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Mental Disorders

Mentalization-Based Treatment (MBT) Continued

Simone Hoermann, Ph.D., Corinne E. Zupanick, Psy.D. & Mark Dombeck, Ph.D.

By way of example, let's examine why mentalization might be a particularly helpful skill for someone with a Borderline Personality Disorder. Attachment theory contends that people with a Borderline Personality Disorder have a particular type of insecure attachment called disorganized attachment. A disorganized attachment is characterized by bouncing back and forth between the desire for interpersonal closeness (intimacy) and the desire for interpersonal distance (autonomy).Thus, a person with disorganized attachment vacillates between pushing others away in one moment, only to want closeness again once interpersonal distance has been achieved. To those on the receiving end of this interpersonal tug-of-war, it can become very confusing.  Indeed, partners of people with Borderline Personality Disorder often feel they can never seem to do anything right.  When pushed away, they try to be respectful of their partners need for space.  However, once they do so, they can be harshly criticized or accused of not loving or caring about their partner enough.

According to attachment theory, our attachment system becomes activated in close relationships.  Thus, someone with a disorganized attachment would be expected to demonstrate this "come-close…no wait, go-away…no wait, come back" pattern in close, interpersonal relationships.  People with the Borderline Personality Disorder exhibit this pattern, and experience relationships in a very intense, but chaotic manner.  Lacking the ability to regulate their intense emotions, they can become easily overwhelmed.  Thus, assisting recovering persons to learn the skill of mentalization would correct these problems. Mentalization allows them to self-regulate and self-soothe, enabling them to relate to others in a calmer and secure manner.  

MBT begins with the development of a warm and empathic therapeutic alliance. This provides a context to learn the important skill of mentalization.  Learning a new skill is similar to the process of training a muscle, with the therapist serving the role of a coach.

The therapist takes on a fairly active role by encouraging the recovering person to reflect upon present-day interpersonal interactions and relationships. This includes interactions that occur  during therapy sessions.  The atmosphere of the therapy sessions (individual and group) is one of curious exploration and investigation. A shared responsibility develops  between the therapist and therapy participant(s).

The mind of the participant literally becomes the focus of treatment.  The therapy participants come to know and understand what their minds are thinking. They also learn to identify and label the feelings that arise in response to what their minds are thinking. Therapy participants learn their thoughts and feelings do not necessarily represent facts.  Recognizing this, they then they evaluate any errors or misjudgments about themselves or others that may have led to some negative consequences.  Some of the techniques the therapist may use to help participants develop this capacity include: 1) helping participants to identify what it is they are feeling, and learning to verbalize those feelings, 2) examining what brought about these feelings, or what happened right before the feelings emerged, and 3) carefully considering the consequences of their behaviors. Just like in TFP and DBT, the focus of the therapy is on what happens in the present; or as therapists like to say, in the "here-and-now," not the "there-and-then" of the therapy participant's life. Typically, there is a weekly session with an individual therapist and a once-a week group session in which group members learn from one another.

Let's take a look at how a MBT group therapy session might go: Jennie tells the group about a conflict she recently had with a friend. Jennie blurts out angrily, "She is so self-centered, she's just a bitch!" The therapist may first guide Jennie to understand her own feelings and motivations and then guides Jennie to understand the feelings and motivations of her friend. Focusing on the here-and-now, the therapist may say, "What are you feeling right now as you talk about this conflict with your friend?" and, "What do you suppose is motivating your anger?"

In addition to identifying her angry feelings, Jennie would be encouraged to become aware of her other (unexpressed) feelings as well. The other group members may assist her.  Could Jennie be feeling a sense of betrayal? Perhaps Jennie's friend is not so self-centered after all. Maybe Jennie's experience of her friend as "as a self-centered bitch" is because of Jenny's own need to be at the center of her friend's attention. Perhaps her recent conflict caused Jenny to become painfully aware that she was not.  Jennie may be feeling sadness or even panic about the possibility of losing an important friendship.  Maybe Jennie is somewhat jealous over her friend's popularity and perhaps she resents having to "share" her friend with other people.  As these unexpressed feelings are explored and expressed (when applicable), the therapist will model for Jennie and for the other group members, an acceptance and kind understanding about each and every experience. Through this new experience Jennie would begin to be soothed and comforted.  As she experiences a soothing response from the therapist, she gradually learns how to soothe herself. 

The therapist will also guide Jennie to evaluate the simplistic conclusion that her friend is "just a bitch." The therapist might ask, "Can you think a little bit more about why your friend might behave like this?" Since Jennie does not yet have the ability to mentalize, she may simply repeat, "Because she's a bitch!" The therapist may then ask if there could be an alternative explanation for her friend's behavior. If Jennie does not generate an alternative idea, the therapist may turn to the group and ask the other group members for ideas. Eventually, the group will attempt to consider what might motivate someone to "behave like a bitch." Members may offer suggestions such as Jennie's friend might feel insecure. Further questioning by the therapist will guide Jennie and her therapy group to understand that often people are motivated to become the center of attention when they feel lonely and neglected. This greater understanding improves Jennie's capacity for a compassionate and empathic response to her friend so that she can more easily resolve the conflict with her. Furthermore, Jennie will be asked to consider the consequences of failing to mentalize, such as losing an important friendship.