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MENTALIZATION: An Examination of this Therapy for BPD
Topics on this Page
MBT Shows Promise
MBT & Reduction in Suicide Attempts
Mentalization & Disorganized Attachment

Mentalization Based Therapy (MBT)  by John M. Grohol, Psy.D.

Mentalization based therapy (MBT) is a specific type of psychodynamically-oriented psychotherapy designed to help people with borderline personality disorder (BPD). Its focus is helping people to differentiate and separate out their own thoughts and feelings from those around them.

People with borderline personality disorder tend to have unstable and intense relationships, and may unconsciously exploit and manipulate others. They may find it difficult or impossible to recognize the effects their behavior has on other people, to put themselves in other people’s shoes and to empathize with others.

Mentalization is the capacity to understand both behavior and feelings and how they’re associated with specific mental states, not just in ourselves, but in others as well. “ Mentalization” is the ability to perceive the mind of others as distinct from one's own and hence to reconsider and reassess one's own perceptions of reality.  It is theorized that people with borderline personality disorder (BPD) have a decreased capacity for mentalization. Mentalization is a component in most traditional types of psychotherapy, but it is not usually the primary focus of such therapy approaches.

In mentalization-based therapy (MBT), the concept of mentalization is emphasized, reinforced and practiced within a safe and supportive psychotherapy setting. Because the approach is psychodynamic, therapy tends to be less directive than cognitive-behavioral approaches, such as dialectical behavior therapy (DBT), another common treatment approach for borderline personality disorder.

In someone with BPD, the difference between the person’s inner experience and the perspective given by the therapist (or others), as well as the person’s attachment to the therapist (or others), often leads to feelings of bewilderment and instability.

Unsurprisingly, this leads to more, rather than less, problems in the person’s life. It has been proposed that people with BPD have hyperactive attachment systems as a result of their history or biological predisposition, which may account for their reduced capacity to mentalize. They would be particularly vulnerable to side-effects of psychotherapeutic treatments that activate the attachment system.

Yet without activation of the attachment system, people with BPD will never develop a capacity to function in a healthy manner in the context of interpersonal relationships.

Mentalization, like socialization or public speaking, is a skill which can be readily learned. People who undergo MBT will find that their therapy experience focuses on learning and practicing this skill in the context not only of their social relationships with others, but also directly with their therapist.


Mentalization-Based Therapy Shows Promise With BPD  by Mark Moran

All of the structured psychotherapies—including dialectical-based therapy, transference-based therapy, and schema-focused therapy—are proving superior to treatment as usual in randomized control trials.

Five years after discharge, patients with borderline personality disorder (BPD) treated with mentalization-based therapy during partial hospitalization followed by maintenance mentalizing group therapy showed clinical and statistical improvement on a range of measures compared with patients receiving treatment as usual.

Those measures included suicidality, diagnostic status, service use, use of medication, global function, and vocational status, according to a report in the March 17 edition of AJP in Advance.

“More striking than how well the mentalization-based treatment group did was how badly the treatment-as-usual group” fared despite extensive treatment, wrote study authors Anthony Bateman, M.D., and Peter Fonagy, Ph.D.“ They look little better on many indicators than they did at 36 months after recruitment to the study. A few patients in the mentalization-based treatment group had made at least one suicide attempt during the postdischarge period, but this was almost 10 times more common in the treatment-as-usual group.

“The treatment-as-usual group also experienced more emergency room visits and greater use of polypharmacy,” Bateman and Fonagy added.

The study, “8-Year Follow-Up of Patients Treated for Borderline Personality Disorder: Mentalization-Based Treatment Versus Treatment as Usual,” is the latest analysis of a randomized trial first reported in AJP in October 1999 and titled “Effectiveness of Partial Hospitalization in the Treatment of Borderline Personality Disorder: A Randomized Controlled Trial.”

Joel Paris, M.D., an expert on BPD, explained that mentalization therapy, developed by Bateman and Fonagy in the 1990s, is based on attachment theory and on observations that BPD patients have a failure of“ mentalization”—the ability to observe their own emotions and those of other people and to appreciate how their behavior may affect others.

“Mentalization-based therapy can be considered as an amalgam of psychodynamic and cognitive methods,” he told Psychiatric News.

For instance, a case report included in the study describes a 24-year-old woman who was referred from forensic services after her arrest for setting fire to her university dormitory.

She had a history of recent suicide attempts and regularly burned herself with cigarettes and a hot iron. In individual sessions, treatment initially focused on clarifying her own feelings and others' experience of her; later it progressed to helping her appreciate how her experiences of self-doubt and emotional turbulence led to a sense of fragmentation that was controlled only by experiences of intense physical pain, according to Bateman and Fonagy.

“The individual therapist identified these processes while focusing on the way she represented her own mental states and those of others with whom she interacted,” they wrote. “Gradually this was explored within the relationship with the therapist.”

They report the patient as stating, “It never occurred to me that what I did had an effect on anyone else.”

As explained in the 1999 AJP report, the original study was conducted at the Halliwick Psychotherapy Unit at St. Ann's Hospital in London. Halliwick offers partial hospitalization consisting of long-term psychoanalytically oriented treatment to 30 patients aged 16 to 65 who have borderline or severe personality disorder.

Forty-four patients were randomly assigned either to treatment by means of partial hospitalization or to standard outpatient psychiatric treatment.

Mentalization-based treatment by partial hospitalization consisted of 18-month individual and group psychotherapy in a partial-hospital setting offered within a structured and integrated program provided by a supervised team.

Treatment for the partially hospitalized group consisted of once-weekly individual psychoanalytic psychotherapy; thrice-weekly group analytic psychotherapy (one hour each); and a weekly community meeting (one hour), all spread over five days. In addition, on a once-per month basis, subjects had a meeting with the case administrator (one hour) and medication review by the resident psychiatrist.



(Excerpt from)    "Affect Regulation, Mentalization, and the Development
of the Self"   
  By Peter Fonagy