Mentalization Based Therapy :

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Mentalization Based Therapy

• Dr Linda Treliving
• Consultant psychiatrist in psychotherapy, NHS
  Grampian

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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

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Mentalization

• the capacity to recognise and understand the
  existence of minds, both ones own and those of
  others.
• to recognize that human behavior is motivated by
  mental statesby things like thoughts, beliefs,
  feelings, and desires.

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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

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What does good mentalizing looklike?

• 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

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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 ones
  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

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• 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).

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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.

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The hyperactivation ofattachment 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

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Attachment provocation in clinical situations

• In the ward
• Stimulation of attachment system in admission
• Changing shifts
• Discussing discharge
• At interview
• Clinician lowering voice
• Increasing intimacy
• Responding/refusing to demands
• Boundary violation however small

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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

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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) , 67,3pp187-211
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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

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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

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Interventions Spectrum
Supportive/empathic
Most involved
Clarification, elaboration
Basic mentalizing and challenge
Least involved
Mentalizing the relationship
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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 patients mind trip their mind back
  to a more reflective process
• Use humour when possible

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Interventions Spectrum
Supportive/empathic
Most involved
Clarification and elaboration
Basic mentalizing and challenge
Least involved
Mentalizing the relationship
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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

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Anthony Bateman, Peter Fonagy

• Mentalization based therapy.
• Weekly group plus individual sessions
• Am. J. Psychiatry 1999 15615631569
• 18-Month Follow-Up
• Am. J. Psychiatry 2001 15836-42
• 8 year follow up
• Am. J. Psychiatry 2008 165 631,

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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 )

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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.

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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
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MBT Scotland

• Thank you for listening
• For more information contact linda.treliving_at_nhs.n
  et