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Mentalization Therapy

Alexis Heitman, Kaylee Jackson & Jenelee Fross

literature review

Literature review

Mentalization and Mentalization Based Therapy

Techniques & Principles Cont...

Symptom, alexithymia and self-image outcomes of Mentalisation-based treatment for borderline personality disorder: a naturalistic study

Techniques & Principles Cont...

Literature Review

Techniques & Principles Cont...

  • Effectiveness of MBT on BPD or other general psychiatric disorders
  • Naturalistic Setting
  • Client Self-Survey
  • MBT proved to be effective
  • Symptom Severity didn't have an impact on the effectiveness of MBT

Challenge:

  • An ability to challenge the client’s perspective whilst exploring their underlying emotional state
  • This is accomplished with the ability to :
  • mount the challenge at an intensity that matches the patient’s way of thinking and functioning
  • grasp the moment to explore the underlying experience of the patient in relation to a rigid psychological state
  • monitor their reaction to the challenge.

Item 3: challenging unwarranted beliefs, Item 8: Pretend mode

Exploration:

  • An ability to help the client develop curiosity about their motivationsμ
  • An ability to help the client identify the failure to read minds and its consequences
  • An ability to share the therapist’s perspective so as to help the client to consider an alternative experience of the same event
  • An ability to help the client shift the focus from non-mentalizing interaction with the therapist towards an exploration of the current feelings and thoughts, as manifest in the client-therapist interaction
  • An ability to draw the client’s/group’s attention to the rupture or impasse so as to explore what has happened, focusing on the felt experience of each participant

Item 6: Stimulating mentalizing through the process, Item 9: Psychic equivalence, Item 12: Stop and rewind

Mentalization-based therapy for parents in entrenched conflict: A random allocation feasibility study

The initial task of MBT is to stabilize emotional expression. Therapist do this by focusing on mentalizing instead of behavior, cognition or insight.

Steps in mentalizing include using techniques of empathy, support and clarification, and then move to other interventions that work on attachment relationships in controlled conditions. The relationship attachment is started with the mentalizing of transference in the client-therapist relationship.

  • The first step in the transference is the validation of the transference and getting the client's perspective.
  • The second step is to explore thoughts and feelings .
  • The third step is the therapist accepting the process.
  • The fourth step is collaborating on the interpretation.
  • The fifth step is for the therapist to present an alternative perspective and the final step is to monitor the reaction of both the therapist and the client.

The biggest thing about MBT is that it is not much different than other interventions, it just focuses on the mentalization aspect which is usually undeveloped or developed wrong during traumatic life events during childhood.

Clarification:

  • An ability to respond to requests by the client for clarification in a direct and clear manner that models a self-reflective stance open to correction
  • An ability to use clarification and elaboration to gather a detailed picture of a behavioral sequence and associated feelings
  • An ability to help the client make connections between actions and feelings
  • An ability to clearly restate and elaborate for the client the therapist’s understanding of thoughts, feelings, beliefs and other mental states described by the client and to do so in a way that opens discourse about these rather than closing it off

Item 12: Stop and rewind, Item 16: Monitoring own understanding and correcting misunderstanding

Affect focus:

  • An ability to communicate to the client/group the affective process that inhibits the capacity to mentalize
  • An ability to identify emotional states jointly with the patient without labeling them unilaterally
  • Capacity to use subjective states to identify an affect shared between patient and therapist

Item 10: Affect focus, Item 11: Affect and interpersonal events, Item 13: Validation of emotional reactions

Literature Review

Techniques & Principles Cont...

  • Effects of MBT on parents and children post dependency case
  • Randomized Study
  • No Quantitative Evidence but Qualitative Evidence present
  • Authors suggest more studies on generalized population

Techniques & Principles Cont...

Mentalization-based therapy (MBT); an overview

Relationship:

  • An ability to critically reflect on when and how to self-disclose:
  • An ability to communicate to the client the therapist’s own way of thinking about experiences brought by the client (disclosing the therapist’s probable emotional reactions and thoughts in the relational context described by the client
  • An ability to communicate to the client, through relevant questions and observations, the therapist’s openness to reflecting on their own ‘non-mentalizing errors’ and how they may have impacted on the client
  • An ability to model honesty by acknowledging the therapist’s own errors
  • An ability to make use of the here-and-now relationship with the therapist to help the client identify failures of mentalization and explore their consequences
  • An ability to identify collapses in mentalizing, as they occur in the patient, the therapist or both in order to identify the rupture or impasse and re-establish mentalizing

Item 11: Affect and interpersonal events, Item 14: Transference and the relation to the therapist, Item 15: Use of countertransference

In utilizing these competencies with the client, the therapist will keep the client in the metalization process and stay mentally close to the client.

Support and empathy:

  • An ability to establish and maintain a supportive, reassuring and empathic relationship with the client
  • An ability to sustain a positive, supportive stance without undermining the client’s autonomy
  • An ability to critically consider the appropriateness of supportive interventions that may involve taking concrete action within therapeutic boundaries
  • An ability to judiciously praise the client when the client uses mentalizing with a positive outcome so as to encourage and support change

Item 4: adaptation to mentalizing capacity, Item 5: Regulation of arousal, Item 7: acknowledging positive mentalizing

  • MBT is organized around an 18-month period
  • Four important dimensions of mentalizing
  • Dialectical Behavior Therapy (DBT) vs MBT

References

Techniques & Principles Cont...

Not-knowing, genuine and inquisitive therapist stance:

  • An ability to communicate with the client in a direct, authentic, transparent manner, using simple and unambiguous statements so as to minimize the risk of over-arousing the client
  • An ability to adopt a stance of ‘not knowing’ which communicates to the client a genuine attempt to find out about their mental experience
  • An ability to sustain an active, non-judgmental mentalizing stance that prioritizes the joint exploration of the client’s mental states
  • An ability to communicate genuine curiosity about the client’s mental states through actively enquiring about interpersonal processes and their connection with the client’s mental states
  • An ability to follow shifts and changes in the client’s understanding of their own and others’ thoughts and feelings
  • An ability to become aware of and respond sensitively to sudden and dramatic failures of mentalization in the client

Item 1: Engagement, interest and warmth, Item 2: Exploration, curiosity and a not-knowing stance, Item 13: Validation of emotional reactions, Item 11: Affect and interpersonal events

Techniques & Principles Cont...

These interventions are broken down into 7 competencies/EBP areas that therapist uses with the client:

1. Not-knowing, genuine and inquisitive therapist stance

2. Support and empathy

3. Clarification

4. Exploration

5. Challenge

6. Affect focus

7. Relationship

Literature review

  • Bateman, A., & Fonagy, P. (2010). Mentalization based treatment for borderline personality disorder. 11-15. Retrieved October 08, 2018, from https://onlinelibrary.wiley.com/doi/full/10.1002/j.2051-5545.2010.tb00255.x.
  • Bateman, A., & Daubney, M. (2015). Mentalization-based therapy (MBT): an overview. Australasian Psychiatry 2015, Vol 23(2) 132–135. DOI: 10.1177/1039856214566830 apy.sagepub.com
  • Bateman, A. W., Bales, D., & Hutsebaut, J. (2014). A Quality Manual for MBT. Retrieved from https://www.annafreud.org/media/1217/a-quality-manual-for-mbt-edited-april-23rd-2014-2.pdf
  • Byrne, G., & Egan, J. (2018). A Review of the Effectiveness and Mechanisms of Change for Three Psychological Interventions for Borderline Personality Disorder. Clinical Social Work Journal,46(3), 174-186. doi:10.1007/s10615-018-0652-y
  • Hertzmann, L., Target, M., Hewison, D., Casey, P., Fearon, P. & Lassri, D. (2016). Mentalization based therapy for parents in an entranced conflict: A random allocation feasibility study. Psychotherapy, 53(4), 388-401.
  • Lof, J., Clinton, D., Kaldo, V. & Ryden, G. (2018). Symptom, alexiathymia and self-image outcome of mentalisation-based treatment for borderline personality disorder: A naturalistic study. BMC Psychiatry, 18(185), 1-9.
  • Reichenberg, L. W., & Seligman, L. (2016). Selecting effective treatments: A comprehensive, systematic guide to treating mental disorders. Hoboken, NJ: Wiley. P496-497

A Review of the Effectiveness and Mechanisms of Change for Three Psychological Interventions for Borderline Personality Disorder

Techniques & Principles

  • Identity and impulsive borderline clusters
  • Focuses on strategies that help the individual maintain
  • Specific measures for mentalizing ability not included

population & Settings

The principles of MBT are to create an attachment that focuses on the relationships and the stimulation of the mentalizing process. There are 17 therapeutic stances/interventions for MBT:

1. Engagement, interest, warmth and authenticity

2. Exploration, curiosity and a not-knowing stance

3. Challenging unwarranted beliefs

4. Adaptation to mentalizing capacity

5. Regulation of arousal

6. Stimulating mentalization through the process

7. acknowledging positive mentalizing

8. Pretend mode

9. Psychic equivalence

10. Affect focus

11. Affect and interpersonal events

12. Stop and rewind

13. Validation of emotional reactions

14. Transference and the relation to the therapist

15. Use of countertransference

16. Monitoring own understanding and correcting misunderstanding

17. Integrating experiences from concurrent group therapy

Overview

Population

  • Originally used as an EBT for Borderline Personality Disorder (BPD)
  • Now also used for clients presenting symptoms of: impulsivity, dysregulated emotions and lack of early attachment.

Settings

  • Has been provided in Inpatient Facilities and general outpatient services
  • Individual, Group or Family Components
  • 'Mentalizing Environment'

Mentalization-Based Therapy (MBT)

  • Mentalization is a process in which we make sense of ourselves, those around us and the world. In the sense of understanding the misunderstood.
  • Mentalization-based therapy (MBT) is the most widely accepted EBT for borderline personality disorder (BPD). It integrates "cognitive and relational components of therapy with a foundation based in attachment therapy. MBT seeks to provide a safe therapeutic environment in which the client can focus on anxiety provoking internal states.”
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