Mentalization-based treatment - summary of chapter 30 of Handbook of personality disorders

Handbook of Personality Disorders
Chapter 30
Mentalization-based treatment

Origins of mentalization-based treatment

Mentalizing is the capacity to understand ourselves and others in terms of intentional mental states. It includes an awareness of mental states in oneself or in other people, particularly when it comes to explaining behaviour. It involves a spectrum of capacities 1) the ability to see one’s own behaviour as coherently organized by mental states 2) to differentiate oneself psychologically form others.

The capacity to mentalize emerges in the context of early attachment relationships. This is a key determinant of self-organization and affect regulation.

The role of mentalizing should be understood as a central element of child social development.

Scope and focus: general or disorder-specific domains of psychopathology

The account of mentalizing and psychopathology focuses strongly on the development of the systems for social processes. These drive many higher-order social-cognitive functions underpinning interpersonal interactions. Four of these functions are of primary importance in understanding many severe personality disorders: 1) Affect representation and related affect regulation 2) Attentional control 3) The dual arousal involved in maintaining an appropriate balance between mental function undertaken by the anterior and posterior posterior portions of the brain 4) mentalization.

These capacities emerge in the context of the primary caregiving relationships experienced by the child. They are affected by the quality of the child’s social context. The developmental achievement of these capacities is particularly vulnerable to extremes of environmental deficiency.

Overview of the treatment model

MBT is organized around the development of an attachment relationship with the patient. It offers a careful focus on the patient’s internal mental processes, primarily of affect, as they are experienced moment by moment. It emphasizes the therapeutic relationship following principles of marking and contingency of affect states, with the active repair of ruptures in the relationship.

The emphasis is on identifying the context in which serious breaks in mentalizing occur, with the aim of restoring mentalizing and eventually enabling he patient to maintain mentalizing. The core to this process is exploring mentalizing problems within the context of the individual attachment experiences that are activated within the patient-clinician relationship.

Basic principles and procedures of MBT are: 1) collaborative process 2) formulation of patient relational and mentalizing problems early in treatment, and a focus on those in each session 3) general processes include Identification of nonmentalizing processes, monitoring of state of affective arousal and identification of mentalizing polarities. 4) Therapist stance includes not-knowing stance of curiosity, authentic interest, responsiveness to internal states of mind, interventions consistent with the patient’s mentalizing capacity, focus on maintaining clinician mentalizing and ppen-minded 5) Trajectory of sessions, interventions are structured from empathic validation to exploration, clarification, and challenge through affect identification and affect focus, to mentalizing the relationship itself 6) a focus on contingency and marking of interventions 7) explicit identification of clinician feelings related to the patient’s mental processing.

Diagnosis, assessment and formulation

In the initial phase of MBT, the diagnosis of PD is discussed with the patient. A crisis plan is made, and a formulation of the patient’s problems is discussed and agreed upon.

In providing the diagnosis, the clinician emphasizes his or her own thinking about the key problem areas for the patient and how they coalesce. This must be presented in terms of the patient’s history and current state, with the aim of stimulating the patient’s reflection on his or her own state. The clinician emphasizes evidence of gradual improvement over time.

The aim is to collaboratively create a platform of understanding on which the treatment can be based. Over the course of treatment, the formulation is revisited by both patient and clinician, and modified as new evidence becomes apparent.

Theoretical foundations

Theory of disorder

The mentalizing approach aims to provide a comprehensive theoretical account of the phenomenology and origins of borderline personality disorder from a developmental psychopathology perspective, leading to a more informed treatment approach.

The approach is strongly rooted within contemporary attachment theory.  

BPD is associated with increased levels of insecure attachment styles.

According to attachment theory, the development of self occurs in the affect regulatory context of early relationships, which requires consistent and contingent and marked mother-infant interaction. To achieve normal self-experience, the infant requires its emotional signals to be accurately or contingently mirrored by an attachment figure. The mirroring must be slightly distorted, if the infant is to understand the caregiver’s display as part of his or her emotional experience rather than an expression of the caregiver’s experience. Disorganization of the attachment system results in disorganization of the self-structure.

Two processes unfold: the development of mentalization depends on the social co-construction of internal states between child and parents and brutality in an attachment context can disrupt mentalization as part of an adaptive adjustment to adversity when a child is in a state of helplessness in relation to those individuals.

Early emotional neglect in particular predisposes an individual to developing BPD by limiting his or her opportunity to acquire mentalization.

Fundamental theoretical constructs

Disruptions in mentalizing

Several factors can disrupt the normal acquisition and later development of mentalizing. Most important is psychological trauma early or late in childhood.

Childhood attachment trauma undermines the capacity to think about mental states in giving narrative accounts of one’s past attachment relationships and even in trying to identify the mental states associated with specific facial expressions. This may be due to 1) the defensive inhibition of the capacity to think about others’ thoughts and feelings in the face of the experience of genuine malevolent intent of others and he overwhelming vulnerability of the child 2) excessive early stress, which distorts the functioning of arousal mechanisms, causing the inhibition of orbitofrontal cortical activity 3) any trauma that arouses the attachment system. Attachment trauma may do so chronically.

The arousal of attachment may have specific inhibitory consequences for mentalization, in addition to that which might be expected as a consequence of increased emotional arousal.

Epistemic trust and epistemic rigidity

Through the down-regulation of affect triggered by proximity seeking in the distressed infant, attachment establishes a lasting bond between child and caregiver and opens a channel for information to be used for knowledge transfer between generations.

Attachment insecurity is associated with a greater likelihood of cognitive closure, a lower tolerance for ambiguity and a more pronounced tendency for dogmatic thinking.

Epistemic freezing is a tendency to defend existing knowledge structures even when they are incorrect or misleading.

Developmental adversity may trigger a profound destruction of trust. Once epistemic trust has been lost, it absence creates an apparent ‘rigidity’, which is perceived by the communicator, who expects the recipient to modify his or her behaviour on the basis of the information received and apparently understood. In the absence of trust, the capacity for change is absent. The person a (temporary) reduced capacity to learn.

The p factor in psychopathology

Psychiatric disorders may be more convincingly explained by a hierarchical model that assumed disturbance to occur at a syndromal (mood disorder), spectral (internalizing), and overarching general psychopathology level. The p factor score emerges when disorders are studied longitundinally, and it is associated with increased severity and chronicity.

The p factor is a statistical construct. It may be an indication of a state of engagement with environmental influences, but conditioned by social experiences of maltreatment. It culminates in a sense of general openness to environmental influence, potentially measured as epistemic trust. An individual with a high p factor score in one in a state of epistemic hypervigilance and chronic epistemic mistrust.

Princples of change

Mentalization in therapy is a generic way of establishing ‘epistemic trust’ between the patient and the therapist, in a way that helps the patient to relinquish the rigidity. This is a trust in the authenticity and personal relevance of interpersonally transmitted information.

The relearning of flexibility allows the patient to go on to learn, socially, from new experiences and achieve change in his or her understanding of social relationships and own behaviour.

The experience of being mentalized is a necessary trigger.

Feeling understood in therapy restores trust in learning from social experience, and serves to regenerate a capacity for social understanding.

There are three staged processes at work in the achievement of therapeutic change in the treatment of BPD 1) the teaching and learning of content 2) the re-emergence of robust mentalizing 3) the re-emergence of social learning beyond therapy.

Principal intervention strategies and method

Engagement to model

MBT begins with a 10-12 session introductory group for 10 patients. This combines psychoeducation with an experiential group process. Each session focusses on a specific topic and the patients undertake a series of structured exercises. Following completion of the group, patients are offered an individual session to review the work prior.

Empathy and support

Use of emphatic statements is a way to deepen the rapport between patient and clinician and a powerful way to maintain mentalization by reducing arousal in the interpersonal interaction.

The therapeutic relationship is intrinsically an emotionally invested relationship in which the representation of the other person’s mental state is closely linked to the representation of the self. The thoughts and feelings of self and other are highly contingent on each other. When two minds are experienced as having overlapping thoughts and feelings and influencing each other, empathy is taking place.

An empathic intervention in MBT is a clinical translation of the process of marking, in the context of contingent responsiveness. The clinician demonstrates that (s)he is in the mental shoes of the patient and able to understand the patient’s feelings and emotions without being taken over by them. The person empathized with experiences compassion, understanding, care and tenderness.

Sympathy is an expression of concern for the other through expression of comprehension of the other’s plight or emotional state.

MBT is mostly concerned with empathic validation.

The clinician needs to come to a conclusion about the overall shape of the current relationship from the perspective of the patient.

The clinician needs to establish an emphatic and validation position before (s)he can do anything else.

Components of empathy

In MBT the clinician must consider two components of empathy: 1) the identification with the feelings of the patient. The clinician recognizes the feeling, manages it in herself, and is not taken over by it. The patient needs to experience the clinician as recognizing the patient’s emotional state, yet not be disturbed by it. MBT requires the clinician to be ordinary, in doubt, say to the patient what you would say to a friend. 2) If the patient feels like this, what are the consequences of that feeling to the patient? To be empathic, it is necessary to identify the emotion and how this leaves the patient.

Exploration and clarification

As soon as the clinician senses that (s)he and the patient have a shared affective platform through the empathic process, exploration and elaboration takes place, with the clarification of mental states. The clinician brings in some of her or his own thoughts about it.

Clarification requires: a reconstruction of events, an emphasis on the changing mental states, a tracing process over time and a recognition that decisions may in the end be capricious yet of value even if they turn out to be a mistake.

Challenge

MBT recommends judiciously challenging the patient. There are a number of indicators for challenge: 1) it is considered specifically when a patient is interminably in nonmentalizing mode 2) less direct attempts to rekindle mentalizing must have bene ineffective 3) the clinician believes that (s)he is being excluded from the process 4) the patient is in danger of believing his or her own narrative without question or reflection.

Challenge has certain characteristics: 1) it is nearly always outside the normal therapy dialogue 2) it is a surprise to the patient and outside the current dialogue 3) the aim is for the patient to be suddenly derailed in his or her nonmentalizing process 4)if the intervention is successful, the clinician initiates a ‘stop and stand’ moment to prevent the patient form continuing in the same mode.

Once a stop-and-stand challenge is effective in halting nonmentalizing, it is important to rewind to the point at which either the patient or the clinician was mentalizing.

Identification of affect and affect focus

Once the clinician and patient are able to maintain a mentalizing interaction, MBT suggests an increasing focus on affect and the interpersonal process characterized by the attachment strategies activated through the patient-therapist interaction. This increases emotional intensity and the clinician can move to mentalizing the relationship.

The focus on affect is to re-create the core sensitivity of people with BPD in the session itself. People with BPD are highly sensitive to interpersonal process. MBT for PD focuses on this area of sensitivity to generate more robust mentalizing around interpersonal processing. To do so, MBT starts by trying to identify an affect focus.

The affect focus is a way of increasing the affective experience within the interpersonal relationship in the session. The affect focus is the clinical exemplification of moving the patient around one of the dimensions of mentalizing. It makes explicit what is currently implicit within the patient-therapist relationship. It requires the clinician to recognize that both (s)he and the patient are making unquestioned, jointly held, unspoken assumptions. The clinician names the shared experience as a process that is shared between them without being characterized explicitly.

Accurate identification of the current affectively salient focus allows the clinician to segue to mentalizing the relationship.

The treatment relationship

The treatment relationship is a focus for MBT at a number of levels: 1) the constant attention to collaboration 2) the development of an alliance through agreed-upon goals and shared focus 3) the empathic position of requiring the clinician to see things from the patient’s perspective 4) the focus on shared affective processes.

The aim of mentalizing the relationship is to create an alternative perspective by focusing the patient’s attention to another mind and to assist the patient in the task of contrasting his or her own perception of him- or herself how (s)he is perceived by another.

Mentalizing the counterrelationship

Working with the counterrelationship is part of the clinical translation of the self and other dimensions of mentalizing.

Mentalizing the counterrelationship links to the self-awareness of the clinician and often relies on the affective components of mentalizing.

Clinicians have to ‘quarantine’ their feelings. How we do that informs the MBT technical approach to countertransference. The clinician must identify experiences clearly as her or his own.

The simplest way to release countertransfernce experience from quarantine without equating the clinician’s feelings with that of the patient is to state ‘I’ at the beginning of an intervention. The clinician’s current experience of the process of therapy with the patient is to be shared openly to ensure that the complexity of the interactional process may be considered. Patients need to be aware that their mental processes have an effect on others mental states nad that these will influence the direction of the interaction.

The process of treatment

Each session there is a recommended stepwise move from a supportive position toward a more relational subject experiential process. MBT requires the clinician to start from an empathic and supportive position before moving toward a more relational focus. Clinicians use empathic validation as the starting point.

Clinicians first need to find out the subjective truth of the patient’s experience and to demonstrate that they have understood it form the patient’s perspective.

The clinician manages process within the session by pacing the flow of the session.

As a session moves forward, it is sometimes necessary either to pause to consider and explore the moment or to move it back to retrace the process or re-examine the content.