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Mentalization-based therapy

Mentalization-based therapy (MBT) is a type of long-term psychotherapy that aims to improve the capacity to mentalize in people with borderline personality disorder (BPD) and other mental health conditions. Mentalizing is the ability to understand how one’s own and other people’s actions are influenced by mental states, such as thoughts, feelings, beliefs and wishes. MBT helps people with BPD to regulate their emotions, control their impulses, and enhance their interpersonal relationships by increasing their awareness of their own and others’ mental states and how they affect behaviour. In this article, we will discuss the history, concepts usage and effectiveness of mentalisation-based therapy.

What is mentalization-based therapy?

MBT draws from several psychotherapeutic approaches, such as psychodynamic, cognitive-behavioural, systemic and ecological therapies, and integrates them into a coherent framework. MBT was developed in the 1990s by Anthony Bateman and Peter Fonagy, based on attachment theory and research on the development of mentalizing in children and adults. It consists of individual and group sessions, usually lasting for 12 to 18 months, in which the therapist creates a safe and supportive environment for the client to explore their current difficulties and to mentalize about them. The therapist also helps the client to identify and challenge their distorted or non-mentalizing modes of thinking, such as teleological (focusing on outcomes rather than intentions), psychic equivalence (confusing reality with one’s own perspective), or pretend mode (ignoring or denying reality).

MBT has been shown to be an effective treatment for BPD, with symptom improvement sustained years after the end of treatment. MBT can also be used for other mental health conditions that involve impaired mentalizing, such as antisocial personality disorder, addiction, eating disorders, and depression.

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Non-mentalizing styles

MBT is based on the premise that mentalization is a key determinant of psychological well-being and interpersonal functioning, and that deficits in mentalization are associated with various psychiatric disorders. MBT helps clients to recover their mentalizing abilities when they enter a state of non-mentalization, which can occur in response to stress, trauma, or attachment difficulties.

Teleological mode is a form of non-mentalization that relies on observable actions or outcomes as evidence for mental states. For example, a person in teleological mode may think that someone loves them only if they buy them expensive gifts or do what they want. Teleological mode is often characterized by a “prove it” attitude that demands concrete proof for feelings or intentions. Teleological mode can lead to distrust, manipulation, or coercion in relationships.

This mode of thinking is typified when a person assumes that actions are driven by goals or outcomes, without considering the underlying mental states. In another example, a person may think that their partner is cheating on them because they want to hurt them, without considering their partner’s feelings or motivations.

Psychic equivalence is a form of non-mentalization that equates internal feelings with external reality, without recognizing that their perceptions may be biased or distorted by their emotions. For example, a person in psychic equivalence may think that if they feel angry, someone must have done something wrong to them, or if they feel guilty, they must have committed a crime. Psychic equivalence is often characterized by a lack of perspective-taking and differentiation between self and others. Psychic equivalence can lead to emotional dysregulation, impulsivity, or paranoia in relationships. In another example, a person may think that they are worthless because they feel worthless, without considering other evidence or perspectives.

Pretend mode is a form of non-mentalization that disconnects thoughts and feelings from reality and evidence. For example, a person in pretend mode may think that they are happy even when they are suffering, or that they are in love even when they are abused. Pretend mode is often characterized by a lack of emotional authenticity and connection with others. Pretend mode can lead to denial, dissociation, or fantasy in relationships. This mode is typified when a person detaches from reality and uses fantasy or imagination to cope with distressing situations, without acknowledging the impact of their actions on themselves or others. For example, a person may act as if they are happy and confident, while ignoring their actual feelings of sadness and insecurity.

Correcting non-mentalizing thinking

People with BPD often have difficulties in mentalizing, especially when they are emotionally aroused or in interpersonal situations. They may resort to non-mentalizing modes of thinking, such as teleological, psychic equivalence, or pretend mode. In MBT, the therapist uses techniques such as clarification, confrontation, challenge, interpretation, questioning, and feedback to facilitate mentalizing and to address maladaptive patterns of behaviour. Some of these techniques are:

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Clarification: This is when the therapist asks the client to elaborate or explain their thoughts or feelings more clearly, to identify and correct any misunderstandings or confusions. For example, the therapist may ask the client: “What do you mean by saying that you hate yourself? Give me some examples of what makes you feel this way?”

Confrontation: This is when the therapist points out any inconsistencies or contradictions in the client’s statements or behaviours, to highlight the gaps or errors in their mentalizing. For example, the therapist may say to the client: “You deny caring about your friend’s opinion, but you seem very upset by what she said. How do you explain this discrepancy?”

Challenge: This is when the therapist questions or challenges the validity or accuracy of the client’s assumptions or beliefs, to encourage them to consider alternative possibilities or perspectives. For example, the therapist may ask the client: “How do you know that your boss hates you? Have you ever talked to him about it? Could there be another explanation for his behaviour?”

Interpretation: This is when the therapist offers a tentative hypothesis or explanation for the client’s thoughts, feelings, or behaviours, based on their observation and understanding of the client’s mental states. For example, the therapist may say to the client: “I wonder if you are feeling angry with yourself because you think that you have failed in some way. Is that possible?”

Questioning: This is when the therapist asks open-ended questions that invite the client to reflect on their own or others’ mental states, to enhance their awareness and curiosity. For example, the therapist may ask the client: “How do you think your mother feels about your decision? What do you think she wants for you?”

Feedback: This is when the therapist provides honest and empathic feedback to the client about their thoughts, feelings, or behaviours, to validate their experience and help them to learn from it. For example, the therapist may say to the client: “I can see that you are feeling very anxious right now. I think it’s understandable that you feel this way, given what you have been through. How do you cope with your anxiety?”

Effectiveness of MBT

MBT has been shown to be effective in reducing self-harm, which is one of the most common and serious outcomes of psychological distress. Self-harm is often a way of coping with overwhelming emotions or trying to communicate distress to others. However, self-harm can also have negative consequences, such as physical injury, infection, scarring, stigma and increased risk of suicide. MBT can help people who self-harm by enhancing their mentalizing skills, which can enable them to better understand and regulate their emotions, communicate their needs more effectively, and empathize with others’ perspectives. MBT can also help them to develop alternative coping strategies that are less harmful and more adaptive.

For example, a person who self-harms may have difficulty in recognizing and expressing their feelings of anger, sadness or loneliness. They may also have distorted beliefs about themselves or others, such as thinking that they are worthless or that others don’t care about them. They may act impulsively on their emotions without considering the consequences or the impact on others. Furthermore, they may also feel ashamed or guilty about their self-harm and try to hide it from others. In MBT, the therapist would help the person to identify and name their emotions, to explore the reasons behind them, and to challenge any unhelpful or unrealistic thoughts. The therapist would also help the person to reflect on how their self-harm affects themselves and others, and to consider alternative ways of coping that are more constructive and satisfying. The therapist would also encourage the person to share their feelings and experiences with others in a safe and supportive environment, such as a group session or a family session.

MBT has been tested in several clinical trials and has demonstrated positive outcomes for people who self-harm. For instance, a study by Rossouw and Fonagy (2012) compared MBT with treatment as usual for adolescents who had borderline personality disorder and had recently self-harmed. They found that MBT was more effective than treatment as usual in reducing self-harm, suicidal behaviour, depression, anxiety and interpersonal problems over 18 months of follow-up. Another study by Griffiths et al. (2019) examined the feasibility of a group-based MBT for adolescents who had recently self-harmed. They found that MBT was acceptable and safe for the participants, and that both MBT and treatment as usual led to significant reductions in self-harm, emergency department presentations for self-harm, social anxiety, emotion regulation difficulties and borderline traits over 12 months of follow-up. They also found that mentalization was a significant predictor of change in self-harm outcomes.

In conclusion, MBT is a promising intervention for people who self-harm, as it can help them to improve their mentalizing skills, which can enhance their emotional well-being, interpersonal functioning and quality of life. MBT can be adapted for different populations and settings, such as adolescents, adults, groups or families. MBT has been supported by empirical evidence from clinical trials that show its effectiveness in reducing self-harm and other psychological difficulties.

Borderline personality disorder

Mentalization-based therapy (MBT) is a form of psychodynamic psychotherapy that has been proven to be beneficial in the management of borderline personality disorder (BPD). MBT encourages an individual to focus on how their mental states affect their own behaviour, as well as the behaviour of others.

MBT has been supported by several studies that have shown its effectiveness in reducing psychiatric symptoms associated with BPD and its comorbid disorders, such as depression, anxiety, self-harm, and suicidal behaviour. For example, a randomized controlled trial by Bateman and Fonagy (2009) compared MBT with structured clinical management (SCM), a treatment that includes medication, psychoeducation, and crisis management. They found that MBT was superior to SCM in reducing suicidal and self-harm behaviours, severity of BPD symptoms, and psychiatric service use after 18 months of treatment. Another randomized controlled trial by Bales et al. (2012) compared MBT with treatment as usual (TAU), which consisted of standard psychiatric care. They found that MBT was superior to TAU in reducing depressive symptoms, interpersonal problems, and social adjustment after 18 months of treatment.

MBT can be delivered in different formats, such as individual therapy, group therapy, or a combination of both. MBT follows a specific structure and technique that focuses on the present rather than the past, and on the interaction between the patient and the therapist. The therapist does not give advice or opinions, but rather asks questions that help the patient explore their mental states and their links to behaviour. The therapist also helps the patient identify and correct mentalizing failures, such as jumping to conclusions, overgeneralizing, or ignoring emotions. The therapist provides a safe and supportive environment that fosters curiosity, reflection, and empathy.

Further reading

If you would like to learn more about MBT, here are some weblinks for further reading:

Mentalization-based therapy (MBT) Tavistock and Portman

Mentalization-Based Therapy | Psychology Today

Mentalization Therapy: Definition and More Verywell Health

Mentalization-based treatment Wikipedia

Metallization-Based Therapy: Approach and Techniques Healthline

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