportive position before moving toward a more relational focus. The clinician first needs to find out the subjective truth of the patient’s experience and to demonstrate that he or she has understood it from the patient’s perspective. Only then can the clinician “sit alongside the patient” so that the clinician and patient start looking at the patient’s story and subjective experience from a shared vantage point. As soon as the clinician senses that he or she and the patient have a shared affective platform, a process of exploration and elaboration takes place with the clarification of mental states. Clarification requires a reconstruction of events but with an emphasis on the changing mental states that were experienced during the events, a tracing of process over time, and a recognition that decisions may in the end be capricious and yet of value. The judicious use of challenge is also recommended in MBT. Challenge is a very important intervention, particularly, as mentioned earlier, when the patient is in pretend mode. There are a number of indicators for challenge. First, it should be considered specifically when a patient is interminably in a nonmentalizing mode. This may be particularly the case if the patient is in prolonged pretend mode, when the patient is in danger of believing his or her own narrative without question or
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reflection. Challenge as an intervention in MBT has certain defined characteristics. It is nearly always outside the current therapy dialogue, so it “comes from left field.” The aim is for the patient to be surprised and suddenly derailed from pretend mode. Once the clinician and patient are able to maintain a mentalizing interaction, MBT suggests an increasing focus on affect and the interpersonal domain. This has the effect of increasing emotional intensity; if mentalizing is maintained under these conditions, the MBT clinician can then move to mentalizing the relationship. The purpose of this move is to recreate the core sensitivity of the patient with BPD in the session. People with BPD are highly sensitive to interpersonal process; arousal in the interpersonal domain triggers much of the emotional dysregulation that is characteristic of BPD, which in turn disrupts mental processing further. MBT for BPD focuses on this area of sensitivity to generate more robust mentalizing around interpersonal processing, that is, relational mentalizing. The aim of mentalizing the relationship is to increase the affective interpersonal experience with the patient while maintaining mentalizing, as this is the core of the interpersonal difficulty for people with BPD. If the patient says something striking in the context of the patient clinician relationship that is of significance in the patient’s external relationships, the first task for the clinician is to validate the patient’s experience. Where is the accuracy in how the patient sees the clinician; in what way was the clinician like that? A patient with BPD told her clinician that he was too modest. To validate this experience, the clinician asked the patient what he does that is “too” modest. The patient explained that the clinician does not stand up for himself at times and seems to accept her criticisms too readily, particularly when she knows she is being difficult and irritable. The clinician and patient together identified a recent example of this, and the clinician accepted his role in the patient’s experience. Importantly, he did not question it as a distortion; it was a valid experience, contributed to by the clinician’s attitude. Next, the clinician had to identify what it was like for the patient to be working with a clinician who is too modest—what did it matter that she has a clinician who she saw as too modest? It shouldn’t really matter, but it did seem to matter to her. It turned out that the patient had seen a video on the internet of the clinician speaking at a conference and experienced him as so modest that she felt that he could not stand up for himself in the face of professional criticism. This experience had led her to self-harm, indicating how serious the issue was for her.
The MBT clinician now has to explore this sensitive area to try to get to an alternative perspective or, at least, a more complex understanding of what has happened. What actually had happened in this scenario was that the patient felt that if the clinician could not be proud of his achievements, it reduced her own achievements in life to futile meaningless events, because she saw them as being minimal compared with those of the clinician. She experienced this in psychic equivalence, so her experience of her achievements as utterly useless meant that she was useless and
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meaningless, and her life was nothing. This is an alternative perspective in MBT. Mentalizing the relationship is not an interpretation in the sense of insight; it is an attempt within the relationship to generate meaningful complexity about what has happened by engaging in a slowly unfolding relational process. At all times, the clinician monitors the reaction of the patient to the alternative perspective. Mentalizing the relationship in MBT must be approached with caution. Side effects stimulated by the clinician are common. For example, the patient’s experience is seen by the clinician as a distortion and the patient is alienated; the process becomes a jointly elaborated pretend mode in which both patient and clinician believe that they are working at depth when they are, in fact, engaged in clever cognitive work but both lose contact with reality. MBT is explicit about managing and working with components of mentalizing the counterrelationship (or the countertransference). Mentalizing the counterrelationship—essentially, using the feelings evoked in the clinician by exchanges with the patient—requires self-awareness on the part of the clinician. Some clinicians default to a state of self-reference whereby they consider most of what they experience in therapy as being relevant to the patient. This default mode needs to be resisted, and clinicians need to be mindful of the fact that their own mental states might unduly color their understanding of the patient’s mental states and that they might tend to equate these mental states without adequate foundation. The clinician therefore has to “quarantine” his or her feelings. How the clinician “quarantines” informs the MBT technical approach to countertransference, which is defined as those experiences, both affective and cognitive, that the clinician has in sessions and thinks might further develop an understanding of mental processes. Feelings in the clinician are not considered initially as a result of projective processes, and the clinician must identify these experiences clearly as his or her own; that is, they are “marked.” The purpose of expressing the counterrelationship is to explore the dyadic interaction in more detail, to explore how mind states affect mind states. As an example, a patient who is intimidating in attitude will evoke a sense of wariness or fear in the clinician, and exploring this interaction in its immediacy will be important if the patient is to modify his or her relationships.
Summary MBT is rooted in a theoretical framework derived from neuroscience and attachment research. The focus of the intervention is on increasing the stability of mentalizing processes in patients with BPD and ASPD whose difficulties arise from vulnerability to losing mentalizing, particularly in relationships. Treatment is structured according to a research-based protocol and organized around identification of the triggers of episodes of nonmentalizing. A relational process is used to promote the ability of patients to maintain their affect and mentalizing within intimate relationships and during stressful interactions.
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