Mentalization-Based Treatment

Mentalizing

Mentalizing

Capacity to understand ourselves and others in terms of intentional mental states

Thinking & feeling at the same time, having the mind in mind, the heart in mind

Recognising that what's inside us influences us in many different ways

Understanding misunderstanding

Fundamental and developmental part of people, and something you never fully "succeed in learning"

Why can humans live in such large social groups?

Because we have the ability to make a whole set of interpretations about the person's mental state, intentions etc, which allows us to collaborate with them

Effective Mentalizing

Being open to alternative perspectives

Taking responsibility, forgiveness, humility

Doubt or curiosity, openness to alternative perspectives

Turn taking

Thinking about life story

Belief in changeability

Awareness of the impact of affect

Etc.

Non-effective mentalizing

Being very certain about the mental states of others (I'm sure he's mad at me")

Rigidity

Apparent lack of interest in mental states

Overfocused

Not: Being highly emotionally aroused, because you can still mentalize (even though it's harder)

What is the theoretical framework of mentalization-based therapy?

Initially, improving the mentalizing capacity

Over the past 10-15 years, more of a complex understanding - concept of epistemic trust was developed

What is the “Window of tolerance” with mentalizing?

The fact that you need to be in a certain state of arousal (not too low, not too high) in order to effectively mentalize. If arousal is too low, there is numbness and shutdown, if it’s too high, you cannot see the other person’s perspective

What is the ideal framework of mentalizing development?

Caregiver:

• Reflects accurately the intentions of the child (mirroring) • Marked (baby-talking is an example of this; establishes "I think you're feeling this") /contingent/congruent

Child develops:

• Affect regulation

• Notion of a mind by being in mind

• Agency and subjective sense of self - only in the presence of someone else they develop

Are prewired to develop mentalizing, but need someone else to develop

Attunement

If you mirror something wrong, you can tell that you were wrong and figure out what the correct answer is (together with the patient)

What are the three mentalizing modes, when do they show up and what happens if something goes wrong?

Teleological (0-1,5 years):

Object constancy (if I can't see it, it's not there, panic when they don't see caregiver).

Their understanding of the world is based on external actions and characteristics.

Internal mental states can only be affected by physical actions/impact.

In patients: Only know they're loved if they get reassurance through Whatsapp messages Sometimes overlaps with:

Psychic equivalence (1,5-3 years):

Own internal = external reality

Concrete understanding/suspension of doubt (I feel (that there's a monster under the bed), so there must be)

Rigid beliefs and thoughts "Knowing/reading" the minds of others

No room for alternative perspectives

In patients: I don't feel stuck, I am stuck. Need to join that perspective initially Flashbacks: Feeling that you are in the situation

Pretend (3-4 years)

Internal reality is disconnected from external reality i.e. Pretend play: chair is a train, if you dress up as a knight you are a knight

Feelings of emptiness / dissociation Have all kinds of insights that are not directly linked to actual mental states Circularity without confusion

Hyper-mentalizing

Dissociation

What are some dimensions of mentalizing?

Cognitive: capacity for perspective-taking and belief-desire reasoning (the capacity to understand people’s actions based on their beliefs and desires)

How do we know that epistemic trust is not innate?

Young children are very mistrustful of new information - first need to develop a good filter

What happened in the experiment where a child was asked to give an object to an experimenter?

1. Child is just asked to give one object to the experimenter (50%)

2. Experimenter expresses preference (70% of time child gives preferred object)

3. Other experimenter asks for the child to give the object (77% child gives object that first experimenter preferred -- generalizing)

4. Pay attention to the child (mentalizing and generalization happens). Don't pay attention to the child: Child doesn't generalize the preference to the second experimenter

What are the 3 mentalizing techniques that people learn about when they do mentalization-based therapy?

1. Teaching and learning content

2. Communication of therapeutic treatment model, group psychotherapy, think about therapy from a common perspective

3. The re-emergence of mentalizing

   1. Reinstating mentalizing when it's lost, entering into a "not knowing" stance

      1. Apply social learning in the wider environment

What is some evidence for mentalizing being an effective treatment?

Since 2017, lots of meta-analyses that show that MBT works for BPD

Symptomatic improvement: people can lose their diagnosing

Interpersonal improvement: less improvement

Less connection to the world around them

Evidence MBT is better for more severe cases or BPD in adolescents

Mentalizing: Now being broadened for use in other disorders as well

How does MBT work?

Not many techniques/exercises in MBT: more of a principle focused therapeutic model

Collaborative process: Client is expert on him/herself

Highly structured and clear focus in the treatment phases and sessional structure

Consistent, coherent, continuous

Acknowledge what the patient brings to the table, not assuming you know "more"

Interventions are focused on affective  arousal level and mentalizing

Active not-knowing therapeutic stance

How are people in MBT told to behave “Like a normal person”

Having a good time = mentalizing

Placing yourself in their shoes

What do I think/feel and how might that help the process

Model honesty, courage, but also humility

We all lose our mentalizing capacity sometimes, even if you're a professional

What are the treatment plans for MBT?

• Dynamic formulation (case conceptualization): Linking mentalizing assessment

• Addressing 5 goals of MBT: Commitment, Reducing general psychiatric symptoms, improve interpersonal relationships, reduce destructive behaviours, improve societal functioning)

• Try to make SMART goals

• For example: Try to get them to consider what they're feeling just before something bad happens (when you feel misunderstood, you withdraw)

• Initial treatment phase: Individual psychotherapy and crisis management, psychiatric consultation

• Intensive treatment phase: Group therapy, individual psychotherapy and crisis management

• Final treatment phase: Lowering frequency of therapy

What are the way different aspects of mentalizing develop in different attachment styles?

What are some strengths of MBT?

Low dropout rates and better effectiveness with patients with more severe symptoms

What is the social commmunicative perspective?

A perspective that includes social and cultural context in developing mentalizing. It proposes that effective changes in mentalizing are due to one of 3 systems

What are the 3 communication systems as proposed by the social communicative perspective

Communication system 1: the treatment should contain effective and self-relevant models of the mind to the patient

Communication system 2: Reactivating the patient’s capacity for epistemic trust within a trusting therapeutic environment. The goal is to enhance mentalizing and foster the virtuous cycle of salutogenesis

Communication system 3: Reengagement with the social world by mentalizing. This frees the patient of isolation

What creates vulnerability for BPD according to MBT treatment?

Early neglect/ early environment incompatible with understanding oneself and others creates vulnerability for BPD

Therapeutic relationship in MBT

Very important, collaborative

Clinician tries to see things from patient’s perspective

Transference not to explain things, but to discuss client-therapist relationship for the benefit of the client

What are the 5 goals of MBT?

Commitment, Reducing general psychiatric symptoms, improve interpersonal relationships, reduce destructive behaviours, improve societal functioning)