Mentalization Based Therapy : Dr Linda Treliving Consultant psychiatrist in psychotherapy, NHS Grampian

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

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. 6

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 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 Supportive/empathic Most involved Clarification, elaboration Basic mentalizing and challenge Least involved 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 17

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 Supportive/empathic Most involved Clarification and elaboration Basic mentalizing and challenge Least involved 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 MBT basic, 3 days 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