Mentalization Based Therapy :
Dr Linda Treliving
Consultant psychiatrist in
psychotherapy, NHS Grampian
Why mentalization based therapy?
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Evidence based
Psychodynamic treatment
Rooted in attachment and cognitive therapy
Requires limited training with moderate levels of
supervision
• Implemented by generic mental health
professionals
• MBT skills accessible to non mental health staff
and is simple intervention for complex group
Mentalization
• the capacity to recognise and understand
the existence of minds, both one’s own
and those of others.
• to recognize that human behavior is
motivated by mental states–by things like
thoughts, beliefs, feelings, and desires.
Mentalization
• Everybody will struggle to mentalize at
times but people with borderline PD and
other diagnoses have more consistent
difficulty and can account for signs and
symptoms
• Underpins clinical understanding, the
therapeutic relationship and therapeutic
change regardless of modality of therapy
What does good mentalizing look
like?
• Perception of own mental functioning
– appreciation of changeability
– developmental perspective
– awareness of impact of affect
• Self-presentation
– consistency in sense of self
• General values and attitudes
– tentativeness and moderation
What does non-mentalizing
look like?
»Excessive detail to the exclusion of motivations, feelings
or thoughts.
»Focus on external social factors, such as the school, the
council, the neighbours.
»Focus on physical or structural labels.
»Preoccupation with rules, responsibilities.
»Denial of involvement in problem.
»Blaming or fault-finding.
»Expressions of certainty about thoughts or feelings of
others.
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Prementalizing modes of cognition
• psychic equivalence - the equation of
one’s mental states with reality
• pretend mode - the dissociation of mental
states from reality
• teleological – only action that has physical
impact can alter mental state in self or
others
Attachment Theory
Attachment theory is about proximity,
an experience of safety and the
consequential development of robust,
flexible psychological processes that
protect the individual from the stresses of
human interaction and everyday life
(Bowlby,1969, 1973, 1980).
Development of affect regulation
and a positive sense of self
– the infants states are noted by the caregiver
– carer communicates their understanding of
the infants emotional experience to the infant
not merely an expression of the carers own
conflicts or an exact copy of the infants
distress.
The hyperactivation of
attachment in BPD
• The attachment system in BPD is hypersensitive
and triggered too readily
• Indications of attachment hyperactivity in core
symptoms of BPD
– Frantic efforts to avoid abandonment
– Pattern of unstable and intense interpersonal
relationships
– Rapidly escalating tempo moving from acquaintance
to great intimacy
Attachment provocation in clinical
situations
• In the ward
– Stimulation of attachment system in admission
– Changing shifts
– Discussing discharge
• At interview
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Clinician lowering voice
Increasing intimacy
Responding/refusing to demands
Boundary violation however small
BPD and attachment
• Borderline patients have a history of
disorganized attachment (94%) which
leads to problems in affect regulation,
attention and self control
• These problems are mediated through a
failure to develop a robust mentalizing
capacity
“The development of an attachment based
treatment programme for borderline
personality disorder”
The mediator between the genotype and the
phenotype is the attachment process…..
Anthony Bateman and Peter Fonagy
Bulletin of the Menninger Clinic
(2003) , 67,3:pp187-211
Mentalization based therapy
• Aims to strengthen patients’ capacity to
understand their own and others mental states
in attachment contexts in order to address
difficulties with –
– Affect regulation
– Impulse regulation
– Interpersonal functioning
Bateman and Fonagy 2009
Mentalization based stance – what
does it look like?
• Therapist adopts a stance of inquisitive,
not knowing
• Alert to patients mentalizing and level of
arousal in session
– Intervenes to restore mentalizing
– Maintains arousal at optimal level
• Collaborative, normal human relationship
Interventions: Spectrum
Least involved Most involved
Supportive/empathic
Clarification, elaboration
Basic mentalizing and challenge
Mentalizing the relationship
Supportive and Empathic
 Respectful of the patients narrative and
expression
 Positive/hopeful but questioning
 Constantly check-back your understanding
– ‘as I have understood what you have
been saying is…
 Spell out emotional impact of narrative
based on common sense psychology and
personal experience
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Clarification, elaboration,
• Make behaviour explicit– extensive detail of
actions
• Trace action to feeling
• Re-construct the events in affective and mental
state terms
challenge
• Surprise the patient’s mind; trip their mind back
to a more reflective process
• Use humour when possible
Interventions: Spectrum
Least involved Most involved
Supportive/empathic
Clarification and elaboration
Basic mentalizing and challenge
Mentalizing the relationship
Mentalizing the relationship
• Using the feelings between the patient and
therapist to understand how each others
minds work.
• Point out feelings where possible
• Comment on recurring life patterns
• Link these experiences to here and now
• Pay attention to feelings engendered in
the therapist
Anthony Bateman, Peter Fonagy
Mentalization based therapy.
Weekly group plus individual sessions
• Am. J. Psychiatry 1999; 156:1563–1569
18-Month Follow-Up
• Am. J. Psychiatry 2001: 158:36-42
8 year follow up
• Am. J. Psychiatry 2008: 165: 631,
Results:
Five years after discharge MBT vs TAU continued to show
clinical and statistical superiority.
• suicidality (23% versus 74%)
• diagnostic status (13% versus 87%)
• service use (2 years versus 3.5 years of psychiatric
outpatient treatment)
• use of medication (0.02 versus 1.90 years taking three
or more medications)
• global function above 60 (45% versus 10%)
• vocational status (employed or in education 3.2 years
versus 1.2 years )
Why mentalization based therapy?
•
•
•
•
Evidence based
Psychodynamic treatment
Rooted in attachment and cognitive therapy
Requires limited training with moderate levels of
supervision
• Implemented by generic mental health
professionals
• MBT skills accessible to non mental health staff
and is simple intervention for complex group.
MBT Scotland
MBT skills, 2 day course
Plus supervision of
cases
MBT basic, 3 days
Plus supervision of
cases
MBT practitioner certificate
Plus supervision of
cases and CPD
MBT Scotland
Thank you for listening
For more information contact
linda.treliving@nhs.net