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

2. 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

3. 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.

4. 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

5. 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

6. 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

7. 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

8. 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).

9. 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.

10. 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

11. 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

12. 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

13. “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:pp

14. 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

15. 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

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

17. 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

18. 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

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

20. 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

21. 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,

22. 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 )

23. 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.

24. 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

25. MBT Scotland
Thank you for listening For more information contact