Manual - MBT Nederland

Manual
for
Mentalization-based treatment (MBT)
and
MBT adherence and competence scale
Version individual therapy
Sigmund Karterud & Anthony Bateman
Version 1/2011
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Foreword
Psychotherapy treatment manuals provide guidance for therapists to deliver specific
treatment modalities for specified patient groups. Luborsky and Barber (1993) defined
treatment manuals as professional literature containing the following three elements:
1) A description of the main principles which underline the therapeutic techniques;
2) 2) specified examples of all therapeutic techniques, and
3) 3) scales and instruments which are designed in order to assess the therapists skill
with the therapy model.
In this manual, the main principles are outlined in two chapters. Firstly we briefly
explain the concept of mentalizing. Second we explain the main principles for mentalization
based treatment (MBT). Third we discuss general requirements for adherence scales. Finally
we describe the MBT adherence and competence scale, followed by a detailed description of
each item of the scale, illustrated by a range of clinical examples. At the end of this manual
you will find the MBT scale, a clinical scale for reflective functioning (RF), and guidelines
for a dynamic MBT formulation.
This manual has, as most other psychotherapy manuals, two principle purposes. The
first is to serve as a tool for training. The second is as a kind of control instrument to monitor
therapeutic practice, i.e. assessment of adherence and competence for research and
supervision purposes.
This manual relies on previous work by Bateman and Fonagy (2004, 2006) and a draft
of an MBT adherence scale suggested by Bateman in the volume “Mentalization-based
treatment for borderline personality disorder. A practical guide” (Bateman & Fonagy 2006).
This draft has been developed further in cooperation between the authors. The work by the
MBT group at Department for Personality Psychiatry, Oslo University Hospital, Ullevaal, has
been essential in this process. This is described in the thesis “Development of an assessment
scale for mentalization-based therapy” by Magnus Engen (2009). The MBT-group has
consisted of Øyvind Urnes, Merete Johansen, Theresa Wilberg, Christian Schlüter, Magnus
Engen, Paul Johansson and Sigmund Karterud. Parts of the manual (the paragraphs on
combined therapy and MBT dynamic formulation) are modified versions of chapters in
“Personality Psychiatry” (Karterud, Wilberg & Urnes, 2010). Other parts (dimensions of
mentalizing, MBT individual mode and item examples) are modified versions of chapters in
“Mentalizing in Mental Health Services” (Bateman & Fonagy, 2010).
Oslo, April 2010
Sigmund Karterud
Anthony Bateman
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Content:
1. Mentalization
Definition
Historical roots
Mentalization, self development and attachment
Mentalization and personality disorders
Dimensions of mentalizing
Implicit and explicit mentalizing
Internal and external mentalizing
Self and other mentalizing
Cognitive and affective mentalizing
Mentalization measured as reflective functioning (RF)
Recommended readings
2. Mentalization-based treatment (MBT)
MBT and mentalization oriented psychotherapy
MBT as day hospital treatment
MBT as intensive outpatient treatment
MBT, personality assessment and dynamic formulation
MBT as concurrent psychotherapy
MBT individual mode
Training in MBT
3. On treatment integretity scales in general
Treatment integrity
Adherence and quality
Connection between adherence, quality and outcome
Constructing the items
Quantifying the scale
4. The structure of the MBT adherence and competence scale
Constructing the items
Quantifying the scale
Rating procedures
Training of raters
Feedback for supervision
5. The items in MBT adherence and competence scale
General considerations
Engagement, interest and warmth
Exploration, curiosity and a not-knowing stance
Challenging unwarranted beleifs
Adaptation to mentalizing capacity
Regulation of arousal
Stimulating mentalization through the process
Acknowledging positive mentalization
Pretend mode
Psychic equivalence
Affect focus
Affects and interpersonal events
Stop and rewind
Validation of emotional reactions
Transference and the relation to the terapist
Use of countertransference
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5.6.
6.7.
7.8.
Monitoring own understanding and correcting misunderstanding
Integrating experiences from concurrent group therapy
MBT adherence and competence scale
Reflective functioning scale (RF)
Mentalization based dynamic formulation
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1. Mentalization
Definition
Mentalization-based treatment (MBT) is grounded in the theory of mentalization.
Mentalization is both a self-reflective and an interpersonal affair (“the problem of other
minds”). It refers to the act of understanding oneself and others, and one’s own experiences
and actions, in terms of mental phenomena, i.e. assumptions, affects, attitudes, wishes, hopes,
knowledge, intentions, plans, dreams, false beliefs, deceptions, etc. The alternative to a
mentalized understanding of self and others is a person who is driven by outer forces, by
simple stimulus-responses, by coincidences, by crude drives and instincts, by disease
processes, etc. Mentalizing can be so simple and obvious that we overlook it, but it can also
be a very challenging business. It presupposes the ability to direct one’s attention to relevant
aspects of intrapsychic and interpersonal phenomena, and for the most part it is implicit and
automatic. In daily life we mentalize each other constantly by attributing intentions to each
other, consciously or unconsciously. Explicit mentalizing means that we engage in a
conscious reflection upon our own and others’ motives and self states. Because of the very
nature of our minds, it will often be the case that our mentalizing endeavours will fail in the
sense that we often misunderstand ourselves and others. We can never be absolutely sure of
what other people are thinking or feeling, and our own thoughts and feelings are also often
vague and unclear. The less proficient we are in mentalizing, the more often we
misunderstand.
Historical roots
The concept of mentalization belongs to a tradition within French psychoanalysis,
understood as the process whereby drives and affects are transformed into symbols (Bouchard
& Lecours 2008). There is also an important link to the British psychoanalyst Wilfred Bion’s
theory (1971) of thinking. The main contributors to the modern content of the concept,
however, are Professor Peter Fonagy and co-workers (2002). The epicentre has been
University College and the Anna Freud Centre in London, but the ongoing discussion about
mentalization in the literature has engaged a wide range of researchers and clinicians (Leuten
et al., 2010). The concept is embedded in a theoretical network containing elements from
evolutionary theory, attachment theory, developmental psychology, psychoanalysis,
neurobiology, group dynamics and personality pathology, to mention the most important.
Historically, it is closely connected to John Bowlby’s theories (1969) concerning “internal
working models” in the mind of young children, contingent upon internal representations of
their attachment experiences. Fonagy and co-workers have developed a general theory of self
development which is rooted in the attachment relationship (Fonagy 1991, 1995, Fonagy &
Target 1997). The theory implies that the attachment relationship among Homo Sapiens is
expanded in scope and function. In addition to providing a system for dealing with fears that
can threaten the security and survival of children, it has become the most important arena for
developing the self and the ability to reflect upon mental states.
Mentalizing, self-development and attachment
The theory of self development and mentalization is thoroughly explained in the
volume “Affect regulation, mentalization and the development of the self “ (Fonagy et al.
2002). Basic questions concerning self development are discussed: How is the self -- which is
the prerequisite for subjectivity and self-reflection -- constituted? (e.g. the experience of being
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separated from other people and things, to be the origin of one’s own actions, to be the agent
and owner of one’s own thoughts and affects, to be able to reflect upon these affects and
thoughts as one’s own) The most important thesis is that the attachment relationship is an
arena where the child’s mental states are experienced, interpreted and mirrored/reflected by an
empathic other; and that it is in this arena the child develops an awareness of himself/herself.
A considerable body of research demonstrates that insecure attachment relationships are
associated with a diminished ability to understand the intentions of others and leads to a
generally lower level of social competence. In particular, disorganized attachment in
childhood is associated with psychopathology in adulthood.
The general theory of self development is in a process of expansion. One important
contributor is the Hungarian psychologist György Gergely, particularly on the problem of
how the core self (which is found among other primates as well) develops into the humane
reflective self (Gergely & Unoka 2008). This development is closely linked to the formation
of self representations and object representations, and to the integration with primary
emotional systems. In order to be able to reflect over oneself and others (objects), the self and
other (and the relationship to important others) must be represented in the memory system.
These representations must be retrievable in the working memory and must be able to be
linked to the past, present and future, and to feelings and relevant alternatives. Moreover, a
consistent self requires there being a unified “actor” who directs the various selfrepresentations, object representations and affect states. Without a reflexive distance, the
individual risks being “lost in emotions”.
Mentalization theory describes how an individual -- through interaction with a
mentalizing other -- achieves a reflexive dialogue with himself or herself. The individual
learns social tools that permit him/her to direct pressures arising from activation of the
primary emotional systems into culturally acceptable forms of expression. It is a theory that
integrates self-consciousness with temperament.
Concepts from developmental psychology that are important to be familiar with
(because they are also used in the clinical treatment literature) are teleological understanding,
psychic equivalence thinking, pretend mode, prementalistic thinking and representational
thinking.
Starting at the age of approximately 9 months, children develop the ability to
differentiate goals from the means to the goal, adapt actions to new situations and select the
means (among various options) that most effectively lead to the goal. One can speak about the
self as a goal-oriented (teleological) actor. The capacity for goal-oriented action does not
require the capacity for cause-effect thinking or the ability to understand intention as cause,
but it links the action to a goal. The term “teleological” is also used about the mode of
thinking in regressive conditions when patients have difficulties believing anything else than
concrete goal-oriented actions: “I won’t believe it until I see it…” and “If you care about me,
then you will…”.
From the age of about two years, the child develops the ability to understand that
others can have intentions (wishes, needs) that can lead to action, without having to
experience the action in real time. For example, the child is now able to contribute in relation
to others’ preferences and to comfort others. We are now talking about the self as an
intentional actor. This ability to think in mentalistic terms is also called “a naïve theory of
mind”. The child is now able to attribute generalised intentions to others, but is governed by a
principle of mental coherence, i.e. that he or she still does not grasp the concept that others
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can contain contradicting intentions. At about this time the child establishes the concept of
“me”. Action impulses, thoughts and feelings become more and more “mine”. The self is
beginning to take form as a self-reflecting actor.
The theory of prementalistic thinking is central to the developmental model. Initially,
thinking is assumed to be at the level of psychic equivalence, which means that the child is
unable to differentiate between inner and outer worlds or between fantasy and reality. These
perspectives are yet to be acquired. One way they are acquired is through play. The nature of
play is precisely to simulate contrasting perspectives on reality. In play, the child imagines
that others are different than they really are. Through play the child learns to juggle between
fantasy and reality. It is most amusing when the two are close together and it is difficult to
differentiate fantasy from reality, e.g. when daddy is almost like the evil troll. When the
ability to differentiate fantasy from reality is not properly developed, the individual continues
to alternate between psychic equivalence thinking where the world might become “too real”,
and a pretend mode thinking which is too separated from reality.
From about the age of four, the child begins to develop a more mature ”theory of
mind”, meaning that intentions are understood as parts of a complex network of
representations of self and other. Such representations motivate behaviour and can more or
less be grounded in reality. The reference now is to the self as a representational actor and it is
at this stage that children first have the capacity to mentalize reasonably accurately. Infantile
amnesia (prior to the age of approximately three) is due to the inability to code personal
experiences as uniquely personal events, i.e. that happened to ”me” in an autobiographical
sense. From now on, the mentalization capacity is growing quickly. The challenge is to be
able to differentiate fantasy from reality in an even more sophisticated manner, i.e. that
thoughts and feelings are representations of reality and not reality itself.
The autobiographical self (from approx. 6 years) is based on the self as a
representational actor. This represents a more thorough transition from procedural memory to
declarative memory (”it happened to me”). Now one can construct more realistic and coherent
stories about one’s own actions and experiences. This ability, however, presupposes the
capacity to maintain multiple representations of oneself and others so that time sequences and
causal and meaningful relations can be made between them. In general, one can say that the
developmental course has as its goal the establishment of the structures and abilities that are
the preconditions for a representational and autobiographical self. To attain this goal depends
on the emotional interaction between the child and attachment figures.
Mentalization theory emphasizes mentalizing ability as the most important aspect of
the self. It provides the self with cohesion. Without mentalization, the individual would be
subject to changing and inconsistent self states constantly at the mercy of inner and outer
events. Mentalization provides meaning and context to these changing self-states. It puts them
in the perspective of one’s own life history and one’s impressions of other people, ongoing
interactions and the future. The ability to mentalize is genetically grounded, but must be
realized through others in order to become manifest.
Mentalization and personality disorders
Mentalization theory is closely associated with the concept and theories of borderline
personality disorder (BPD). This connection reflects the close working relationship between
Peter Fonagy and Anthony Bateman in London, both analysts and active clinicians who treat
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and carry out research on difficult-to-treat borderline patients. Together they developed
mentalization-based treatment (MBT) (Bateman and Fonagy 2004). It is however important to
emphasize that impaired mentalization ability is something that characterizes all personality
disorders. To a certain extent this is self-evident since one of the general criteria for a
personality disorder is that the person suffers from maladaptive thought patterns, e.g. a
tendency to distort and/or interpret interpersonal events in a rigid manner. Mentalization
theory explicates what characterizes distorted and rigid interpretational patterns. The focus is
on ”prementalistic” thought patterns: psychic equivalence thinking and pretend mode. Psychic
equivalence thinking is schematic, concrete, black-white and insisting. The reality it refers to
is ”too real”. There is no room for other perspectives. In pretend mode the relationship to
reality is diffuse. Thought (and speech) is vague, metaphoric and emotionally flat. Cognitive
theory describes distorted and rigid interpretations as maladaptive cognitive schema.
Mentalization theory is less schematic. It emphasizes the importance of affect, context and
attachment more strongly and the therapeutic consequences are different. But the main point
is the same: in all personality disorders the ability to properly interpret interpersonal events
intersubjectively, is impaired to some degree.
An individual suffering from paranoid personality disorder will, for example, interpret
other people as more evil than they actually are, and themselves as more vulnerable to a
conspiracy than that which is actually the case. This is a consequence of the person’s impaired
mentalization ability. But the theory goes even further. It also refers to ”unmentalized
affects”. In the case of paranoid PD, there is a chronic narcissistic rage, an ”alien self” and
projective identification (Fonagy et al. 2002). An individual suffering from paranoid PD
attracts every manner of humiliation without ever being able to forget them. Total
irreconcilability is at its heart and the individual’s thoughts revolve around the theme of
vengeance. It is this interwoven complex of self representations, affects and representations of
others which is poorly mentalized. This means that when the individual experiences new or
old humiliations, he/she quickly resorts to psychic equivalence thinking and becomes rigid,
unreasonable and insisting on his/hers own version of reality. Previous humiliating
experiences and the resulting rage take centre stage and block out nuanced intersubjective
thinking. Accordingly, mentalization-based treatment will necessarily focus on affects.
Mentalization theory emphasizes the general phenomenon which the example of
paranoid PD illustrates: that thinking is influenced by one’s emotional state. If one is
interested and curious, then one is likely to have optimistic thoughts. If one is depressed, one
is likely to have sad and distressing thoughts. If one is manic, one has lofty and unrealistic
thoughts. If one is scared, one may have disconcerting thoughts, and if one is angry, the focus
may be on revenge. Mentalization theory integrates both a “bottom-up” and a “top-down”
perspective. Emotions influence us from ”below” in a way that can make us lose a more
overall perspective on reality. The ability to mentalize allows us to approach emotions ”from
above” and put them into perspective. Mental health depends on a balance between the two
extremes: ”lost in emotions” or ”lost in cognition.”
Dimensions of mentalizing
Mentalizing is a multi-dimensional construct and breaking it down into dimensional
components is helpful in understanding mentalization based treatment (MBT). Broadly
speaking mentalization can be considered as four intersecting dimensions: automatic/
controlled or implicit/ explicit, internal/ externally based, self/other orientated, and
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cognitive/affective process. Each of these dimensions possibly relates to a different
neurobiological system (REF).
None of us, manage to integrate all components of mentalizing all of the time and nor
should we. Normal people will at times move from understanding themselves and others
according to their perceptions of what is in the mind to explanations based on the physical
environment – ‘I must have wanted to because I did it’; ‘If they behave like that they
obviously want to spoil everything’. This is particularly the case in powerful affective states
when our cognitive processes fragment in the face of a wave of emotion. So, personality
pathology does not simply arise because of a loss of mentalizing. It occurs for a number of
reasons.
First it matters how easily we lose it. Some individuals are sensitive and reactive,
rapidly moving to non-mentalizing modes in a wide range of contexts.
Second it matters how quickly we regain mentalizing once it has been lost. We have
suggested that a combination of frequent, rapid and easily provoked loss of mentalizing
within interpersonal relationships with associated difficulties in regaining mentalizing and the
consequent lengthy exposure to non-mentalizing modes of experience is characteristic of
borderline personality disorder (Bateman & Fonagy, 2004). Individuals with borderline
personality disorder may be ‘normal’ mentalisers except in the context of attachment
relationships. They tend to misread minds, both their own and those of others, when
emotionally aroused. As their relationship with another person moves into the sphere of
attachment the intensification of relationships means that their ability to think about the
mental state of another can rapidly disappear. When this happens, prementalistic modes of
organising subjectivity emerge, psychic equivalence and pretend mode, which have the power
to disorganise these relationships and destroy the coherence of self-experience that the
narrative provided by normal mentalization generates.
Third, mentalizing can become rigid, lacking flexibility. People with paranoid
disorder often show rigid hypermentalization with regard to their own internal mental states
and lack any real understanding of others {Nicolo, 2007 #9372} (Dimaggio et al., 2008). At
best they are suspicious of motives and at worst they see people as having specific malign
motives and cannot be persuaded otherwise. The mental processes of people with antisocial
personality disorder (ASPD) are less rigid than those found in paranoid people. Their
mentalizing shows flexibility at times but when uncertainty arises they structure within prementalistic ways of organising their mental processes and how they understand the world and
their relationships.
Finally the balance of the components of mentalizing can be distorted. Patients with
narcissistic personality have a well-developed self focus but a very limited understanding of
others. In contrast patients with ASPD are experts at reading the inner states of others, even to
the point that they misuse this capacity to coerce or manipulate them, whilst being unable to
develop any real understanding of their own inner world. In addition they lack abilities to read
accurately certain emotions, an externally based component of mentalizing, and fail to
recognise fearful emotions from facial expressions. This implicates dysfunction in neural
structures such as the amygdala that subserve fearful expression processing. Marsh and Blair
{, 2008 #9354} in a meta-analysis of 20 studies showed a robust link between antisocial
behaviour and specific deficits in recognizing fearful expressions. This impairment was not
attributed solely to task difficulty.
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Implicit/explicit mentalizing
Most of us mentalize automatically in our everyday lives - not to do so would be
exhausting. Automatic or implicit mentalizing allows us to rapidly form mental
representations based on previous experience and to use those as a reference point as we
gather further information to confirm or disconfirm our tentative understanding of
motivations. This is reflexive, requires little attention and is beneath the level of our
awareness (Satpute & Lieberman, 2006). If it does not seem to be working we move to more
explicit or controlled mentalizing which requires effort and attention. It is therefore slower
and more time-consuming and most commonly done verbally. Our capacity to manage this
controlled mentalizing varies considerably and the threshold at which we return to automatic
mentalizing is, in part, determined by the response we receive to our explicit attempts to
understand someone in relation to ourselves and the secondary attachment strategies we
deploy when aroused and under stress.
Behavioural, neurobiological and neuroimaging studies suggest that the move from
controlled to automatic mentalizing and thence to non-mentalizing modes is determined by a
‘switch’ between cortical and sub-cortical brain systems (Arnsten, 1998) (Lieberman, 2007)
and that point at which we switch is determined by our attachment patterns. Different
attachment histories are associated with attachment styles that differ in terms of the associated
background level of activation of the attachment system, and the point at which the switch
from more prefrontal, controlled to more automatic mentalizing occurs [Luyten, submitted
#3361]. Dismissing individuals tend to deny attachment needs, asserting autonomy,
independence and strength in the face of stress, using attachment deactivation strategies. In
contrast, a preoccupied attachment classification or an anxious attachment style are generally
thought to be linked with the use of attachment hyperactivating strategies [Mikulincer, 2008
#3342]. Attachment hyperactivating strategies have been consistently associated with the
tendency to exaggerate both the presence and seriousness of threats, and frantic efforts to find
support and relief, often expressed in demanding, clinging behavior. Both AAI and self-report
studies have found a predominance of anxious-preoccupied attachment strategies in BPD
patients [e.g. \Fonagy, 1996 #2899; Levy, 2005 #2343]. In borderline patients we and others
have noted a characteristic pattern of fearful attachment (attachment-anxiety and relational
avoidance), painful intolerance of aloneness, hypersensitivity to social environment,
expectation of hostility from others, and greatly reduced positive memories of dyadic
interactions [e.g. \Gunderson, 2008 #3125; Critchfield, 2008 #3451; Fonagy, 1996 #2899].
An important cause of anxious attachment in BPD patients is the commonly observed
trauma history of these individuals. Attachment theorists, in particular Mary Main and Erik
Hesse, have suggested that maltreatment leads to the disorganization of the child’s attachment
to the caregiver because of the irresolvable internal conflict created by the need for
reassurance from the very person who also (by association perhaps) generates an experience
of lack of safety. The activation of the attachment system by the threat of maltreatment is
followed by proximity seeking, which drives the child closer to an experience of threat
leading to further (hyper)activation of the attachment system [Hesse, 2008 #3371]. This
irresolvable conflict leaves the child with an overwhelming sense of helplessness and
hopelessness. Congruent with these assumptions, there is compelling evidence for
problematic family conditions in the development of borderline personality disorder,
including physical and sexual abuse, prolonged separations, and neglect and emotional abuse,
although their specificity and etiological import has often been questioned [e.g., \ZweigFrank, 2006 #3452; New, 2008 #3227]. Probably a quarter of BPD patients have no
maltreatment histories [Goodman, 2002 #3470] and the vast majority of individuals with
abuse histories show a high rate of resilience and no personality pathology [McGloin, 2001
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#3471; Paris, 1998 #3472]. Early neglect may be an underestimated risk factor [Watson, 2006
#3394; Kantojarvi, 2008 #3398], as there is some evidence from adoption and other studies to
suggest that early neglect interferes with emotion understanding [e.g. \Shipman, 2005 #3397]
and this plays a role in the emergence of emotional difficulties in preschool [Vorria, 2006
#3396] and even in adolescence [Colvert, 2008 #3395]. One developmental path to
impairments in mentalizing in BPD may be a combination of early neglect, which might
undermine the infant’s developing capacity for affect regulation, with later maltreatment or
other environmental circumstances, including adult experience of verbal, emotional, physical
and sexual abuse [Zanarini, 2005 #3457], that are likely to activate the attachment system
chronically [Fonagy, 2008 #2949].
BPD patients who mix deactivating and hyperactivating strategies, as is characteristic
of disorganized attachment, show a tendency for both hypermentalization and a failure of
mentalization. On the one hand, because attachment deactivating strategies are typically
associated with minimizing and avoiding affective contents, BPD patients often have a
tendency for hypermentalization, i.e., continuing attempts to mentalize, but without
integrating cognition and affect. At the same time, because the use of hyperactivating
strategies is associated with a decoupling of controlled mentalization, this leads to failures of
mentalization as a result of an overreliance on models of social cognition that antedate full
mentalizing [Bateman, 2006 #10690].
This has important clinical implications for MBT. The therapist needs to develop
strategies related to excessive demand and dependent behaviour as well as ensuring ability to
manage sudden therapeutic ruptures, often characterised by dismissive statements about the
therapists inadequacies with the accompanying danger of leaving treatment
Internal and External mentalizing
The dimension of internal and external mentalizing refers to the predominant focus of
mentalizing (Lieberman, 2007). Internal mentalizing refers to a focus on one’s own or others’
internal states, that is thoughts, feelings, desires; external mentalizing implies a reliance on
external features such as facial expression and behaviour. This is not the same as the
self/other dimension which relates to the actual object of focus. Mentalization focused on a
psychological interior may be self or other oriented. Again, this distinction has important
consequences for MBT. Patients with BPD have a problem with internal mentalizing but they
also have difficulties with externally focussed mentalizing. Inevitably both components of
mentalizing inform each other so borderline patients are doubly disadvantaged. The difficulty
is not so much that patients with BPD necessarily misinterpret facial expression, although
they might sometimes do so, but more that they are highly sensitive to facial expressions and
so tend to react rapidly and without warning (Wagner & Linehan, 1999) (Lynch et al., 2006).
Any movement of the therapist might trigger a response – glancing out of the window, for
example, might lead to a statement that the therapist is obviously not listening and so the
patient might feel compelled to leave; a non-reactive face is equally disturbing as patients
continuously attempt to deduce the therapist’s internal state using information derived from
external monitoring. Anything that disrupts this process will create anxiety, which leads to a
loss of mentalizing and the re-emergence of developmentally earlier ways of relating to the
world.
A reduced ability to arrive at an emotional understanding of others by reading their
facial expressions accurately exaggerates a compromised ability in BPD to infer mental states
from focusing on internal states . To maintain or repair cooperation during
social/interpersonal exchange and interaction, we have to understand social gestures and the
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likely interpersonal consequences when shared expectations about fair exchange or social
norms are violated by accident or intent. To do this we have to integrate external mentalizing
with an assessment of the underlying internal state of mind of the other person. The
importance of this interactional process in the pathology of BPD has been creatively
demonstrated experimentally. Using a multi-round economic exchange game played between
patients with BPD and healthy partners, King-Casas and colleagues (King-Casas et al., 2008)
have shown that behaviorally, individuals with BPD showed a profound incapacity to
maintain cooperation, and were impaired in their ability to repair broken cooperation on the
basis of a quantitative measure of coaxing. They failed to understand the intentions of others –
an internally based task. They expected their partners to be mean to them and they were
unable to change this understanding even when evidence suggested it was incorrect, for
example when their partner was generous. In other words they were unable to read the
intentions of their partner and to alter their own behaviour reciprocally. This gradually led
their partner in the game to become mean, suggesting that they were provoked to become the
very person they were being seen as. Analogously, therapists working with patients with BPD
must bear in mind the risk of being provoked into becoming the very therapist that their
patient accuses them of being
Self and Other Mentalizing
Impairments and imbalances in the capacity to reflect about oneself and others are
common and it is only when they become more extreme that they begin to cause problems.
Some people become experts at reading other people’s minds and if they misuse this ability or
exploit it for their own gain we tend to think they have anti-social characteristics; others focus
on themselves and their own internal states and become experts in what others can do for
them to meet their requirements and we then suggest they are narcissistic. Thus excessive
concentration on either the self or other leads to one-sided relationships and distortions in
social interaction. Inevitably this will be reflected in how patients present for treatment and
interact with their therapists. Patients with BPD may be over-sensitive, carefully monitoring
the therapist’s mind at the expense of their own needs and being what they think the therapist
wants them to be. They may even take on the mind of the therapist and make it their own.
Therapists should be wary of patients who eagerly comply with everything said to them.
Such compliance may alternate with a tendency to become preoccupied and overly concerned
about internal states of mind, leaving the therapist feeling left out of the relationship and
unable to participate effectively.
Cognitive and Affective mentalizing
The final dimension to consider relates to cognitive and emotional processing – belief,
reasoning, and perspective taking on the one hand and emotional empathy, subjective self
experience, and mentalized affectivity on the other (Jurist, 2005). A high level of mentalizing
requires integration of both cognitive and affective processes. But some people are able to
manage one aspect to a greater degree than the other. Patients with BPD are overwhelmed by
affective processes and cannot integrate them with their cognitive understanding – they may
understand why they do something but feel unable to use their understanding to manage their
feelings; they are compelled to act because they cannot form representations integrating
emotional and cognitive processes. Others, such as people with antisocial personality
disorder, invest considerable time in cognitive understanding of mental states to the detriment
of affective experience.
Mentalization measured as reflective functioning (RF)
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An operationalised measure has been developed for mentalization: reflective
functioning (RF) (Fonagy et al. 1998). RF is scored on the basis of a transcript of the adult
attachment interview (AAI) on a scale from -1 (negative or bizarre mentalization) to +9
(sophisticated mentalization). It is possible to achieve good reliability when scoring RF, but it
requires long training. Since scoring is quite time- consuming, the RF-scale is primarily a
research instrument and not suitable for everyday clinical use. Efforts are underway to make
RF scoring easier. Levy et al. (2005) are testing out a scale containing 53 items (”Reflective
Function Questionnaire”), which can be used in various contexts, such as psychotherapy
sessions. A similar scale (RFQ54) is being tested by Fonagy and co-workers. Low RF has
been found for borderline PD and antisocial PD, and low RF in young mothers predicts
insecure attachment patterns for their children (Fonagy et al., 200x). In a recent study,
borderline patients who underwent transference-focused psychotherapy were shown to
increase their RF score (Clarkin et al., 200x).
Recommended reading
A considerable literature is available on mentalization. The following sources are
highly recommended: ”Mentalization-based therapy. A practical guide” (Bateman & Fonagy
2008), ”Psychotherapy for borderline patients. A mentalization-based approach” (Bateman &
Fonagy 2004), ”Handbook of mentalization” (Allen et al., 2007), “Mentalizing in clinical
practice” (Allen et al., 2008) and “Mentalization in mental health services” (Bateman et al.,
2010). The website www.mentalisering.no provides access to an updated wide range of
articles on mentalization.
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2. Mentalization-based treatment (MBT)
MBT and mentalization-oriented psychotherapy
Mentalization-based treatment is founded in the theories of mentalization, personality
disorders and psychodynamic treatment. The MBT approach is relevant not just for
personality disorders, but also for the treatment of depressions, anxiety disorders, posttraumatic conditions, eating disorders and substance abuse disorders (Allen et al. 2008). MBT
is a psychodynamic approach in the sense that the main instrument of change is the
intersubjective interaction taking place between therapist and patient. It is therefore possible
to modify different psychodynamic practices to increase the focus on mentalizing to become a
”mentalization-oriented psychotherapy”. Bateman & Fonagy (2006) suggest that all
psychological therapies exert their influence through their effect on the patient’s ability to
mentalize. MBT cultivates this focus. Even though MBT in the following sections will be
described in a more rigid form, we believe that many of the principles presented here may be
integrated into everyday psychodynamic therapeutic practice.
MBT as day hospital treatment
Guidelines for MBT exist in two formats: as a long-term day hospital treatment
programme and as an intensive outpatient treatment programme. Originally MBT emerged as
a day hospital treatment (Bateman & Fonagy 1999, 2001). The study that documented the
effectiveness of treatment was small with respect to number of patients, but the treatment
results were impressive. In all, 42 low-functioning borderline patients (GAF = 35) in London
were randomized to either experimental day hospital treatment or to the control condition,
treatment as usual. The day hospital treatment programme lasted up to 18 months and was
followed by outpatient group psychotherapy twice a week for a further 18 months. Treatment
as usual consisted of consultations with psychiatrists, pharmacological therapies, crisis teams,
visits to emergency wards, admission to hospitals or other type of day hospital treatment.
After 18 and 36 months, major differences between the groups became evident in a wide
range of variables: suicide attempts, self-injury, hospital admissions, depression, anxiety,
general symptom distress, interpersonal functioning and use of medication. Over the long
term, the treatment also proved to be cost-efficient (Bateman & Fonagy 2006). In a long term
follow-up the differences between the experimental and control groups were maintained
eight-years after randomisation (Bateman & Fonagy 2008). A study in the Netherlands (Bales
et al., 2010) has also showed excellent results for MBT day hospital treatment.
Guidelines for MBT day patient treatment are available in publications from Bateman
& Fonagy (2004, 2006). The treatment focus is upon attachment behaviour and mentalization
skills and consists of a well-choreographed collaborative effort combining individual therapy
and group therapies. The group therapies are the arena for ”mentalizing in practice”.
Experiences from the groups and from the treatment programme in general, as well as from
other life experiences, are discussed in more detail in the individual therapy sessions. The
treatment framework is an important element. Crisis plans are developed and close contact is
maintained with families and health service professionals. Pharmacological treatment is
followed up closely by a psychiatrist. In addition to the mentalization-based interactional
group therapy, patients also attend expressive group therapy sessions (psychodrama, creative
group therapy or group art therapy). More informal interaction takes place in connection with
activities and excursions. Expressive (psychoeducational) mentalization group therapy has
been added recently.
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MBT as intensive outpatient treatment
There have been claims that the treatment results by Bateman & Fonagy (1999) are
not necessarily attributable solely to the mentalization component of the complex day hospital
treatment. Eighteen months of day hospital treatment involves a large number of potential
change mechanisms. The precise content of the treatment technique has also been unclear. In
response to this criticism, an attempt was made to purify MBT to an intensive outpatient
treatment programme. The treatment components include individual therapy for one hour a
week and MBT group therapy once a week for a period of 1.5 to 3 years. The treatment starts
with a psychoeducational MBT group meeting weekly over the course of 2-3 months. The
treatment technique is described in Bateman & Fonagy (2006).
MBT as an intensive outpatient treatment programme, lasting 18 months, has been
tested in a randomized study with 134 borderline patients where the control group was given
”structured clinical management”. The results showed that patients in both treatments
improved, but that the MBT group experienced a more rapid and significant improvement on
variables such as suicide attempts, hospitalizations, symptoms and social adjustment
(Bateman & Fonagy 2009). Outpatient MBT has a larger potential than the more costly
intensive MBT day hospital treatment programme, which is meant for patients scoring below
GAF=40. Most borderline patients function on a somewhat higher GAF level. As long as the
patient has some modicum of structure in their lives, e.g. a place to stay, some social network,
not being involved in self-destructive, ongoing addiction behaviour, being able to adhere to a
treatment agreement and collaborating on a crisis plan, then outpatient MBT will usually be
sufficient. MBT requires a specialized team and is well-suited for Mental Health Centres. At
Ullevål University Hospital, Oslo a programme has been developed to include external
psychiatrists and psychologists in private practice in the treatment programme as individual
therapists. However, there is a challenge to establish close enough cooperation with private
practice professionals to gain synergies from the conjoint individual and group therapy.
MBT, personality assessment and dynamic formulation
MBT requires the administration of a customary personality assessment to map the
type and scope of personality pathology. Guidelines for such asessment are described in
Karterud, Wilberg and Urnes (2010). The treatment is suitable for borderline patients in
general, but may also be effective in treating personality disorders strongly associated with
borderline PD, e.g. paranoid, antisocial (with low degree of psychopathy), narcissistic and
histrionic PD. It is more uncertain how patients with cluster C PD will respond. Treatment of
traumatized persons, mood disorders, panic disorder and eating disorders with this approach is
described by Allen et al. (2007), Rudden et al. (2008) and Skårderud (2008).
During assessment, an MBT dynamic formulation should be developed in order to
consolidate the focus and therapeutic alliance. Guidelines for developing an MBT dynamic
formulation are described in the appendix.
MBT as concurrent psychotherapy
This manual is meant to describe the individual therapy component of MBT. A
separate manual will be developed for MBT group therapy. Both therapeutic components,
however, must adhere to professional guidelines for concurrent psychotherapy. It is therefore
appropriate to review these guidelines at this point.
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Concurrent group and individual therapy appears in the literature by Wender and Stein
(1949), who describe their experiences from an outpatient clinic in New York. Since this
publication, two books on concurrent psychotherapy (Ormont & Strean, 1978; Caligor,
Fieldsteel & Brok, 1984) have been published, as well as a number of articles summarized by
Karterud et al. (2007).
According to Porter (1993), concurrent group and individual therapy is an effective
and specialised treatment form that has its own indications, counter-indications, therapeutic
mechanisms, developmental stages and technical requirements. When the therapy is
conducted properly, there should be a synergistic effect since the two components
complement each other and address different needs. Group therapy is particularly suited for
exploring interpersonal problems, while individual therapy is better suited for exploring
intrapsychic phenomena. Early on, concurrent therapy was viewed as being especially
appropriate for treating borderline patients (Stein, 1964). There is always a danger of a split
developing between the different therapists and the different formats, and this has been a
central theme in the literature (de Zulueta & Mark, 2000; Kegerreis, 2007).
The terms ”combined” and ”conjoint” psychotherapy are commonly used for this type
of therapy. One refers to combined psychotherapy when one and the same therapist conducts
both the group and individual therapy. In conjoint psychotherapy different therapists are
involved. The risk of developing splitting attitudes is a strong argument for combined therapy,
in which one and the same therapist maintains full control. In practice, however, conjoint
therapy is the most common. One reason for this is that not all individual therapists are likely
to master group therapy; nor are all group therapists likely to fully master individual therapy.
There are also good arguments for sharing the therapeutic burden when treating demanding
patients. There is no research that has investigated differential effectiveness between conjoint
or combined therapy programmes.
In conjoint psychotherapy, collaboration between the therapists is a critical factor.
This collaboration assumes a fundamental respect for the unique elements of the different
therapies and a personal and professional respect between the therapists. Many patients will
over shorter or longer periods devalue one of the components and have a tendency to idealise
the other. Even as therapists, we all have a remnant of unmentalized narcissism that tempts us
to accept, implicitly or explicitly, such a split, if we are so lucky to be the idealised party. In
practice, group therapy is most often the component to be devalued because it is the most
complicated dynamically and puts larger demands on the patient’s mentalization ability.
Another reason is that insulting and humiliating episodes are more likely to occur in group
therapy sessions than in individual therapy sessions. In combined treatment processes, we
recommend that the individual therapist asks about recent group experiences at practically
every session. The therapist must also go closely through episodes in which the patient has
felt himself or herself misunderstood, overrun, ignored or poorly treated. These episodes are
grist for the therapeutic mill. It is indeed by working through such episodes that the patient’s
mentalization ability may be challenged, stimulated and in time improved. The patient’s
experiences in group therapy must be a central focus of the individual therapy, on an equal
footing with relationships to other attachment figures.
In time, the individual therapist will develop an inner image of the patient’s
attachment processes based upon the stories told by the patient. The therapist will also gain a
picture of the group with its therapists and other members. The unique feature of the conjoint
16
therapy format is that the individual therapist is able to speak with the group therapist to learn
their version of what the patient is telling in terms of stories and reflections. This access to
other perspectives is important in being able to withstand the often immense pressure that
comes from patients for therapists to share their experience of the world.
In one example from our practice, the patient devalued the group for more than a year.
The individual therapist asked regularly about her group experiences, and continuously was
given the response that the sessions were almost unbearable -- they were incredibly boring,
meaningless, a waste of time and that the patient did not benefit at all from being there. No
particular events, patients or therapists stood out, just simply everything was a waste of time.
As a result, the patient did not attend for group sessions more than every other time. Actually
she submitted to the group only because it gained her access to the individual therapy.
Through the concurrent therapy, the individual therapist obtained more direct contact with this
patient’s tremendous tendency to devalue others and with her destructiveness, which also
manifested itself in other aspects of her life as well. The group therapists were extremely
frustrated by the devaluation of the group and were often tempted to terminate the treatment.
Due to the individual therapist’s encouragement and assurances that the patient seemed to be
progressing, albeit slowly, the group therapists continued treatment. It is important to keep in
mind that the group therapy situation, being immensely complex, might easily provoke
patients, resulting in a collapse of their mentalizing capacity. That is probably why our patient
could not provide a better explanation for her attitude than that “everything” was terribly
boring and meaningless. It came as a great surprise, when, after about a year, the therapist
asked the usual “how was your last group session,” and the patient responded “well, it was
actually quite ok”. After this turning point, major changes took place in this patient’s life and
in her ability for intimacy. The turning point consisted of her realising that one of the other
group members was genuinely interested in her life, and that she herself managed to engage in
a meaningful dialogue with that person in the group itself, without being trapped in
pseudomentalization, which was her customary response.
When treating borderline patients, it is most important that all the therapists involved
speak regularly to each other. The patients are of course informed that the therapists exchange
information. It is the group therapist’s role that is the most difficult in this collaborative effort.
He/she must be careful not to divulge information to the group “behind the patient’s back”. In
a practical sense, it is an advantage if the therapists belong to the same team. They should
meet regularly for professional exchange, at least once a week. There should also be weekly
supervision. It is more complicating if therapists are working at different sites. In such cases
one should think creatively and find solutions suitable for the local conditions. One must of
course meet and get to know each other, but the ongoing information exchange can also take
place on the telephone. It is also possible to exchange information by e-mail if the information
is not sensitive and made anonymous.
It is important that patients are well informed in advance that the MBT concurrent
treatment is a “package deal”. If a patient drops out of one of the components, then the other
component is automatically terminated. This is a guiding principle for the overall treatment
programme. It should help patients think twice before impulsively ending the part of the
therapy that they dislike.
If the patient does leave the MBT programme, the therapist/clinic should provide a
supportive alternative or ensure that the referral agency takes care of further treatment.
17
MBT individual mode
A supportive and empathetic attitude is the foundation for MBT individual therapy.
The therapist must offer himself/herself as a possible attachment figure, thereby becoming
emotionally involved in the patient’s life. The therapist must “care”. Within this holding
relationship, the therapist must find space for investigating, together with the patient, the
patient’s mentalization problems as they manifest themselves in the patient’s life, in areas
such as unmentalized affects, inconsistencies of self, unjustified conceptions of
himself/herself and others and relationships between people, and with special a emphasis on
psychic equivalence thinking and pseudomentalizing. In general one can say that the process
of the encounter between therapist and patient is more important than the content of the
patients’ narratives. MBT places little emphasis on insight in the traditional sense. The most
important objective of MBT is to improve the patient’s mentalization abilities and through
this his/her experience of a more coherent sense of self and competence in interpersonal
functioning. With this aim in mind, the quality of the therapeutic dialogue is crucial. In
individual and group therapy according to MBT principles, the therapist is always trying to
engage the patient in a dialogue which challenges low reflexive functioning (RF). E.g. the
therapist invites the patient to reflect upon alternative explanations of affective interpersonal
events, which are reviewed in detail. Over time, as the relationship to the therapist becomes
more consolidated, this very relationship (transference) moves to the forefront of the therapy.
This relationship, which optimally develops into an attachment relationship, is particularly
well suited for investigating the interaction between “two minds”.
The MBT approach to BPD structures treatment, organizes interventions according to
specific principles bases on an understanding of the development of the disorder and cautions
against therapy techniques which may be harmful because of the core pathology of unstable
mentalizing. It should be pointed out that the aims of MBT are modest: This is not a therapy
aiming to achieve structural/personality change or to alter cognitions and schemas, rather it is
a therapy to enhance embryonic capacities of mentalization so that the individual is better able
to solve problems and to manage emotional states particularly within interpersonal
relationships or at least feels more confident to do so.
The therapist’s mentalizing therapeutic stance should indicate: a) humility deriving
from a sense of “not-knowing”, b) patience in taking time to identify differences in
perspectives, c) legitimizing and accepting different perspectives, d) actively questioning the
patient about their experience – asking for detailed descriptions of experience (“what
questions”) rather than explanations (“why questions”), e) careful eschewing of the need to
understand what makes no sense (i.e. saying explicitly that something is unclear). An
important component of this stance is monitoring one’s own mistakes as a therapist. This not
only models honesty and courage through such acknowledgements and tends to lower arousal
through the therapist taking responsibility, but also offers invaluablbe opportunities to explore
how mistakeks can arise out of mistaken assumptions about opaque mental states and how
mistunderstanding can lead to massively aversive experiences. In this context, it is important
to be aware that the therapist ts constantly at risk of losing their capacity to mentalize in the
face of a non-mentalizing patient. Consequently, we consider therapist’s occational
enactments as an acceptable concomitant of the therapeutic alliance, something that simply
has to be owned up to. As with other breaks in mentalizing, such incidents require that the
process is “rewind and the incident explxored”. Hence, in this colloborative patient-therapist
relationship the two partners involved have a joint responsibility to understand enactments.
There is a constant temptation for therapists to piece things together, to make sense of
things according to their own models of mental functions, in short to mentalize and to deliver
18
their understanding or insight to the patient. In principle this aspect of therapist activity is
antimentalizing – the therapist takes over the mind of the patient rather than stimulating the
patient to develop his own mentalizing process. This leads tro a number of problems. First,
the aim of treatment is to stimulate mentalizing process when it is not present or to maintain it
when it becomes vulnerable to collapse.This is unlikely if the therapist “secretly”, that is
silently within his own mind, pieces things together making tham into a more coherent
narrative according to his own theories and understanding of human function. Paradoxically,
it is the clever or highly trained therapist who is more likely to turn off a patient’s mentalizing
by taking an expert role. Once he finds himself knowing why something is wrong with the
patient and how it can be corrected, he is not mentalizing. Knowing takes many forms – we
profeess a deep understanding of unconscious process, are sure about good and bad thought
processes, we empathically tell patients what they are feeling, all of whhich is non-me
ntalizing stances. The MBT therapist needs to stimulate consideration of underlying processes
rather than socratically demonstrate their inaccuracy, and help the patient attend to his
feelings instead of methodically naming them for him.
Second, the coherence of the therapists understanding might have adverse
consequenses for therapy by inadvertently stimulating pretend mode if the process of
understanding is circumvented. Unable to make personal sense from the therapists
understanding or at best only able to use a cognitive understanding, the patient takes over the
model of the therapist and uses it to develop meaningless representations. These have no
depth; they do not link with earlier representations and understandings or integrate with
emotional experience, and so fail to stimulate integration of mentalizing processes. As a result
the understanding becomes sealed from the external world, lacks utility outside therapy, and
cannot be applied in an ever-widening range of circumstances and contexts.
Once the therapist has adopted the therapeutic stance and stimulated a mentalizing
process his task is to maintain mentalizing within himself and his patient whilst at the same
time recognizing that therapy will potentially destabilize mentalizing by stimulating the
attachment process. Mentalizing will be threatened simply because the therapist probes,
stimulates feelings, asks questions, all of which make the patient anxious. Alert to this, the
therapist moves emotionally closer to the patient during a session only to the point at which
he judges the patient is on the verge of losing mentalizing. At this moment he moves back,
distancing himself from the patient, to reduce the level of emotional arousal.
Here we come across a clinically significant paradox – just at the time that the
therapist will naturally move emotionally closer to the patient we ask that he moves away.
Any person talking with someone who is becoming increasingly disturbed or upset will
naturally become more sympathetic and caring. In being so he will become softer in his
demeanor, speak more quietly and try to demonstrate an ever more profound understanding of
the patients emotional state. Yet this will stimulate the patient’s attachment system leading to
additional loss of mentalizing, particularly in patients with BPD because of the
hypersensitivity of their attachment system. So we ask the therapist to behave counter to his
natural tendency of becoming increasingly sympathetic when the patient becomes emotional
and to distance himself even if momentarily. Once mentalizing is regained he can regain
emotional involvement, probe again, empathize, and focus on the patient-therapist
relationship. But he should not be surprised to find that this rekindles the attachment system
so he needs to monitor sensitively for further loss of mentalizing and to step back rapidly
when necessary. We are not recommending that a caring therapist becomes uncaring. But
caring wrapped in a cloak of sweetness, concern, and sympathy at this moment will add fuel
to the fire, inflaming attachment needs and stimulating further mental deterioration in the
patient just at the time when the task is to stimulate more robust mental processes.
19
A patient became distressed when talking about her boyfriend being sexually
unfaithful. She talked about leaving him but that she loved him and so could not do so. The
therapist made many sympathetic noises during this story and made increasingly supportive
statements about the problem for the patient in coping with her conflicting experience. The
patient became more distressed becoming inconsolable for most of the rest of the session.
This evoked a feeling in the therapist that she should offer an additional session. This
immediately increased the patient’s needs as she then asked if the current session could go on
for longer saying that she thought she could not leave the room. Inadvertently the therapist
had aroused the patient’s dependency and made her more vulnerable by becoming more
sympathetic and offering additional sessions to the patient at a time when she needed to step
back from the patient.
Stepping back in the face of distress needs conscious effort on behalf of the therapist if
it is to be done sensitively. Not only does it go against his instincts and natural tendencies but
it also defies all he learned in training. Therapists tend to lower their voice, speak softly, and
express apprehension in their facial expressions as they become increasingly concerned and
sympathetic; so in order to reduce the power of the emotional interaction the therapist needs
initially to respond in a somewhat matter of fact manner or move the patient away from the
current focus rather than continuing to focus either on affect or the interaction between patient
and therapist, both of which will continue to stimulate the patient’s attachment needs. In the
example above the therapist would have been better to move the patient away from an internal
focus on her affect and to de-emphasise the patient-therapist relationship perhaps by pushing
the patient to consider the motivations of the boyfriend, for example – a movement out of the
session itself to consider someone ‘out there’. The aim is to help the patient maintain some
elements of mentalizing, in this case consideration of others minds, when contrary aspects are
overwhelmed, in this case reflection about the self. Insistence on further exploring internal
states at times of emotional arousal only serves to overburden the patient so we suggest
contrary moves at these times.
We do not recommend that you become contrary in your relationships with your
patients but rather that you consider moving patients outwards when they are self-focused and
inwards when they are other-focused, and yourself towards the patient when he moves away
and away from him when he moves towards you. We envision a balancing act as you and
your patient see-saw up and down, moving forward the areas of reflection and dialogue, and
oscillate back and forth as you titrate the intensity of the attachment relationship. At some
points your patient will become self-focused, and this is often to be commended; yet this selfreflection may begin to take on a ruminative quality or become rigidified in a negative,
shameful, self-condemning mode. At such times, you should try to move your patient out of
his or her mind and into another person’s mind: “How do you think that affects her?” “What
was going on for her that led him to do that?” You should not be deflected from this task once
you have decided that it is an appropriate move in treatment. Many patients respond by saying
they don’t know, and then they quickly return to their ruminative concern about their own
state of mind. Then you may need to be more insistent: “Bear with me a bit—I was wondering
what you made of what was happening for him that made him respond like that?”
You will also need to make the converse move at times. Patients who are preoccupied
with understanding others and what they are like may need pushing to reflect on their own
state of mind: “What did you feel about that?” “How do you understand your reaction?”
Such moves reflect the balance between self and others inherent in the concept of
mentalizing. This balance must be mirrored in the movement between the patient and
20
therapist within a session; a reciprocal flow of attention moves back and forth from your
patient to you and vice versa. You must demonstrate your own capacity to reflect on the
process at any given moment, once again exemplifying the active stance.
The various elements in MBT individual therapy will be reviewed in more detail in the
chapter describing the MBT assessment scale. It is recommended to use this scale when
training therapists, for supervision purposes and for evaluating therapy sessions for research
purposes. We will first discuss the general requirements that should be posed for any
psychotherapy adherence and competence rating scale.
MBT training
The Anna Freud Centre in London runs introductory courses and two-day advanced
courses on a regular basis. In addition there are local introductory courses in the Nordic
countries (Norway, Sweden and Denmark), Netherlands, and the USA as well as advanced
courses in MBT individual mode. The internet sites of e.g. the Anna Freud Centre and
Mentalization.no provide information about current courses.
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3. General considerations on treatment integrity scales
Treatment integrity
The term ”treatment integrity” refers to the degree of consistence between the
therapist’ actual performance and the underlying theory and ideals, intentions and norms
specified in the therapy manual (Perepletchikova et al. 2007).
Therapy manuals were first designed by therapists working in the behaviourist
tradition (Wolpe 1969). Psychotherapeutic manuals were developed later; first for cognitive
therapy (Beck et al., 1979), and later for psychodynamic and interpersonal therapy (Luborsky
1984, Klerman et al. 1984). The demand for evidence-based treatment and the rise of
randomized controlled trials (RCT) to the pinnacle of the evidence hierarchy ushered in the
need for treatment manuals. In principle, the results from a RCT study can say something
about the likelihood that one treatment is better than another treatment or no treatment at all.
In order to make correct inferences from an actual treatment to a true effect in an RCT, it is
necessary to ensure, since psychotherapy is a craft, that the clinician has learned the treatment
being studied properly and that it is practiced in compliance with the guidelines. In modern
psychotherapy research, there are increasing demands for documentation of treatment
integrity. Earlier research is open to criticism in this regard. In a review of randomized
psychotherapy studies, Perepletchilova and Kazdin (2007) found that only 4 % of the studies
satisfied their criteria for documentation of treatment integrity.
An assessment of treatment integrity is also essential in order to differentiate between
treatments, i.e. to specify how a specific treatment regime differs from others.
The concept of treatment integrity contains two components: 1) treatment adherence,
i.e. the extent that the therapist uses prescribed techniques and avoids proscribed techniques,
and 2) the therapist’s competence, i.e. level of skill and quality in his/her performance.
Adherence and competence
The literature on assessment scales reveals an ongoing discussion about adherence
versus competence. The discussion is particularly relevant for complex psychotherapy
approaches and less relevant for more straightforward behavioural therapies. Perepletchikova
et al. (2007) differentiate between technique-based approaches (e.g. cognitive-behavioural
therapy) versus non-technique-based approaches (e.g. psychodynamic therapy and other
process-oriented therapies).
Technique-based therapies are easier to assess due to their explicit focus on welldefined strategies and techniques. A treatment manual for this type of therapy will often
present specific problems to be addressed by specific interventions. An example is when a
therapist provides instructions and guidelines for exposure to fear stimuli between sessions.
Such interventions must naturally be carried out within the framework of a caring and
empathic therapist-patient relationship, but there is an assumption that variables such as
timing, choice of words, etc. play a less important role. Adherence in this context is more
important than competence. The main idea is that the therapist conducts certain interventions
and that the patient does certain prescribed acts. A rater evaluating this type of therapy might
quite easily be able to register the type and number of specific interventions delivered.
22
The situation is more complicated in a non-technique-based psychotherapy in which
the relationship to therapist and interactional processes play a more central role. An example
of this is item 4 in the MBT assessment scale: “Adaptation to mentalizing capacity”. Here the
idea is not to administer specific interventions with the goal of teaching the patient specific
behavioural patterns or skills (e.g. self-assertiveness). Adapting to the patient’s mentalizing
capacity refers more to an interactional mode that pervades the entire therapy lesson as a
whole, or at least large parts of the session. It is a quality of the very discourse. Counting the
number of times such interventions are “delivered” is less relevant. The question is whether
the therapy is being practiced in accordance with its theoretical essence. The quality of the
therapy reveals itself in either an attuned presence or in an absence in cases when, for
example, the therapist “is talking over the head of the patient” or when the therapist is not
sufficiently challenging.
The above examples illustrate some imortant differences between adherence and
competence. Adherence is usually easier to measure because it involves a quantitative
judgment on a scale e.g. ranging from “no adherence” (absence of intervention) or “some
adherence” to “considerable” or “complete”. In contrast, competence is often judged based
on the level of accordance with short (qualitative) descriptions.
Even though it is meaningful to differentiate between adherence and competence,
several studies show that raters struggle to distinguish between the two concepts
(Perepletchkova et al. 2007). Among the reasons for this may be weak definitions in the
manuals, comprehension problems on the part of the raters, insufficient training of the raters
or the fact that the distinction is more relevant for some items and less for some others, as
illustrated in the example above with “adaptation to mentalizing capacity”. Moreover, Barber
et al (2006) found that raters had a tendency to interpret an intervention as being of a higher
quality the more often it was used. the difference may be more relevant at some stages than
others. It is not a matter of course that all items of an integrety rating scale should be assessed
for both adherence and competence.
Inconsistent definitions and procedures, such as those raised above, will undermine the
reliability of both adherence and competence measures, as well as the relationship between
these aspects for the various items. McGlinchey and Dobson (2003) have pointed out that
there is a definition-contingent relationship between the two concepts: competence
presupposes adherence, but adherence does not necessarily presuppose competence. A
moderate correlation, however, is to be expected between these two phenomena. A very low
correlation or none at all is not a good sign. If this is the case, then one must look closer at the
definitions (validity). A very high correlation may also be a problem, because it may indicate
that the two concepts are too similar and have not been clearly differentiated by the
definitions. One of the concepts could then be considered redundant and dropped. Most
studies find a moderate to high correlation. In the ”Yale Adherence and Competence Scale”
(YACS-II), for example, researchers found that adherence and competence correlated
somewhere between r=.27 to r=.54 on items measuring therapists’ abilities to evaluate
patients, support them and work in accordance to defined goals.
Connection between adherence, competence and outcome
The architects behind a certain treatment would like adherence, competence and
outcome to be correlated in such a way that the more a therapist complies with the treatment
guidelines and the more he/she is able to practice the method in a qualitatively proficient
manner, then the better the outcome. But it need not be this way. First of all, the type of
23
treatment may prove to be ineffective; or it may be shown to be ineffective for certain types of
disorders or certain types of patients, e.g. adherence (e.g. transference interpretations) may be
good for some patients (poor object relations), but less important for others (better object
relations). Ideally, one would expect that competence contributes something in addition to
adherence: given adequate adherence, the way in which the therapy is practiced should have a
positive effect on the outcome.
There is no consensus on the empirical evidences for such a claim, however. Wampold
(2001) maintains, for example, that there is no basis to claim a positive relationship between
adherence and outcome of psychotherapy. This touches on the issue of the significance of
”non-specific” versus specific factors on treatment outcome. If it is generally the case that
specific factors play a subordinate role in the outcome of psychotherapy, then one should not
expect that adherence to these factors would play any significant role. More recent research,
however, seems to indicate that adherence does play a role in the treatment of more “difficult”
patients. Giessen-Bloo et al. (2007) found a positive correlation between adherence and
outcome in long-term psychotherapy for borderline patients, and Høglend et al. (200x)
showed that adherence played a role when differentiation was made between crucial patient
characteristics (e.g. good versus poor object relations). Furthermore, several studies have
shown that quality measures are positively related to the outcome of therapy (Luborsky et al.
1985, O’Malley et al. 1988, Barber and Crits-Cristoph 1996).
In summary, measuring treatment integrity is a precondition for being able to claim
that a treatment has been administered in accordance with the manual. To what extent the
treatment has any effect beyond what one may expect from non-specific factors is an
empirical issue to be explored in every research trial. Adherence and quality are only two of
many variables that can influence the outcome of psychotherapies.
Selection of scale items
Waltz et al. (1993) have proposed several principles when selecting items for an
integrity scale. The items should reflect the following:
1. Interventions, behaviours or processes that are unique and essential for the
treatment to be evaluated,
2. Interventions, behaviours or processes that are essential for the treatment, but
not unique to the treatment
3. Interventions, behaviours or processes that are acceptable, but neither unique
nor essential
4. Interventions, behaviours or processes that are proscribed.
No generally accepted norms have been agreed upon for how much of each point
should be included in an integrity scale. Psychodynamic scales usually contain mostly items
that reflect points 1 and 2.
The selection of items will ideally take place in close collaboration with recognized
experts in the treatment in order to ensure face validity, coverage and representativeness.
In order to emphasize that it is the therapist’s activity that is being judged, all
qualifying statements should be of the type “to what degree did therapist X do…?” Or
alternatively when the scales are differentiated with respect to quality: “the therapist’s
interventions were….”, or “the therapist did….” or “the therapist ignored…”, etc.
24
Furthermore, terms should be as specific and concrete as possible and preferably refer
to observable behaviour whenever possible. For example: “the therapist ignored the patient’s
constructive mentalizing efforts”.
Scale features
Most assessment scales feature a 7-point Likert scale.
Adherence involves primarily frequencies and extensiveness. Frequency is simply the
number of times the therapist carries out an intervention, and extensiveness is the time and
attention that the therapist gives to the intervention. These variables may be scored by using
the following scale (the example is taken from YACS-II):
Criteria for rating adherence and extensiveness:
Notations
1
Not at all
The intervention never explicitly occurred
2
A little
The intervention occurred once and was not addressed in any depth
/
3
Infrequently
The intervention occurred twice, but was not addressed in depth or detail
//
4
Somewhat
The intervention occurred one time and in some detail OR the intervention occurred 3-4
times but all interventions were very brief
Ø
///
5
Quite a bit
The intervention occurred more than once in the session, and at least once in some detail
or depth OR the intervention occurred 5-6 times, but all interventions were very brief
Ø//
/////
6
7
Considerably
Extensively
The intervention occurred several times during the session and almost always with
relative depth and detail OR the intervention occurred more than 6 times, but all
interventions were very brief
Ø//Ø/Ø
The intervention occurred many times almost to the point of dominating the session and
was addressed in elaborate depth and detail OR the intervention occurred briefly at such
a high frequency that it became difficult to count
ØØØØ/ØØ
///////
//////////////////
In the column for notations, useful symbols are specified for use on the worksheet.
The symbol “/” indicates the presence of the intervention and the symbol ”Ø” indicates the
presence of the intervention in detail and breadth. Practical scoring advice is discussed later in
connection with the MBT integrity scale.
Competence/quality/skill level refers to the therapist’s demonstration of the following:




expertise, competence and involvement
suitable ”timing” of interventions
clear and understandable use of language
ability to respond in relation to patient’s point of view
Competence may be scored in accordance with the following scale (YACS-II):
25
Criteria for rating quality (skill level):
0
Not at all
The intervention was not observed
1
Very poor
The therapist handled this in an unacceptable, even ”toxic” manner
2
Poor
The therapist handled this poorly (e.g. showing clear lack of expertise, understanding, competence, or
commitment, inappropriate timing, unclear language)
3
Acceptable
The therapist handled this in an acceptable, but less than ”average” manner
4
Adequate
The therapist handled this in a manner characteristic of an ”average”, ”good enough” therapist
5
Good
The therapist handled this in a manner slightly better than “average”
6
Very good
The therapist demonstrated skill and expertise in handling this issue
7
Excellent
The therapist demonstrated a high level of excellence and mastery in this area
It is important to differentiate between competence/skill level and effectiveness in the
here and now. In principle, an intervention can be competently conducted without necessarily
having a positive effect on the patient. On the other hand, there will often be this type of
relationship between quality and response on the part of the patient, but not necessarily.
When it comes to scoring competence, the rater’s starting point should be at “4 =
adequate”. The basic assumption is that the therapist is average (”good enough”). One should
therefore try to observe deviations in a positive or a negative direction from this starting point.
Manuals should contain examples that can be used to guide raters when they are determining
the degree of deviation from a ”good enough” practice.
A useful idea is to mark the presence (indicated by the symbol ”/”) on the scoring
sheet with the number that indicates competence level. For example, the notation “/2”
indicates a short intervention given a poor competence score, while the notation “ /6“ indicates
an intervention with a very good competence score.
4. Structure of the MBT adherence and competence scale
As previously mentioned, the architects behind MBT are Anthony Bateman and Peter
Fonagy. While working with the volume ”Mentalization-based treatment for the borderline
patient – a practical guide” (Bateman and Fonagy 2006), Bateman developed an “MBT
adherence scale” consisting of 15 items. In collaboration with Anthony Bateman, the scale
was translated into Norwegian, tested and further developed by a research group at the
Department of Personality Psychiatry, Oslo University Hospital, described in the MA theses
”Development of an assessment scale for mentalization-based treatment” (Engen 2009). This
scale was later substantially reworked by the authors of this manual. In the following, the
developmental process and the most important changes will be described.
Defining and selecting the items
Since the original 15 items were chosen by the architects behind MBT, one assumed
that the items had a high degree of content validity, that they sufficiently covered a wide
26
range of MBT interventions, and that most of the items could be easily identified in therapy
sessions conducted in accordance with MBT guidelines.
After our review, however, we decided to remove the following item from the original
15 items: “The interventions are brief, simple and within the patient’s ability to mentalize.
The therapist refrains from using metaphors, analogies and symbols”. This item contained two
separate elements, of which the latter deals with something which is proscribed. An attempt
was made to split the item in two. However, the use of metaphors, analogies and symbols
proved to be a therapeutic practice that occurred very rarely among the therapists that were
studied at Oslo University Hospital. Secondly, we concluded that the first part overlapped too
much with the item “adaptation to mentalizing capacity.”
The remaining 14 items were found to be a combination of essential and unique items,
and essential but not unique items. E.g. the item “exploration, curiosity and a not-knowing
stance” is essential, but not unique, while the item “psychic equivalence” is more essential
and unique. In practice, the difference between essential and unique proved to be vague. Most
psychotherapies attempt to promote exploration and curiosity, challenge the patient, focus on
affect, link affect to interpersonal events, etc. The unique aspect of MBT lies less in each
individual item per se, than in the overall “package” of item design and context. While many
therapies may have interventions that “promote exploration and curiosity” on the part of the
patient, the unique feature of MBT is the consistent emphasis this exploration of one’s own
and others’ motives. This is not something that takes place sporadically, by chance or at
certain occasions. It is a dominating characteristic in terms of frequency, scope and quality of
the therapeutic dialogue as a whole.
The original 15-item scale contained no items covering general psychotherapy factors.
Since MBT is a specialized form of psychodynamic psychotherapy, the research group felt
that good MBT had to rest on a foundation of generally sound psychotherapeutic principles
and that it therefore was relevant to include some general factors known to be of importance
for psychotherapy. Four such items were selected from the Norwegian version of ”Cognitive
Therapy Adherence and Competence Scale” (Nordahl et al. 2006):
1) Warm/genuine/congruent,
2) Attention,
3) Empathy and
4) Cooperation.
However, even though these items were formulated in non-specific cognitive language, they
proved to communicate nuances that were somewhat in contradiction to MBT. One example
of this is competence level 4 for the item of empathy: ”The therapist exhibited good capacity
for empathy. Seemed to understand patient’s perspective (based on both subtle and obvious
signs from patient)”. Such a formulation suggests that the better the therapist understands the
patient’s perspective the better. MBT emphasizes, however, that the therapist should assume a
not-knowing and inquisitive stance, i.e. trying to explore, together with the patient, the
patient’s perspective, rather than trying to understand it on his/her own. Thus, being “very
empathetic” is not a main objective in MBT. The research group found that rating these items
proved to be difficult and the three items concerning attention, empathy and cooperation were
therefore deleted. The item “warm/genuine/congruent” was retained.
27
In the original scale, two items dealing with transference were combined and a
separate item regarding content and process was established. The following items were also
added: an item concerning countertransference, an item about checking one’s own
understanding and correcting misunderstandings, an item about validation of feelings and an
item about integrating the simultaneous group therapy component. All of these items were
deemed to be characteristic of MBT. In all, 17 items were considered sufficient to cover most
of the variations of MBT that could be expected based upon a wide range of patients,
treatment contexts and therapeutic stages.
Quantifying the scale
These 17 items are rated in accordance with a 1-7 Likert scale for adherence in which
“1” represents no observable occurrence of the intervention and “7” extensive occurrence.
For two of the items (“engagement, interest and warmth” as well as “adaptation to
mentalizing capacity”) a frequency assessment is deemed to be irrelevant.
All 17 items are scored on a 0-7 Likert scale for competence, in which “0” signifies
“Not at all (the intervention was not observed)”, “1” is very poor and “7” is excellent. In the
event of no occurrence, one should assume that there would be no need for any competence
rating. However, things are more complicated. The rater may observe unequivocal signs of a
phenomenon that the manual instructs the therapist to address. E.g. clear signs of
pseudomentalizing functioning. If the therapist does not address this, the adherence rating is
1. However the quality with respect to this item is low, since the phenomenon is ignored, and
this should be noted with a low competence rating. On the scale worksheet the notation 4
contains a brief description of what is deemed adequate (good enough) competence. Later
sections of this manual contain examples of adequate and not so adequate interventions.
After each item has been assessed, the rater decides on an overall score for the specific
therapy session, for both adherence and competence. A global assessment is made not on the
basis of an arithmetic average of the 17 items, but on the basis of an overall clinical
judgement, with particular emphasis on the items 2) Exploration, curiosity and a not-knowing
attitude, 6) Stimulating mentalization through the process, 10) Affect focus and 11) Affect and
interpersonal events. These four items are considered somewhat more important than the
others.
Rating procedures
The rater makes his/her notes on the worksheet on an ongoing basis while he/she is
watching the video recording of the session.
The object to be rated is the observable behaviour of the therapist. The rater must try
to understand what the therapist is trying to do in terms of the 17 items of the scale. At any
one time, the question is which item the therapist is working on, or if the therapist is
intervening in ways that are outside of the framework of the model.
Therapy manuals often emphasize that it is the therapist’s behaviour that is to be
scored, and not the patient’s behaviour or the patient’s responses. However, the patient’s
behaviour is not irrelevant. The success criterion for an MBT session is to what degree the
therapist succeeds in involving the patient in an engaging and exploratory dialogue. The rater
will have to make notes on the interaction between therapist and patient. In particular it is
28
important to be aware of the therapist’s response to the patient’s answers. If the patient rejects
an appropriate intervention on the part of the therapist, then how does the therapist react?
Does he/she try again with a different choice of words or formulation? Does he/she do
something else before trying the same type of intervention again? Does the therapist change
focus? Or does the therapist adapt to the patient’s mentalizing level? A skilful MBT therapist
may switch strategy, for example, by changing to a different MBT item when the patient
responds defensively to a given intervention.
The above mentioned questions refer to the fact that patients’ actual mentalizing
capacities may be temporarily reduced or more permanently impaired due to serious
psychopathology. If a patient responds well to straight-forward interventions and is quickly
brought into an exploratory dialogue, then the rater may observe a smaller range of
interventions. Most of the session may deal with exploring emotions in interpersonal contexts.
If the patient is stuck at a lower level of mentalization, then it is reasonable to expect a larger
range of interventions, e.g. carefully challenging rigid attitudes, interventions directed at
pretend mode and psychic equivalence, interventions that involve transference and
countertransference. In the latter case the session is more likely to take on a more distinct
MBT flavour. However, this does not necessarily mean a larger degree of adherence than in
the case in which therapist and patient are engaged in a more relaxed mentalizing discourse.
During the video recording, the rater takes notes on the type of interventions delivered
by the therapist. What counts as a specific intervention, is loosely defined. It can be a single
statement, or it could be a series of statements that are linked together in a sequence. A
definable statement is noted by the symbol “/”. If the statement is followed up extensively, it
is noted with the symbol “Ø”. There are no clear rules for when a longer sequence on the
same theme should be given an additional “Ø”, e.g. if the therapist spends a long time (several
to many minutes) investigating the same interpersonal event. The rater may want to add new
notations as new aspects of the interaction are investigated, e.g. the patient’s own feelings
versus the other person’s feelings, own motives versus the other’s motives, to what degree the
attitudes are challenged, to what degree the tension level is optimal, etc. One and the same
intervention may therefore be rated on several items. This also applies for more limited
interventions. For example: “You say that you got angry when you spoke with your mother on
the telephone yesterday evening. Can we look at how this got started?” This intervention
should be marked with a “/” for affect focus, for affect and interpersonal events and for
promoting exploration and curiosity.
The MBT scale is normative in the sense that it contains a number of instructions for
the therapist. As already noted, it is possible to score a “0” for adherence while at the same
time receiving a score for competence. We will here add an additional argument for this.
Example: The manual says that one should challenge unwarranted attitudes of oneself and
others. If such unwarranted attitudes manifest themselves, but the therapist does not comment
on them, then it would be correct to score a ”0” for adherence, i.e. that no such interventions
were observed. But “0” for adherence could also mean that there were no such phenomena. It
is important to be able to distinguish these situations from each other, and this is being done
through the additional competence rating.
”Error variance” is permitted on the work sheet. Raters are free to vary with respect to
their notations. No reliability testing is conducted at this level.
29
When observing the video recording, the raters are free to stop the recording in order
to reflect, and he/she may rewind and look at a sequence again if needed.
One should be wary of halo effects that can affect the ratings. In principle, one should
be able to rate different types of psychotherapy with respect to MBT adherence and
competence. If the rater suspects that the session in question is not an MBT session, but e.g. a
case of supportive psychotherapy, he/she must be careful not to underrate the therapist. NonMBT sessions may have many good MBT interventions! A rater can become influenced
emotionally by a session, and it is important not to let one’s own feelings affect the rating
process. The rater may begin to develop a like or a dislike of either the therapist or patient.
One must be careful not to give “pleasant” therapists a bonus, and one must avoid punishing
less likeable therapists. If one recognizes a therapist from an earlier session, then one must be
careful not to allow previous ratings to influence the scoring in a new session. In other words,
the rater must be careful not to establish a fixed impression of the therapist, e.g. that he/she is
generally good or not very good. One must also be aware of possible halo effects within one
and the same session, i.e. that a very high or low score on one item will influence the scoring
on other items, or that a very “good” sequence influences subsequent ratings in not so good
sequences.
When one has looked through the entire video, the time comes to rate the individual
items. One must then review the notes and check the scale. How often was the individual item
observed? To achieve an adequate adherence scoring of “4”, the intervention must have been
observed briefly 3-4 times, or at least once extensively. As mentioned earlier, when it comes
to competence, one should compare with the brief descriptions that indicate a competence
level of 4. A higher or lower competence level than this must be consistent with the
descriptions which are specified for each individual item later in this manual.
An overall assessment is made at the end of the scoring session. A score of 4
represents an adequate performance both in terms of adherence and competence. For
adherence, this means that most individual items have received a minimum score of 4,
indicating that the rater’s general impression is that a wide range of MBT-type interventions
have clearly been demonstrated. A score of 4 indicates that the therapist has adequate
knowledge about MBT and that he/she is able to reasonably implement the recommended
interventions in practice. Similarly, the competence of the performance should also have been
demonstrated sufficiently. Most individual items should be scored at least 4 and the general
impression should be that the therapist masters the technique to a reasonable degree. This
means that there is a relatively good “flow” during the session, that the sequences fit together,
that word choice and timing are adequate, that the therapist tries out new MBT strategies
if/when interventions fail, that the entire session is guided by an attempt to engage the patient
in a mentalizing dialogue and that there are no extended sequences featuring other types of
techniques (supportive therapy, problem solving, guidance, etc.). A low competence rating
means that the therapist did other things than that which is prescribed for MBT, that he/she
delivered MBT interventions in an inflexible or clumsy way or that he/she failed to follow up
interventions adequately.
A level 4 performance also means that the session can be approved in a research
context. In order for a completed therapy to be approved as MBT, the requirement might be
that the majority of the sessions display a quality level of at least 4, or that the overall
numerical average of all the scores is at least 4.
30
Training raters
There is not necessarily a strong association between being an expert clinician
(therapist) and a good rater (Jacobson 1998). Both skills are important. Clinical experts need
training on using the assessment scale. On the other hand it is hard to become a good rater
without extensive clinical experience with this type of treatment.
The ideal training of raters starts with a training seminar that gives a presentation of
the scale, of general scoring procedures, discussion of clinical examples and provides
supervision on scoring 3-4 expert-rated sessions. New raters then score 10 full treatment
sessions which have been assessed by experts in advance (Caroll et al. 2000, Nordahl et al.
2006). The level of proficiency achieved is determined on the basis of the candidate’s interrater-reliability on these 10 sessions.
Expert-assessed therapy sessions involve at least three experts, all of which must have
extensive experience practicing MBT and in using the MBT scale. The three experts need to
reach a consensus on the individual item scores and the overall scores.
In a research context, it is common that raters are checked by comparison with expert
ratings after a certain number rated sessions in order to prevent “rater drift”, i.e. changes in
scoring practice over time.
Feedback and supervision
The MBT scale is well-suited for teaching MBT as well. By using the MBT integrity
scale, the therapist candidate can obtain feedback on his/her performance in terms of the
following:
 the type of interventions he/she uses frequently versus infrequently
 the clinical phenomena he/she overlooked, i.e. ”missed opportunities”
 to what extent the therapist uses non-MBT techniques
 high and low quality interventions
 advice in terms of improving his/her therapeutic skills
31
5. Items in the MBT assessment and competence scale
General considerations.
As noted priviously, the following list of intervention categories should not be
considered the ultimate truth about MBT. Therapists improvise creatively in the flow of
psychotherapy and may enhance mentalization by means that are not covered by the following
list. However, we consider adherence to the following principles to be the best way we know
for the time being to learn, supervise and judge psychotherapy sessions as to their mentalizing
qualities.
We remind the reader about the general principles which were outlined in the chapter
on MBT individual mode, e.g. refrain from traditional knowing, monitoring own mentalizing
process along with that of the patient, regulate closeness and balance the interaction by
contrary moves. Here we will add some general principles for the intervention process.
From a practical standpoint and for clarity when training people in mentalizing
interventions we suggest effective mentalization-based interventions unfold gradually along a
specific line although it is inevitable that the line is often not followed in an orderly way in
sessions. Nevertheless we exhort MBT therapists to follow it as best they can.
First the therapist identifies a break in mentalizing indicated by psychic equivalence,
pretend mode, or teleological understanding. This indicates that mentalizing is vulnerable and
marks a point at which the therapist needs to try to re-stimulate mentalizing. Next, the
therapist asks the patient to rewind to the moment before the break in subjective continuity
occurred. If necessary the therapist suggests where he noted a change. Then, the therapist
explores the current emotional context contributing to the break in the session by identifying
the momentary affective state between patient and therapist. Fourth, the therapist explicitly
identifies and owns up to his own contribution to the break in mentalizing. It is only after this
work has been done that the therapist seeks to help the patient understand the mental states
implicit in the current state of the patient-therapist relationship (mentalize the transference).
Inevitably our suggestion of using this step-wise procedure meets with some criticism
for being too prescriptive, reifying an interactive and dynamic process, and being reductionist
about a complex process. There is some merit to this censure. Yet we hope that the specificity
of the procedure will ensure that the therapist thinks carefully about what he is doing and so
avoids working with a patient beyond their current mental capacity.
Patient: As far as I can see your receptionists have been trained to ignore patients
Therapist: What makes you say that?
Patient: I rang the bell and no one answered. I could see through the window and
there were people in the office talking. So obviously they did not want to let me in.
Therapist: I don’t quite follow. Why in earth would they not want to let you in?
The patient’s statement about the reception staff and his conclusions suggest that his
mind is operating teleologically – he understands others motives by the actual outcome which
in this case was that they did not let him in.
Patient: Because I am 6ft and big and they were frightened of me.
Therapist: Well you are over 6ft and very large but I was unaware that they had not
let you in before so what was different this time.
32
Patient: You don’t believe me do you? They would not let me in. I eventually got in by
attracting their attention by leaving my finger on the bell until they answered.
Therapist: I am glad that you got in but can we go back to your sense that they didn’t
want to let you in. It occurs to me that it is more complex than the fact that you are over 6 ft
and large as the staff know who you are.
Patient: Well most people take one look at me and move away.
The therapist is trying to rewind to the point at which the patient appears to have little
doubt about his conclusions. This does not have much effect and so the therapist rightly
rewinds to an earlier point.
Therapist: Well it is awful to feel that you are not wanted. I can understand that so
can we go back further – what were you like in yourself before the session.
Patient: Fucked off. I think that the housing department is trying to trick me.
The therapist was then able to explore the patient’s experience of the housing
department and his suspicion that they were trying to deceive him and absolve themselves of
responsibility for his accommodation. In short they did not want him. Having done this the
therapist explored the patient’s experience and state of mind after leaving the housing
department and enquired how this might have impacted on his experience with the reception
staff. In doing so he also identified the affect focus within the session.
Therapist: Just going back in the session you reacted quite strongly about my
questioning your reasons for why the staff did not let you in, by saying that I did not believe
you. Are we still sitting here with me thinking the situation is more complicated and you
feeling that I don’t really believe your explanation.
The patient reacted immediately.
Patient: Well you don’t do you.
Therapist: I can see that when I pointed out that you have always been over 6 ft and
large that you could think I didn’t believe you. In some ways I suppose that I do not think that
that was the primary reason that they did not answer the bell.
Here the therapist is indicating that he has had a role in stimulating the sense of
disbelief in the patient.
Patient: So I was right that you did not believe me.
Therapist: Yes to some extent. It occurs to me that you listen very carefully to how I
say things to see if I believe you or not much of the time.
Patient: I suppose that I don’t really trust you to be on my side.
The therapist has at this point identified the affect focus relevant to the current session
and can move towards mentalizing the transference if the patient shows some flexibility and
ability to reflect on his own state of mind and that of the therapist.
33
1. Engagement, interest and warmth
This item is not unique to MBT. It is highly valued in most psychotherapies. The key
terms engagement, interest and warmth could be supplemented with the terms authenticity,
empathy and caring. Their opposites are cold, disinterested, uncaring, reserved and distanced.
This item is meant to reflect perhaps the most important general factor in psychotherapy. It
refers to a therapist who “cares” and who is able to communicate this in a manner so that the
patient feels welcomed, respected, important, listened to and taken seriously. The item reflects
MBT’s and mentalization theory’s roots in the attachment tradition. The ability to mentalize
grows out of an experience of being understood. Through this experience the individual will
find culturally acceptable verbal means of expressing his/hers state of mind. The therapist’s
role is somewhat similar to that of a parent. It is a matter of ”minding a mind”. It requires an
interest in and involvement on the part of the parent/therapist to find out what is in the
child/patient’s ”mind”, an interest that is sustained by a desire to be helpful. For parents this is
a natural response in relation to one’s offspring and linked to the emotional system of ”care”
(Panksepp 1998). For the therapist, it is a cultivated response that is sustained by the
emotional systems of care and exploration/seeking.
The idea here is not of overwhelming warmth bordering on invasiveness, which is
likely to be harmful to patients with BPD, but more about a balanced friendliness. It should be
genuine, not superficial. Although this item is generic for the psychotherapies, the MBT
version of it contains a specific quality of autenticity. The mentalizing therapist needs to make
his mental processes transparent to the patient as he tries to understand him, openly
deliberating whilst ‘marking’ his statements carefully. This requires directness, honesty,
authenticity, and personal ownership that is problematic partly because of the dangers of
boundary violations in the treatment of borderline personality disorder. Our emphasis on the
need for authenticity is not a license to overstep boundaries of therapy or to develop a ‘real’
relationship; we are merely stressing that the therapist needs to make himself mentally
available to the patient and must demonstrate an ability to balance uncertainty and doubt with
a continued struggle to understand. This becomes particularly important when patients
correctly identify feelings and thoughts experienced by the therapist. The therapist needs to be
prepared for questions that put him on the defensive – ‘you’re bored with me’, you don’t like
me much either do you’ etc. Such challenges to the therapist can arise suddenly and without
warning and the therapist needs to be able to answer with authenticity. If he does not do so
the patient will become more insistent and evoke the very experience he is complaining of, if
indeed the therapist was not already feeling it at the time.
The therapist need not like all aspects of a patient, but the patient must arouse a
positive involvement on the part of the therapist. Positive involvement may be challenged and
threatened by the therapist’s countertransference, but unless the therapist has an initial
positive attitude toward a patient, then he/she should refer the patient to another therapist.
Engagement, interest and warmth are factors that should pervade the therapy as a
whole, and it is therefore less relevant to link this item to specific interventions. This is the
reason why this item is not scored for adherence. It is more a sort of a precondition for the
other interventions, such as “exploration, curiosity and not-knowing stance”. Even though it
refers more to a general attitude than to specific interventions, but certainly involves nonverbal signals (e.g. smiling, a friendly facial expression, body language, etc.), a number of
phrases clearly communicate interest and involvement, such as: “I have thought about you
34
since we last met” (“holding mind in mind”), or “I’m sorry to hear that” (empathy), or “too
bad”, or “that sounds good”, in addition to questions such as “how was it?”, “what were you
feeling then?”, “what did you think”?
Guidelines for competence assessment
Low (1-3): At the lowest level, the therapist appears cold, uninvolved and
disinterested, with a reserved body language. He/she gives the impression of having little or
no empathy. Questions are delivered in a mechanical manner. On a somewhat higher level,
he/she does not appear directly cold and disinterested, but more reserved and distanced. The
therapist acts and reacts with little vitality and spontaneity, and the therapeutic process seems
slow and lethargic. At level 3 there are sequences in which the therapist seems more involved,
but the overall impression is still one of reservation and distance. It is also possible to be
overly involved and blinded by one’s own therapeutic focus and thus overlook the patient’s
point of view.
Adequate (4): The therapist appears genuinely warm and interested. The rater gets the
impression that the therapist cares. Several concrete comments communicate this positive
attitude.
High (5-7): The therapist seems definitely genuinely interested and involved, and
he/she expresses his/her empathetic attitude in a natural and spontaneous way as well as a
capacity for autenticity. At the highest level, the therapist’s involvement is dynamic with
flashes of disarming humour, but without this undermining the feeling of a genuinely
empathetic stance.
2. Exploration, curiosity and a not-knowing stance
This item also refers to an underlying attitude that should characterize the entire
therapy process. It is a most crucial item for MBT. It may of course occur in other
psychotherapies as well, but hardly as consistently. Earlier versions of the assessment scale
differentiated between a not-knowing stance and promoting exploration and curiosity.
Practice has shown, however, that these phenomena are so closely related that they practically
never occur independently of each other. This also is consistent with a concept analysis.
Exploration and curiosity arise out of a state of not knowing and of a desire to find out.
Exploration and curiosity are linked to the primary emotional system “seeking”. It is usually
associated with a scrutiny of the surroundings, of unfamiliar others, and a search for food,
resources, sex, etc. The unique aspect here is that it is applied for the exploration of the inner
world. The starting point is that the patient has poor mentalizing abilities to find out about and
understand mental phenomena, or that these abilities are temporarily shut down due to
emotional activation. The essence in MBT is that patients need to develop their ability to
mentalize through the therapeutic process. The therapist must therefore be consistent, clear
and pedagogical with respect to the following fundamental principles: 1) Even though mental
states and mental phenomena are not transparent, they are not incomprehensible, 2) they can
be made more understandable via exploration, and 3) this type of exploration requires
inquisitiveness and a not-knowing attitude.
The therapist’s most important task is therefore to be a tolerant companion in an
exploratory process and not an all-knowing expert who thinks he/she has privileged access to
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other people’s inner worlds. Like a companion on a journey, the therapist must engage the
patient in a common effort to find out about certain phenomena. The therapist must
communicate the attitude that he/she cannot simply see into the patient’s inner world, but that
he/she depends on the patient’s assistance. Mental states are not transparent, but they can
become apparent through dialogue. The therapist must accept that both he/she and his/her
patient experience things only impressionistically and that neither of them has primacy of
knowledge about the other or about what has happened. This is more easily weitten than it si
enacted in therapy. Both patients and therapists may behave as if they are sure about what the
other is thinking oro feeling. The therapist shall refrain from statements or interpretations that
have a conclusive character in relation to the patient’s or others’ mental states without having
first arrived at a common understanding with the patient based on an abundance of
information.
This item emphases the importance of awakening/stimulating the patient’s interest in
mental states and motives in himself/herself and in others. An interest in other people’s
motives is a precondition for conducting the necessary work that is needed to find out other
people’s mental landscape and what drives them. As previously mentioned, the starting point
is that the person has unwarranted or a vague and unclear conception of their own or others’
motives and that these are assumed to be the one and only truth. Such unwarranted
conceptions are also the basis for cognitive therapy. In contrast to cognitive therapy, however,
the MBT therapist does not carry out a mapping of maladaptive schema, but attempts instead
to stimulate the patient’s curiosity and interest about their own and others’ motives and
challenges rigid and unwarranted views when they appear in the here and now.
The therapist must have activated his/her own seeking system and, by way of genuine
curiosity for the patient’s mind, he/she hopefully stimulates the patient’s own curiosity.
The beauty of the not-knowing stance is that it reminds the therapist that they do not
need to understand what the patient is saying or to struggle to make sense of it within another
framework such as the patients traumatic past or their cognitive schemas. The MBT therapist
eschew his need to understand. The therapist should not feel under obligation to understand
the non-understandable. Patients with BPD become muddled as they talk about themselves
and others when they become aroused, as do normal people. But feelings disrupt mentalizing
more rapidly in patients with BPD and, as the mentalizing processes of the patient are list, the
therapist is likeliy to understand less and less. This is a moment for the therapist to intervene,
most simply by saying “I am not sure that I understand this. Can you help me do so”? The
cardinal error under these circumstances is for the therapist to take over the mentalizing and to
try harder and harder to make sense of what the patient says and subsequently to deliver his
understanding. Relieved of having to understand, the novice therapist is in a more confident
position. It allows him to be less fearful of making errors.
Low presence of this item means that the therapist is not particularly interested in
understanding mental phenomena, but is more concerned about behavior, support, problem
solving or manipulating mental phenomena with medication. The opposite of an open,
seeking, curious and non-knowing attitude is a closed, convinced and assertive attitude. A
therapist with a “closed” attitude establishes often an idea about what “really” is the patient’s
problem, what he/she ”really” is afraid of, what he/she ”really” is feeling or what the patient’s
closest relations ”really” have in terms of hidden agendas. Such a therapist’s objective is then
to convince or persuade the patient to accept his/her view. These types of interventions are not
covered by this rating system. The rater should still make notes on the worksheet when and to
36
what degree such interventions occur. It might be that the therapist in some sequences is
assertive and persuasive and that he/she in other sequences is more open and exploring. In
such a case, the persuasive section will contribute to lowering the competence score.
Guidelines for occurrence and scope
The focus here is on the curiosity for motives and mental states and not curiosity for
facts or systems. In the course of a session, both the patient himself/herself and a number of
other persons will have been mentioned. With low occurrence, the therapist does not pose
questions about these persons’ mental states or motives. The patient’s explicit and implicit
perceptions are quietly accepted. With high occurrence, many questions are posed that are
designed to promote seeking and curiosity about the patient’s own motives as well as those of
others:
“What do you think made her say that?”
“Why did he do that, do you think?”
“Yes, I hear what you are saying, but I wonder why you said it in exactly that way?”
“It is possible he said it to hurt you, but might there be other reasons as well?”
“Based on what you have told me, is it possible that your mother often overlooked
you. Why did she do that, do you believe?”
The scope of this item deals with to what degree the therapist follows up such
questions in detail and depth:
“Yes, that makes sense, but how does it relate to X, do you think?”
“Am I right in thinking from what you’ve been telling me that you thought that she
believed that what she was doing wasn’t too obvious?”
”Why? Are you suggesting that it was because Y was present?”
By way of similar questions, motives may become understood within a broader
interpersonal and social context.
In general the therapist must be careful in suggesting possible motives that may be
driving patients or others, even though he/she may have good arguments to support his/her
view. MBT is not an insight-oriented therapy. The goal is to develop the patient’s own
abilities to mentalize. However, if one encounters mental blockages that stand in the way of
any type of exploration, then the therapist can make suggestions, such as in the following
example:
“I understand that you have difficulties understanding why X behaved as he did. It is
not easy for me to understand it either. I do not know him other than through what you have
told me. But could he simply have been exhausted?”
The following are incidents of low competence:
”You have been traumatized and that is why you can’t stand such situations.”
”You are doing this because you are carrying an unconscious guilt complex.”
Guidelines for assessing competence
Low (1-3) The therapist does not pose questions about mental states. The therapist
makes assertive claims about the patient’s or some other person’s motives. The therapist’s
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questions about motives are poorly formulated, mechanical and superficial. They may also be
poorly timed and appear like ruptures in the ongoing conversation. The therapist accepts
responses that sound like clichés.
Adequate (4) The therapist poses appropriate questions designed to promote
exploration of the patient’s and other’s mental states, motives and affects and communicates a
genuine interest in finding out more about them.
High (5-7) The therapist poses adequate questions about the patient and others’ mental
states, motives and affects. They are posed in a friendly and welcoming manner. The
questions are followed up with respect to details and an exploration of the interpersonal
context. The therapist challenges responses that sound like clichés.
3. Challenging unwarranted beliefs
Patients often have unwarranted opinions about themselves and others and about
relationships between people. Such unwarranted opinions are in themselves a sign of poor
mentalizing abilities. They must be challenged, but in a friendly and sensitive manner; not
categorical and unsympathetic, but consistent with a curious and not-knowing stance. Typical
unwarranted opinions about oneself have been well documented in the cognitive tradition. It
may be that a patient describes himself as dumb, ugly, less worthy than others, not deserving
of anything good, deserving punishment, or that he is a victim; or it could be the opposite, that
the patient states he is better than others, more intelligent, deserving of special treatment, etc.
Unwarranted opinions about others often takes the form of fixed rather cliché-like ideas
about others’ supposedly inflexible personality characteristics, for example that others are
dumb, lazy, ruthless, nice, envious, jealous, unsympathetic, greedy, bad, etc. It may involve
attitudes about groups expressed in general terms: ”Health system bureaucrats don’t care at all
about us patients”, or ”estate agents are just greedy”. Or it can be about specific persons: “She
never cared about me”, or “my mother was always nice”. Often it may relate to unwarranted
opinions about other people’s motives in specific contexts: “He did it to punish me”, or “yes, I
hit her; she asked for it”. It can also be about relationships between people: ”My parents’
relationship was always good. Never an angry word was spoken between them” or ”yes, there
is a lot of hitting, kicking and arguing, but I don’t think the relationship between us is worse
compared to most people”.
The fact that the therapist suspects an opinion to be unwarranted relates to the fact that
it is often one-sided, rigid and fixed, global (applies to the entire person or everyone in a
category of persons), lacks empirical proof, seems improbable or seems overly exaggerated.
Guidelines for occurrence and scope
Interventions that belong to this item often take the following form:
”I noticed that you described yourself as dumb, and I have also heard that earlier. I
wonder what you mean by that?”
”A second ago you described yourself as ugly. What did you mean by that?”
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”You say that you experience yourself as less worthy than others. But in the last
session you said that you felt OK. Is it possible that your self-confidence fluctuates… Do you
have any thoughts about why your self-confidence may be down today?”
”A while ago you said that all employees at the unemployment office were idiots. I am
unsure about how I should interpret that statement; is it a manner of speech, is it because you
were upset or is it because you really meant it?”
”You said that your mother was always nice. I don’t know exactly how I should
interpret this statement. Can you explain it a bit more?”
”Based on what you have told me, it is quite possible that he did it to punish you; but
could there be other reasons as well?”
”You say that she asked for it. For me it is difficult to understand how someone could
want to be beaten up. Could you tell me more about your thinking here?”
Examples of low competence would be the following:
‘How in earth could you think that?’
”That is the craziest thing I’ve ever heard”.
”That sounds like an incredible exaggeration”.
”I don’t believe that at all”.
”What a bunch of rubbish”.
Low competence would also be exampled by the therapist apparently not noticing and
therefore not responding to the patient’s tendency to be absolute about his views of himself
and others.
Guidelines for assessing competence
When it comes to this item, it may be that the phenomenon of unwarranted opinions
about oneself and/or others does occur in the therapy session, but that the therapist does not
comment on it. This should result in a score of “0” for adherence. Logically then there should
not be a score for competence. One cannot assess the competence of something that does not
occur. However, as already explained in the previous paragraph, the fact that the therapist
does not respond to the occurrence says something about poor skills on the part of the
therapist with respect to this item. No reaction to the actual occurrence should receive the
lowest competence score (1-2).
Low (1-3) Lowest competence is when the therapist does not react to obviously
unwarranted opinions. The next lowest score should be given when the therapist confronts the
patient in an unsuitable manner. Level 3 interventions are not completely unsuitable, but are
superficial in the sense that the therapist accepts a cliché-like response or abandons the topic
without a more careful examination.
Adequate (4) The therapist confronts and challenges unwarranted opinions about
oneself or others in an appropriate manner.
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High (5-7) High competence interventions are formulated in a friendly and slightly
provocative manner. The therapist does not accept cliché-like answers, but finds new ways to
move on without seeming to be condescending. He/she finds an acceptable way to end the
sequence if the patient insists on his or her perceptions, for example, by accepting the
patient’s view. At the same time he/she may leave the door open for other perspectives, as in
the following: ”I understand that you see this in a specific way. I see it a bit differently,
however. How do you feel about us having different views on this subject?”
4. Adaptation to mentalizing capacity
The term mentalizing capacity refers to the reflective functioning (RF) scale, which is
an operationalisation of mentalization. On the basis of transcripts from the adult attachment
interview, the patient’s understanding and reflections are scored on a scale from -1 to 9, where
level 5 is considered ”good enough”. Most people will typically vary somewhat depending on
the topics being discussed, so that the ongoing scoring may fluctuate, for example, between 3
and 7. In such a case, the patient’s overall mentalizing capacity might be rated as 5.
Borderline patients are on average rated somewhat under 3 (ref. 200x). In addition to the fact
that people usually fluctuate around a mean, the mentalizing capacity may drop significantly
as a result of emotional activation and/or entanglement in strong interpersonal conflicts. The
therapist must therefore 1) adjust and adapt to each individual patient’s more typical style and
2) also be prepared to adjust in relation to crises and breakdowns.
One must also consider the stage of the treatment. Early on, the alliance may be fragile
and the patient may at this stage not be used to the style of discourse practiced in
psychotherapy. The risk of misunderstandings is greater at this early stage. This has to be
added to a “natural” fear activation in the encounter with a stranger.
The therapist must thus make up his/her mind about where the patient is in terms of
actual mentalizing capacity. It may be worthwhile to have the RF scale in mind. A simplified
version for clinical purposes is available at the back of this manual. At level -1, the patient has
bizarre perceptions about himself/herself and/or others, or he/she rejects psychological
perspectives with threatening hostility. At level 1, non-mentalized perceptions are common,
i.e. behaviour and social incidents are ascribed to mechanical and non-psychological factors
and not inner motives. At level 3, the patient has an understanding of the link between
behaviour and motives, but this link is not very credible and may likely be exaggerated,
cliché-like, peripheral, incomplete, etc. At level 5, there is an adequate understanding of the
link between behaviour and motives, and at level 7 the understanding is sophisticated. At
level 9 the mentalizing capacity is exceptional. Typical high-level mentalizing is when
behaviour is attributed to varying and complex motives that are in turn influenced by the
actor’s personal story, his family and cultural background and the family and socio-cultural
context in which he/she lives.
Adapting to the patient’s level of mentalization involves a sort of “tuning in to the
patient’s wavelength”. Therapists may overestimate or underestimate their patients. When
overrating patients, they speak “above their heads”. Conversely, therapists might be
excessively supportive, not challenging enough or infantilize the patient.
Most often the problem is that the therapist ”aims too high”. Many therapists overestimate the mental capacities of patients with BPD. A patient with difficulty in mentalizing
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self and other cannot understand complex statements related to self and other within the
patient- therapist relationship, for example ‘you think that I think that you….’ Such
interventions are likely to increase confusion when there is already perplexity about self and
other especially if the patient is currently unable to mentalize. At other times the patient may
be able to differentiate what is in his own mind and contrast it with what is in someone else’s
mind. At these times more complex interventions become possible.
In MBT, therapists follow a general principle that the greater the emotional arousal of
the patient, the less complex the intervention should be. Supportive comments, gentle
exploration of a problem, and clarification require less mental effort on behalf of the patient
and so are considered ‘safe’ interventions during high states of arousal. In contrast
interpretive mentalizing and mentalizing the transference heighten arousal and so carry the
danger of stimulating use of secondary attachment strategies either of hyperactivation leading
to over-arousal of the patient or deactivation inducing pretend mode, both of which decrease
mentalizing. We therefore suggest that these interventions are used with care. They are likely
to be of most benefit when the patient is optimally aroused, that is able to remain within a
feeling whilst continuing to explore its context – so-called mentalized affectivity (Jurist,
2005).
Following the principle that interventions must be in keeping with a patient’s
mentalizing capacity, other techniques commonly used by therapists are deployed with
caution in MBT. When a patient asks a direct personal question for example, it is assumed
initially that it is arising in the context of anxiety, indicating that the patient is attempting to
structure the mentalizing process. Immediately reflecting the question asks the patient to
perform more mental work at a time when they are struggling to maintain their mental
processing. So the MBT therapist takes on the mental work to help reduce the internal anxiety
of the patient at any time when the patient’s mentalizing capacity is vulnerable to collapse. If
they are unable to answer the question then they should say so and give their reasons – they
may be unwilling to answer the question because it is a personal matter, they may not know
the answer, or the patient might have stimulated some confusion. It is far better to say ‘I don’t
know how to answer your question and it confuses me so can I think about it’ than it is to
reflect the question by saying ‘what do you think’? The former responses indicate that the
therapist is now responsible for working out what is happening whereas the latter places
further mentalizing responsibility back with the patient. To this extent it potentially overloads
the patient’s capacities.
To reiterate: In the beginning especially, the interventions should be short and concise.
One should avoid long and circuitous explanations, the use of difficult words and phrases and
references to unconscious phenomena. To the extent that the therapist starts off on more
extensive explanations, he/she should check carefully if he/she is being understood. Patients
often pretend that they understand – either because they don’t want to disappoint the therapist
or because they don’t want to give the impression of being “stupid”. A different variant is that
the patient “understands” as part of a pseudomentalizing strategy where the words live a life
of their own, disconnected from feelings and deeper contexts. One should also (particularly at
the beginning) avoid the use of metaphors, allegories and symbols.
Assessment of frequency and scope
This item relates more to a general attitude than to specific interventions. Optimally,
all interventions should be adapted to the patient’s mentalizing level. It is therefore not
41
meaningful to count frequency in the form of positive occurrences. The item is therefore not
scored on occurrence.
Assessment of competence
Low (1-3) The therapist initiates long interventions that seem to go ”over the head” of
the patient. The interventions are formulated in a language that is difficult to understand. The
therapist introduces complicated metaphors and theoretical symbols. The therapist does not
register that the patient is not following his/her train of thought and the therapist fails to adapt
to the right mentalizing level. The observer gets the impression that the therapist and patient
are ”talking past each other”. Alternatively, the therapist may use much too simple vocabulary
and concepts and avoid contextualizing that do not challenge the patient sufficiently.
Adequate (4) The therapist seems to have adapted to the patient’s mentalizing level
and the interventions are for the most part short, concise and unpretentious.
High (5-7) The therapist shows a high degree of competence and expertise with
respect to following the patient and adapting to his/her level, and at the same time challenging
him/her in a way that does not seem condescending, humiliating or offending.
5. Regulation of emotional arousal
The therapy should take place in an atmosphere characterized by optimal emotional
arousal. As already mentioned in item 2, the therapist must work to prime and activate the
patient’s emotional system for exploration/seeking/engagement. Optimally, this should be
accompanied by a feeling of vitality. With a friendly and caring attitude on the part of the
therapist, one should expect that the patient’s fear system should gradually be downregulated.
However, the therapist’s constant focus on affects may very likely activate fear in addition to
the primary emotions of anger, separation anxiety, lust, love and joy, as well as more complex
social emotions such as jealousy, envy, guilt, shame, etc. The therapist has an important task
with respect to regulating the level of emotional arousal (corresponding to parents’ regulating
function in relation to their children). The level must not be too high so that it overwhelms the
patient (confuses him/her, puts him/her off, leading to uncontrolled emotional outbursts,
seriously impairing mentalizing ability, etc.); nor should it be so low that the therapy is boring
or uninteresting.
The therapist helps regulate the patient’s emotional arousal through his/her general
attitude (interest, warmth, friendliness, engagement and focus on affects), through non-verbal
communication and through specific interventions. More difficult for therapists is having to
up-regulate the patient who seems to have closed down their emotional states. Patients
become monosyllabic, fail to respond to comments from the therapist by elaboration, and
appear disinterested. The therapist may feel like giving up and increasingly ask questions. In
general the therapist needs to focus the session within the patient-therapist relationship whith
those patients who appear to have closed down their emotional processes.
Assessment of occurrence and scope
Confronted with an elevated arousal level it is important to have a reasonably adequate
understanding of what is triggering the patient so that the therapist can avoid further
42
provocations and be helpful with calming down. Examples of interventions that count for this
item are the following:
“I see that it made you sad. We touched on a sensitive topic. Take your time… Are
you doing ok? Is it still just as painful?...”
“It’s clear that something is upsetting you. I am not quite sure what it is. It might be
something I said or the very subject we are discussing. Maybe you need some time for
yourself before we try to find out about the reason behind your reaction, what do you think?”
“I understand that this makes you angry. How distressing is it for you? Are you furious
inside? Is it OK to be where you are right now, or would it be better for you to take a moment
and wind down a bit? Earlier it helped if you …”
“Hi Trine. Are you doing OK? Did your thoughts wander off a bit just now? We have
been discussing a difficult topic. Maybe you need some time to collect your thoughts?”
Examples of interventions for conditions of low emotional arousal:
“How are you doing, any feelings about what we’ve been talking about just now?”
“Earlier in the session I got the impression that you were really interested in what we
were talking about. Now it seems you’ve lost interest. Did we lose focus or was it me who
moved it away from the important things?”
”I am a bit unsure how important what we are talking about right now is for you”.
Low competence:
”I see that it really pisses you off. That’s an honest reaction. It’s important to get in
touch with your feelings. Let it out!”
Assessment of competence
Low (1-3) The patient is overly emotionally aroused during the session and there are
strong emotional outbursts that the therapist does nothing (or little) to regulate. In fact, he/she
says or does something that fires up already excessively activated feelings. Alternatively, the
session is emotionally flat, dull and without involvement on the part of either party, and the
therapist does nothing to ”raise the temperature”.
Adequate (4) The therapist plays an active role in terms of maintaining emotional
arousal at an optimal level (not too high so that the patient loses his or her ability to mentalize
and not too low so that the session becomes meaningless emotionally).
High (5-7) The therapist shows great skill in regulating the emotional arousal level.
When the temperature falls, the therapist introduces interventions that increase the emotional
intensity and upon heightened outbursts the therapist works to ease the pressure on the patient.
The therapist clearly shows that he/she is tuned in to the patient’s state of emotional arousal.
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6. Stimulating mentalization through the treatment process
MBT is a type of treatment in which one attempts to promote the patient’s mentalizing
capacity through the therapeutic process here and now, i.e. through discourse and the
relationship to the therapist. The process itself is therefore more important than ”the content”.
By content, we mean the topics being discussed. This does not mean that the topic is
irrelevant. The ”topics” in MBT all revolve around one’s own and other’s mind and the
relationship to important others. In MBT, less emphasis is put on ”insight” when discussing
the topics, if insight refers to something in the direction of the following examples:
”I have low self-esteem”.
”I have low self-esteem because I was pushed around and bullied as a child”.
”I have a problem with aggression”.
”I have a tendency to get stuck in depressive thought patterns. I was abandoned as a
child and lost all hope”.
”My mother neglected me because she drank”.
”My dad actually loved me, but his work took all his time”.
”I have not realized before now that I was incredibly jealous of my little sister”.
”I have major problems forgiving my father because he favoured my little brother”.
”After I was raped I’ve been experiencing PTSD symptoms”.
In MBT, the object for scrutiny is how one thinks and feels about one’s own and other
people’s experiences and minds, and how social processes affect the parties involved. In
MBT, the therapist must focus the patient’s attention on the very experience of self and others
and stimulate an exploration of relevant aspects. ”The process” is how this is done. In a
sophisticated MBT process, the therapist involves himself/herself and uses the relationship
here and now as a “training arena”.
The most important sign of a successful MBT session is that the patient gets involved
in a mentalizing discourse. The telltale sign of this type of discourse is firstly the subject
itself, i.e. what is being discussed. Next is the way it is being discussed. In a good mentalizing
discourse, images, concepts, feelings and intersubjective transactions are challenged in a way
that leads to new and often surprising and refreshing viewpoints. The observer gets the
impression that through the discourse the patient is experiencing something new. Mental
phenomena are thought of in a different way. This type of therapy might be contrasted to a
supportive one in which the therapist listens, confirms, and encourages the patient to move on,
but where the patient does not think new thoughts about mental processes.
It is difficult to restrict this item to single interventions. A mentalizing process takes
time. It is a process of construction. It depends on a chain of interventions in sequences that
can last for minutes or take large parts of the session to complete. For example:
Patient: ”It happened again yesterday”.
Therapist: ”What was that?”
P: ”I got pissed off and almost flipped out.”
T: ”Tell me what happened.”
P tells a story about his visit to the unemployment and social services office.
T: ”Let us stop here and go back to the beginning. When did you start feeling that you
were getting irritated?”
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P: ”I think I was a bit irritated already before going to the office. In fact, yes, when I
think about it, I was irritated even before going to the meeting. I’d been dreading it for several
days”.
T: ”Why was that, do you think?”
P: ”I don’t know. I just did”.
T: ”Try and remember”.
P: ”I don’t know, because my case should actually be uncomplicated. I wonder if it
might have something to do with that particular office.”
T: ”What is it with that office, do you think?”
P: ”Well … maybe it’s not that office, but the people who work there.”
T: ”What is it with those people, do you think?”
P: ”Well, maybe not people, but I think it’s that lady who sits in the reception”.
T: ”What about her?”
P: ”She is so arrogant.”
T: ”Well, that’s possible. But what exactly make you feel that?”
P: ”It’s her whole attitude. Or maybe it’s because of what happened the last time I was
there”.
T: ”What happened then?”
The therapist is exploring together with the patient this incident, what happened, how
the patient interpreted the incident, how the incident could be interpreted differently, and then
returns to the actual meeting at the unemployment and social services office, etc.
This item overlaps quite a bit with “exploration, curiosity and not-knowing stance”.
This item emphasizes process aspects, i.e. the goal is to initiate a mentalizing process about
the patient’s experience of the events.
Assessment of occurrence and scope
As mentioned earlier, there is no sense in scoring individual interventions here as
indicators of adherence. The unit to be assessed here must be shorter or longer sequences that
indicate if a certain process is being set in motion. The opposite might be a closure of
exploration through an explanatory interpretation. The sequence described above may count
as an example. In the case of good to extensive adherence, there should be several similar
types of sequences. In the case of low adherence, the therapist does not pose exploratory
questions about mental phenomena, but concentrates on problem solving, coping strategies,
psychososial support, or promoting insight through interpretation.
Assessment of competence
Good performance means that the therapist poses relevant questions that are
formulated in such a way (short, direct, unpretentious) that they promote wonder and
afterthought. The questions are followed up in longer sequences that deal with relevant
thoughts, perceptions, feelings, relations, intersubjective transactions and here and now
phenomena. Indicators on the part of the patient that he/she is involved in a mentalizing
process are statements such as the following:
“Maybe ...”, “Don’t really know…When I think about it, maybe it’s like that”, “I
wonder if it could be ...”, “Never thought of that before..., yes, hum ...”…”Not in that way,
but perhaps ...”, “When I think about it, it’s like…”.
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If a patient hesitates to let himself or herself participate in such a discourse, then one
should look closer at the therapist’s interventions. Are they open and inviting enough? Are
they too abstract or too simple, i.e. poorly adapted to the patient’s mentalizing capacity? Or is
it that the interventions themselves are good enough, but that the patient is in a state of mind
that blocks all exploratory thinking (psychotic, intoxicated, seriously depressed, bordering on
psychosis, on the brink of a breakdown, dissociated, etc.)?.
Low (1-3) The therapist shows little or no interest in entering into an exploratory
process together with the patient. He/she seems to view mental phenomena as unimportant, or
is more interested in describing and categorizing mental phenomena and telling the patient
about this “insight” rather than using the process here and now as a tool for encouraging
mentalization.
Adequate (4) The aim of the interventions clearly seem to be to stimulate the
mentalizing of experiences of self and others in an ongoing process and is less concerned
about content and interpretation of content in order to promote insight.
High (5-7) In the case of high competence, the therapist is particularly skilled with
respect to expanding the dialogue in such a way that is both natural in relation to the topic and
refreshing, perhaps even surprising. The therapist is sensitive and present. There is a focus on
the patient with his/her past and contemporary history in mind, and the therapist is inviting the
patient to explore relevant connections and contexts. The therapist does not do the
mentalizing work for the patient!
7. Acknowledging good mentalization
The therapist should support and gently praise the patient when he/she has dealt with a
situation in a way that reflects good mentalization. This is important pedagogically as an
illustration of what the therapist means by good mentalization. It also contributes to
strengthening the patient-therapist alliance. Finally, it is also important for the patient’s selfesteem. He/she receives recognition for mastering an activity that is a valued objective for the
joint therapeutic project. The therapist’s praise is also positive reinforcement.
Examples of good mentalization are situations in which the patient masters the
situation through reflection and regulating emotional arousal, in contrast to reaction modes
such as emotional outbursts, confusion, disassociation, withdrawal, self-destructive behaviour,
overeating, intoxication or suicidal gestures. It may, for example, involve situations where the
patient deals with problems on his/her own, such as when he/she decides to “sleep on” an
incident, instead of calling the boyfriend or girlfriend late at night and destructively arguing.
Or it could involve an interaction that is dealt with in a new and better way, a conversation, a
constructive argument, an earlier unbearable feeling, or a sequence in therapy in which the
patient has dared to address a sensitive topic without collapsing.
Confirmation of mentalizing behaviour should also take place in a ”mentalizing
manner”. This means that the therapist checks as they go along whether his or her assessment
is consistent with the patient’s own assessment, and that the therapist encourages the patient
to reflect about the event in the here and now: ”How is it for you now when you think back
about it?” ”What was different, do you think?”
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Assessment of occurrence and scope
This item involves interventions where the therapist acknowledges and gives his/her
approval not just with a smile or a confirmatory nod or ”mm”, but also verbally. The
following types of interventions count:
”What you are telling me about what happened yesterday evening is a bit new, isn’t it?
Isn’t it the type of situation where your previously would have done X? It is perhaps an
example of what we have been talking about in therapy, about trying to control your feelings
and reflect on them and trying to understand things in new ways. It seems that you dealt better
with the situation this time. How is it for you now when you think back on it?”
”It seems that the conversation that you had with your mother yesterday evening took
a different path than the usual one between the two of you. If that’s the case, then it sounds
positive. What was different do you think?”
”It seems that you enjoyed better the encounters with your friends on this trip. It seems
as if you were more involved and enthusiastic. You have told me about similar trips earlier
where you felt lonely, ignored and unhappy. What was different this time?”
“That was good to hear. I am happy for you that it went so well. It meant a lot for you.
It was a difficult situation, but you managed it without having to take any medicine or getting
stoned or high. It seems that you were able to contain the painful feelings without collapsing
and you managed to uphold your ability to think. It must have felt like a victory. Or am I
exaggerating?”
There does not need to be several occurrences of this type of dialogue for it to count as
an adequate degree of adherence. One occurrence is sufficient if it is of a reasonable scope. If
there are obvious incidents that the therapist overlooks, however, then the absence of
interventions should be scored as low competence.
Assessment of competence
Low (1-3) Low competence is when there are obvious examples of good mentalization
that are overlooked, neglected or misunderstood. Low competence also includes comments
that are short and delivered with little empathy or conviction, almost as if they are forced in
order to adhere to the manual; or if the therapist says something like ”sounds good” without
leaving an opening for reflection.
Adequate (4) The therapist identifies and explores good mentalization and this is
accompanied by approving words or judicious praise.
High (5-7) The therapist identifies, explores and supports good mentalization in a way
that is consistent with the patient’s mentalizing capacity and is accompanied by longer
reflections that add further dimensions to the event.
8. Pretend mode
Pretend mode is a mode of discourse in which the patient speaks about a topic in a
superficial, emotionally flat, but often detailed way so that one gets the impression that it is
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”just talk”. It is a manner of dialogue with a monologue-like form where the person doesn’t
check out whether what he/she is saying provides any meaning to the conversation partner, or
where the person uses words and concepts that seem to have a psychological content, but that
are used in an exaggerated, distorted or cliché-like manner so that the content is lost. In
pretend mode, the patient’s contact with social reality is poor. He/she is relating to a pseudoreality consisting of words, concepts and perceptions that are not grounded. The term
intellectualizing covers part of this phenomenon. Other relevant associations are “The
Emperor ’s New Clothes” and to the term “bullshit” as it now is used within the social
sciences (ref 200x).
In pretend mode, the person is running on idle. No development takes place in pretend
mode. It’s wasting time here and now. But for the patient it is a form of discourse that is
meaningful based on the person’s history. It is a way to relate to others that can make
relationships possible, although distanced and abstract. The advantage of pseudo
mentalization is that it might function as a distancing strategy. The person may have many
acquaintances, but no close friends. It is a poor strategy in terms of gaining intimacy with
respect to feelings and being open to one’s own vulnerability. The latter requires a
mentalizing approach and not a pseudomentalizing manner of speech.
The following are examples of speech in pretend mode:
”Most people simply do not interest me. They have an aura reflecting an inability to
process the complexities that exist between people. I need an input of energy that hits my
chakra so that the totality of the existence may reveal itself in the shape of an immediacy that
makes it possible to endure our world, which is on the verge of destruction”.
Patient: ‘I realise that my problems were created by my up-bringing’.
Therapist: ‘Tell me more about what makes you say that?
Patient: ‘Well, my relationship with my mother was good for some of the time and bad
at other times. I became a sort of non-person who was destined to be neurotic and the black
sheep of the family. Yes that is it. I was the black sheep of the family. The black sheep. So I
became the person who was not going to go anywhere in my like leaving me adrift. I float
around like a piece of flotsam and jetsam and never know what is going to happen next. It
might have been partly my father too. He didn’t give me a sense of who I was. He should
have done that so I could develop a sense of myself.’
Pretend mode is often accompanied by typical countertransference reactions. When
listening to empty and aimless talk, the therapist will often experience boredom and lose
interest. Listening to ”bullshit” may also be irritating because of the pompous exaggerations,
or because the therapist simply doesn’t fathom what the patient is talking about. The most
serious danger is that the therapist will collude with pretend mode joining with the patient in
developing descriptions masquerading as explanations with personal meaning. Believing that
the patient is making progress the therapist continues the exploration of the content of pretend
mode without realising that it has no links with the patient’s emotional life or reality. This can
lead to endless inconsequential talk. Patient’s take on the therapist’s perspective without fully
understanding it or integrating it into their sense of self. Not uncommonly, for example,
patients latch onto the diagnosis of borderline personality disorder and start accounting for
their actions accordingly; after an impulsive break-up, the patient declares, “There goes my
borderline stuff again!”—as if this were an explanation.
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Patients are different with respect to the role pretend mode plays in their lives. For
some this is a typical conversation and relational style, while others may resort to pretend
mode when they regress or do not know what to say. In either case, the therapist must point
out and challenge pretend mode behaviour.
Assessment of occurrence and scope
Psychotherapy sessions vary in terms of involvement, interest and vitality and the
therapist must tolerate sequences of confusion and bungling. It is a question of judgment
when such a rollercoaster ride takes on the form of clinically significant pretend mode. Nor is
it the case that all therapy sessions are characterized by clinically significant pretend mode.
When the therapist notices this tendency, he/she should implement MBT strategies such as
posing exploratory questions, adapting an affect focus, regulating the emotional arousal, etc.
If such attempts do not have the desired effect and the patient continues with a flat or
pompous style, then this should be challenged. In order for it to be rated, however, the episode
must be long enough so that the observer becomes aware of it, which often means that he/she
becomes a bit impatient and gets the impression that both parties are wasting time or that the
conversational style prevents exploratory mentalization. Examples of such interventions are
the following:
”Earlier in the session I got the impression that you were rather focused on what we
were talking about. Now it seems that some of that focus is gone. Have we lost our
direction?”
”In the past 10 minutes it seems like we have jumped from one thing to the other,
without really catching on to any one thing. Do you agree that it has been like that?”
”I am not quite sure that I understand what you mean by waves of energy between
people. Is it possible to explain this by giving a concrete example?”
”I must admit that I do not follow you in your train of thought here. Earlier we talked
about your tendency to use words and expressions that make it difficult for me to understand
what you are talking about. I think we are in that mode of conversation now, or what do you
think?”
Low competence: ”The words are getting the better of you. It’s boring me”.
”These are just empty words”.
”Now you are intellectualizing”.
Assessment of competence.
Low (1-3) The therapist ignores clear and clinically significant instances of pretend
mode. He/she follows up the patient’s pseudomentalizing mode of speech with seemingly
interested questions and comments, and long sequences take on a character of pseudo-therapy.
Alternatively, the therapist confronts the patient in an insensitive or humiliating manner.
Adequate (4) The therapist identifies pretend mode and intervenes to improve
mentalizing capacity.
High (5-7) The therapist points out the pretend mode style of conversation in a
friendly and sensitive manner, and does this by using various word and examples if the first
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intervention does not succeed. Alternatively, if the therapist does not succeed in obtaining a
reflection over the pretend mode activity, then he/she tries other strategies (for example
challenge) in order to establish a more meaningful dialogue.
9. Psychic equivalence
Psychic equivalence describes a prementalistic form of thinking in which the
individual has a tendency to equate mental phenomena with physical phenomena and vice
versa. There is little difference between fantasy and reality. A perception about the world is
mistaken for the world itself. There is little space for other people to think and experience
things in other ways than that of the protagonist. Thinking about oneself and others is
characterized by unwarranted generalizations and one-sided categories, such as “he is always
bad” or “she is always good”. Clinicians often characterize psychic equivalence as
concreteness of thought: what is thought is real. Patients with BPD have an overriding sense
of certainty in relation to their subjective experience. Experienced in the psychic-equivalence
mode, even a passing thought feels real; no alternative perspectives are possible. Thoughts
therefore have to be acted upon. Psychic equivalence suspends the “as-if” mode of
experience. Everything imagined, sometimes frighteningly, appears to be “for real.” This
experience can add drama as well as risk to interpersonal relationships, and patients’
exaggerated emotional reactions are justified by the seriousness with which they suddenly
experience their own and others’ thoughts and feelings. The vividness and bizarreness of
psychic equivalent subjective experience can appear as quasi-psychotic symptoms
In the same way as for pretend mode, this may be a mode of thinking and relating that
characterises some individuals to a greater or lesser extent, or it may be a mode that
individuals resort to when being stressed or in an emotionally aroused state. In the latter case,
interventions aimed at regulating psychic equivalence should target the emotional arousal
level. In a state of emotional arousal, we all have a tendency to resort to psychic equivalence:
“I am a failure ...”, “everyone is stupid ...”, “life is terrible ...”, “the entire world is just
horrible ...”. Nuances, alternative interpretations and the possibility of other perspectives are
lost.
Similar to pretend mode, psychic equivalence is a position where no psychological
development takes place. Patients must therefore be helped to get out of this mode. This is
easier said than done since psychic equivalence is a state governed by intense emotions. It is
also a state of mind that can arise from -- or approximate to -- a psychosis. All therapists
know that it is useless to challenge (in the sense of reality testing) a person in a state of, for
example, paranoid delusion. Challenging psychic equivalence therefore requires great skill
and empathy.
Psychic equivalence may be accompanied by attitudes of self-righteousness, absolute
certainness and arrogance that can be provoking. The therapist must be careful not to let
his/her interventions be influenced by countertransference.
Assessment of occurrence and scope
This item overlaps with the item ”challenging unwarranted beliefs”. All psychic
equivalence involves unwarranted beliefs, but not all unwarranted beliefs are part of psychic
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equivalence. Some unwarranted beliefs are due to habitual thought patterns, lack of
information, manners of speech, etc., which make them easier to regulate.
Psychic equivalence can be reduced simply by having the patient calm down: “Now
I’m doing a bit better. I can see that I get rather one-sided when I get upset”. Interventions
that qualify this item must be somewhat more than the therapist’s ability to calm the patient
down. It must be an explicit verbal intervention aimed at an expression of here-and-now
psychic equivalence. The following are examples of this type of intervention:
“You say that no one in the group likes you. That’s strange. What do you base that
impression on?”
“As far as I got it, it was a comment from Linda that got you thinking that no one likes
you. Is that right?... I agree with you that the comment, as I hear it from you, sounds critical.
But the fact that someone criticizes you, does that mean that they do not like you?”
”I understand that you experience all of the other group members as boring and that
that also applies for the conversations you are having there. But is’nt it a bit strange that
everyone and everything is so boring? Doesn’t anyone or anything there interest you? How
should we understand this ?”
“You seem convinced that the same thing will happen again so there is no reason to
try. Can we look at this for a second?... Is it that you think that you can’t handle situation X?
Or that he will not be able to accept Y?”
Often the therapist needs to suggest exploring the patient’s emotional experience of
functioning in psychic equivalence:
‘What is it like for you to be in the group when your experience is that no one likes
you? It is good that you have been able to continue to attend’.
‘With him being so completely inattentive how do you manage how you feel when
you are with him’?
Poor competence:
”I must admit that this is wearing me out. I have suggested both X and Y and Z, but
you just reject all of my suggestions”.
”I don’t know if I can help you. Whatever I say is wrong”.
”It doesn’t seem like we are getting anywhere with this. Maybe we should talk about
Y instead”?
Assessment of competence
Low (1-3) The patient shows clear signs of psychic equivalence mode, but the
therapist deals with this in a way as if he/she accepts it rather than challenging it.
Alternatively, the therapist challenges psychic equivalence in a superficial or even
condescending way.
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Adequate (4) The therapist identifies psychic equivalence functioning and intervenes
to improve mentalizing capacity.
High (5-7) The therapist exhibits a good to excellent skilfulness in the way he/she
intervenes in relation to psychic equivalence, i.e. with tact, empathy and creativity, and
without signs of negative countertransference.
10. Affect focus
All personality disorders are characterised to some degree by emotional dysregulation,
and this is particularly the case with borderline PD. This is why MBT focuses on affects. The
key is affects awareness, affect tolerance, an understanding of affects and an ability to
adaptively express affects. It is important to gain an accurate understanding of what the
patient’s emotional problems are about. For some, it is about impaired access to affects
(awareness); for others it is about the intensity of affects, possibly combined with a poor
tolerance, that dysfunctional affetcs are acted upon (e.g. intense feelings of jealousy or envy),
that their inappropriateness is poorly understood, or problems with finding a culturally
accepted outlet.
For this item there is a particular emphasis on affects in the here and now. This means
identifying the atmosphere of the session or something that might be shared between patient
and therapist.The affect focus is the current affect shared between patient and therapist at any
given point in a session. It fluctuates and tends to operate just beneath the level of awareness
of both the patient and therapist. It is the therapist’s task to try to identify it and to express it
so that it becomes available as part of the joint work. Identification of the affect focus is
subjective, and requires the therapist to monitor his own mental states extremely carefully - he
might begin to worry about the patient, notice something about how the patient behaves
towards him, find himself unable to think clearly, and yet not understand what is contributing
to his experience. All of these are examples of information that can be used to identify the
affect focus. Eschewing the need to have a fully formed understanding, the MBT therapist
expresses his experience to the patient for joint consideration, ensuring that he describes his
experience as arising from within himself.
Identifying the affect focus is an important step in MBT because it links general
exploratory work, rewinding with clarifications, and challenge to mentalizing the
transference. It is here that detailed work is done between patient and therapist with the
attachment relationship at its most powerful.
The aim is ”to mentalize the affects”, e.g. to give them a name, to bring them into a
symbolized and reflective space and to let them have an influence on the mind in a regulated
way and in an intersubjective context.
Assessment of occurrence and scope
Examples of interventions relevant for awareness of affects are the following:
”What did you feel when X?”
”Did this generate other feelings as well?”
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”It seems like you are reacting to what we are talking about. Tell me what you are
feeling? … Is it difficult to say something about it? Is it primarily a type of restlessness? …
Try to concentrate … where do you feel it? …What do you associate with this feeling?
Interventions relevant for a tolerance of emotions:
”What does that emotion do to you? … Does it make you nervous? … Afraid that it
might overwhelm you? … What would happen if it became very intense? … Do you wonder
about how you would react? ...
”It seems to me that there is a connection between the fact that you were feeling X last
night and that you started drinking. What was it about X that was difficult for you to accept?”
Interventions relevant for understanding emotions:
”It seems like sadness is a feeling that you try to avoid. It’s as if you quickly have to
get rid of it when you notice it coming over you. You have talked about how it does
something to you that you don’t like. That you feel pathetic. Can we talk a bit more about
that? Sadness is a feeling that most people experience. It is a natural reaction to losing
something.”
Interventions relevant for expressing emotions:
”What would be a suitable way for you to express these feelings, do you think? …I am
thinking in relation to X in particular. How much do you think he/she can stand? … In this
therapy I believe you feel freer than in other settings. How much do you think I can stand?”
”How strong do you believe that your emotional message need to be, in order for you
not to be misunderstood?”
The above mentioned interventions concerns affect consciousness in a general sense.
Whenever possible they should be linked to an exploration of the current affect shared
between patient and therapist in the session:
“You know, as you are talking you seem nervous about it and I am a bit nervous too. It
osccurs to me that we have only 15 minutes left of the session and that we both might be
sitting here worrying that we haven’t consolidated the good work you did last night”
“This uneasiness that you feel in the beginning of the sessions, can we find out more
about that?”.
“How is it to talk about this here?”.
“Yes, I’m smiling. ... No, it isn’t because I’m laughing at you. Quite the contrary, I
think it’s nice to listen to you when you talk about things the way you are doing now”.
Low competence:
”I don’t think you should control those feelings. Tell him straight out what you feel!”
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”Yes, I hear and see that you are sad, but what you are actually feeling is a rage
because you were dumped, but you just don’t want to admit it”.
Assessment of competence
Low (1-3) The therapist does not focus on affects. To the extent that the patient talks
about or shows affects in the here and now, it is not noticed or commented upon. The therapist
focuses on affects, but only in a cursory way. The therapist misunderstands the patient’s
affects or misunderstands the kind of problem which the patient has with particular affects.
The therapist encourages the patient to reveal dysfunctional affects. The therapist persistently
tells the patient how he is feeling.
Adequate (4) The interventions focus primarily on affects -- more than on behaviour.
The attention is directed at affects as they are expressed in the here and now, and particularly
in terms of the relationship between patient and therapist.
High (5-7) The therapist’s interventions are to a large extent directed at the patient’s
affects and they cover many aspects of emotional processing. The therapist is able to dwell on
affects without him/her repeating himself/herself -- instead switching in a skilful manner
between different affects, the self, others, the here and now and the relationship to the
therapist.
11. Affects and interpersonal events
Affects are important in themselves, but especially as elements in the ongoing
interpersonal interaction that takes place between people. Good mentalizing capacity means
allowing oneself to be influenced and informed by emotional reactions. The ability to interact
authentically and flexibly to other people without losing oneself (ignoring or suppressing
one’s own feelings) assumes the capacity to maintain openness with respect to what that
interaction might do to you on a purely emotional level. The therapist should therefore be
active in terms of linking emotional reactions to interpersonal transactions, particularly more
recent events. Through this therapeutic discourse the patient is “trained” in understanding and
dealing with intersubjective emotional interactions.
Of particular importance in this process is working in detail. The therapist should not
accept generalisations about affects but try to explore the feelings in detail in relation to the
movement in an interpersonal interaction described by the patient. It is not enough, for
example, to accept that the patient felt hurt during an interaction with their boyfriend. It is
necessary for the therapist to explore exactly what it was that led to the patient to have the
feeling they describe – was it something about how the boyfriend said what he was saying or
was it something about what he was saying, for example. The therapist can then move the
patient forward ‘frame by frame’ as it were so that important features are not missed. Clearly
this should be done sensitively and the therapist should desist if the patient is finding it
difficult, for example many patients with BPD find it hard to identify affects, but the principal
of exploring mental detail in relation to the interpersonal event should not be lost. This
process links to the next item, item 12 which is a more generic process and not necessarily
related to affects.
Assessment of occurrence and scope
The following are examples of interventions that count for this item:
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”You seem a bit on edge today, I’m wondering how you are doing... So you’re quite
irritated then? ... When did it start? ... So it was the encounter in the hallway with patient Y
from the group that you reacted to. … What happened between the two of you? … You felt
that she ignored you, is that what you felt? … What was it that she did or didn’t do that made
you feel that way? .. .How did you react then? … Do you have any thoughts about why she
behaved the way she did?”
”We should look at the incident that happened yesterday morning in a bit more detail.
Tell me from the start, what happened exactly? … You were talking on the telephone. … So it
was when your mother said “that’s obvious dear” that you reacted. … As far as I can
understand, it made you feel discouraged, disappointed and irritated… A range of different
affects. Earlier these feelings have made you withdraw from the conversation, but this time
you tried to deal with what she said. How was that?”
”You didn’t come to the last session. … Maybe that was because there was something
you reacted to in the session before? … So you felt like you were thrown out of the session.
Suddenly it was over. .... What did you think about me then and afterwards? ...”
”You say that you don’t feel welcome here. What are you reacting to, do you think? ...
Is it something that I did? Can we try to find out about it?”
“You say that it’s difficult when you feel other people are irritated or angry at you.
What does that feeling do to you? … Am I right in saying that it makes you feel bad? … It’s
as if other people’s thoughts about you quickly become your own. Is it like that? .. .It’s almost
like you lose yourself in a way – lose your self-worth and confidence. Is that an accurate way
of describing it? .. It seems like you see this more clearly after the fact, but not when you are
in the middle of it. It’s like your feelings overwhelm you. ...”
Low competence: ”You are much too sensitive. Just ignore it.”
Assessment of competence.
Low (1-3) The therapist is not particularly concerned about the patient’s affects and
does not comment on interpersonal events. The therapist comments a bit on the patient’s
feelings, but does not place them in an interpersonal context. The therapist misunderstands the
patient’s feelings and is more concerned about communicating his/her impression than finding
it out together. The therapist draws conclusions too quickly about other people’s feelings. The
therapist ends the exploratory work too quickly.
Adequate (4) The therapist connects emotions and feelings to recent or immediate
interpersonal events.
High (5-7) The therapist exhibits a high degree of skill in investigating the connection
between affects and interpersonal events, with particular focus on the patient’s beliefs and
interpretations of their own and other’s reactions and makes appropriate use of the here and
now in exploring affects and interpersonal events.
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12. Stop and rewind
”Stop and rewind” is a technique that is particularly relevant when ”things are going
too fast”, i.e. when the patient races through a story, often in an emotionally aroused state of
mind, or ”jumps to conclusions”. With this technique, the therapist tries to slow down the
pace of the discourse, both for his/her own sake and for the sake of the patient. It is important
to try to understand the detail in situations that have taken a destructive course. The therapist
should invite the patient to engage in a detailed review of the events and adopt an
intersubjective perspective.
Assessment of occurrence and scope
Among the interventions that count for this item are the following:
”Please let us stop for a second, this is going a bit too fast for me”.
‘I’m getting a bit breathless and my mind is racing. Can we just go back to…
”I’m sorry, but I’m not able to keep up with you now.”
”I think I lost you. Can we go back to X? Or where was it the entire thing started? Can
we go a bit slower now, step by step? So it started when you began clicking through his
mobile telephone, is that right? Or did it start earlier?”
”I see, now I think I’m beginning to understand a bit more. You had been looking
forward to showing her this video recording that you made on Sunday with the music that you
had composed. What happened then? She simply didn’t want to look at it? … Not at all? Did
you hesitate to ask her then? … So that was what you meant when you said that she should
have taken the initiative? … How did you know that she didn’t want to look at it? ...”
Assessment of competence
Low (1-3) There is at least one incident in which the patient reacts in a maladaptive
way to an interpersonal event without the therapist stopping, trying to slow down the pace and
together with the patient look closer into the incident. The competence is scored somewhat
higher if the therapist at least stops and makes an attempt, but then gives up too soon.
Adequate (4) The therapist identifies at least one incident in which the patient reacts in
a maladaptive way to an interpersonal event, then tries to slow down the pace and find out
about the incident step-by-step.
High (5-7) As above, but in a more convincing and empathetic manner, the therapist
shows a great deal of understanding for the various elements in the sequences and explores
them extensively, taking a lead in keeping the patient focussed.
13. Validation of emotional reactions
As mentioned in the introduction, good mentalizing capacity is closely linked to
having one’s emotional reactions as a child reasonably understood and mirrored by
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attachment figures. In patients with personality disorders, various forms of damaging
responses to their emotions have taken place. Emotions may have been ignored, neglected,
misunderstood, wrongly labelled, provoked, attacked, etc. The outcome is some kind of
confusion in terms of what is a normal reaction.
Interestingly despite this it is important that the MBT therapist recognises that the
problem in BPD is not necessarily that an emotional response is abnormal, for example
pleasure when anger seems more appropriate. It is more that a normal emotion is experienced
more intensely than normal. In addition the feeling does not dissipate as rapidly as it does in
other people who are able to ‘collect’ their thoughts more quickly than patients with BPD.
In MBT, one works with affect consiousness and emotional interactions with other
people. During this process, the therapist will come across situations where the patient’s
emotional response is clear and the intersubjective interaction is reasonably understood, but
where the patient is still faced with the dilemma of whether “it was right for him/her”. There
might still be problems of allowing oneself to have certain feelings -- if one is “bad” when
one feels a particular way, if it is unnecessary or a waste of time to feel X and Y, if one has a
right to express feelings X and Y, if others may suffer because of ones feelings, etc. In the
face of these types of questions that can come at the end of a therapeutic sequence, the
therapist should not take a “not-knowing” stance any longer, but express what he/she feels is
appropriate for the patient. E.g. the answer to whether one has a right to feel
hurt/devastated/angry as a result of sexual abuse is “yes”. This item does not mean that the
therapist should resort to counselling. It is meant to cover situations in which the therapist
confirms feelings in a simple way such as “I’m sorry to hear that”. The therapist makes it
clear that the patient’s response is understandable in the situation he is describing and that the
therapist is taking it seriously as a valid reaction. It is not simply that the therapist is taking
the feelings from the perspective of the patient. This is axiomatic in the not-knowing stance
and may relate to an empathic stance as we suggest above. It is much more that the therapist
validates the patient’s perspective as an understandable emotion that might be felt by anyone normalising.
Assessment of occurrence and scope
Examples of interventions that count in this context are the following:
”You’re asking what I think -- if you are right in feeling the way you do? Let us first
look at the situation in more detail, then we can come back to your question”.
”Yes, it seems to me that you have good reasons to react to this”.
”I think most people would become angry in a situation like that”.
”Yes, I think we can call this jealousy. … It seems that this is a feeling that you do not
want to acknowledge. I understand that it can be uncomfortable. On the other hand, it is an
emotion that is part of being human”.
”Yes, I also get the impression that you react more strongly than most people in such
situations”.
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”You are wondering if you are overreacting or underreacting. Yes, it is important to
have a measure for that type of thing. In this case I think you are reacting less than most
people would have.”
”So you felt nothing after you knocked her down. I think that is difficult to understand.
Let’s go through it more detail?”
Low competence: ”You are asking whether you were right in feeling ignored in this
situation. That is not easy to answer. It was a rather complex situation and your perspective is
just one of many possibilities. Besides there is a group dynamic going on here …”
Assessment of competence
Low (1-3) The patient demonstrates some form of emotional confusion that he/she
implicitly or explicitly presents the therapist with, but the therapist ignores it, avoids
commenting on it in a normative fashion or provides a confusing response.
Adequate (4) The therapist expresses a normative view on the warranted nature of the
patient’s emotional reaction(s) after these are sufficiently investigated and understood.
High (5-7) The therapist shows a high degree of sensitivity to the patient’s underlying
emotional confusion, brings this up and allows for a normative reflection in which the
therapist himself/herself acknowledges his/her own view.
14. Transference and relation to therapist
Since MBT is assumed to exert its influence by engaging the patient in an exploratory,
mentalizing dialogue, the relationship to the therapist is obviously of paramount importance
(as with other psychodynamic psychotherapies). This relationship is characterized by a
combination of rational, collaborative elements and irrational elements that are remnants of
earlier problematic object relations. The latter is what is usually called transference. When the
therapist works with the relationship to himself/herself, it may have to do with the alliance, an
understanding of the nature of the therapy itself, of existence and intersubjectivity,
irrationality or new relational experiences. All these elements are important for the process of
mentalizing and the therapist should make use of every opportunity to use the therapeutic
relationship to promote them.
However we have cautioned practitioners about the commonly stated aim of
transference interpretation, namely to provide insight, and secondly about genetic aspects
such as linking current experience to the past because of their potential iatrogenic effects. We
therefore coined the phrase mentalizing the transference which could equally be termed
mentalizing the relationship. Mentalizing the transference is a shorthand term for encouraging
patients to think about the relationship they are in at the current moment (the therapist
relationship) with the aim of focussing the patient’s attention on another mind, the mind of a
therapist, and helping the patient to contrast their own perception of themselves with the way
they are perceived by another, by the therapist or indeed by members of a therapeutic group.
When it comes to transference phenomena, MBT puts little emphasis on insight in a
traditional sense. This means that transference is not primarily used to promote insight, but
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rather to promote mentalizing behaviour. In MBT, one is less concerned about understanding
the here and now in light of the past; the focus is on doing something about the here and now.
In short, this means that transference phenomena are not interpreted in light of the past
as in the following example: ”You have difficulties accepting anything good from me because
I remind you too much of your father to whom you are in constant opposition”.
Transference phenomena should be dealt with as current phenomena that are difficult
to understand in themselves: “Several times recently I have noticed that you have rejected
what I have suggested. You seem to have good arguments, but it seems also as if you have
become more critical of me. Is this an accurate perception? … Is it possible to find out more
about this? Can you tell me more about what is irritating you? Is it something about the way I
am expressing myself?
If I understand you correctly, you have got the impression that I am to a certain extent
authoritarian and that I care about you in a childish way that you don’t believe in. Let’s look
at the authoritarian aspect first. What is it about me that you find authoritarian? … I
understand what you mean, but is it possible look at this from a different perspective? What
do you think?”
As evident from the above-mentioned example, transference phenomena are dealt with
the same way as unwarranted beliefs are dealt with (item 3). They are highlighted in an
attempt to establish them as an object of joint attention, and then explored using the MBT
approach.
We have set out a series of steps to be followed although not all of them need to be
present to score this item. The therapist needs to show an ability to explore the patienttherapist relationship, linking some of the following steps. Our first step is the validation of
the transference feeling through the second step of exploration. The danger of the genetic
approach to the transference is that it might implicitly invalidate the patient’s experience. The
MBT therapist spends considerable time within the not-knowing stance, verifying how the
patient is experiencing what he states he is experiencing. This exploration leads to the third
step. As the events which generated the transference feelings are identified and the behaviours
that the thoughts or feelings are tied to are made explicit, sometimes in painful detail, the
contribution of the therapist to these feelings and thoughts will become apparent. The third
step is for the therapist to acknowledge the ways in which he may have contributed towards
the patient’s experience.
Most of the patient’s experiences in the transference are likely to have some basis in
reality, even if they only have a very partial connection to it. It often turns out that the
therapist has been drawn into the transference and has acted in some way consistent with the
patient’s perception of her. It may be easy to attribute this to the patient but this would be
completely unhelpful. On the contrary, the therapist should initially explicitly acknowledge
even partial enactments of the transference as inexplicable voluntary actions that need to be
explored and for which he accepts agency rather than identifying them as a distortion of the
patient.
Authenticity is required to do this well. If the therapist really cannot identify some
aspect of themselves or their actions that might have been involved in creating the patient’s
experience, then he and the patient will accept that they hold alternative perspectives and that
the question remains open for future exploration. Drawing attention to the therapist’s
contributions may be particularly significant in modelling to the patient that one can accept
59
agency for involuntary acts and that such acts do not invalidate the general attitude which the
therapist tries to convey. Only then can distortions be explored.
The fourth step is collaboration in arriving at an alternative perspective. Mentalizing
alternative perspectives about the patient therapist relationship must be arrived at in the same
spirit of collaboration as any other form of mentalizing. The metaphor we use in training is
that the therapist must imagine sitting beside the patient rather than opposite him or her.
Patient and therapist sit side-by-side looking at the patient’s thoughts and feelings, where
possible both adopting the inquisitive stance. The fifth step is for the therapist to present an
alternative perspective and the final step is to monitor carefully the patient’s reaction as well
as one’s own.
An exploration of the relationship to the therapist is a demanding task. It is intimate
and sensitive. A precondition should be a well established alliance. In MBT, the therapist is
initially supportive, pedagogical and containing. Mentalizing the transference is something
that can be gradually addressed when the therapy is well underway and the patient is
reasonably stable. In the therapy’s early stages, however, the therapist can still comment on
what are called “transference traces”, which is a term that refers to attitudes relating to earlier
therapists, health services in general, the treatment programme as such, etc. An example of
this type of comment is the following:
“You told me that in previous therapies everything used to start out fine, but then it
was as if the therapist would lose interest in you for some reason. You would then become
disappointed and would stop talking about what was most important to you. Then you would
quit. We should be aware of that kind of development, so we can possibly avoid it this time.”
“You told me that you have often been misunderstood by people in the health services.
It is important that you tell me if you feel the same thing is happening here with me.”
Assessment of scope and frequency
As previously mentioned, it is important for this item to take into consideration
whether the session is early, middle or late in the course of the treatment. Early on, the
therapist should be careful in terms of exposing the patient to extensive explorations of
interactional processes in the here and now. Later, however, the relationship to the therapist
should take on a more prominent role, which will likely include the irrational elements that
we call transference.
The following types of interventions can be included in this item:
“How are you when you are here?”
“Does the same apply here as well? … No? ... What is the difference do you think?”
“At the end of the last session, things went a bit fast and I got the feeling that you
didn’t like how we ended the session. I’m not sure if I’m right. ... How do you feel about it
now?”
“You say that you would prefer that I start the sessions. Can we discuss this?”
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“You mentioned a second ago that you think I am disappointed with you. How did you
come to that conclusion?”
“I understand that you react strongly to being here with me, almost filled up with
disgust. It’s a good thing that you can contain it. Let’s try to find out – when and how did it
start?”
Low competence:
”When you were growing up you were used to getting things the way you wanted by
expressing strong emotions. You are now doing the same thing here, but you probably have
noticed that it will not work”.
Assessment of competence
Low (1-3) The therapist does not comment on how the patient relates to the therapist
during the session, even though it would have been relevant. The therapist ignores obvious
transference phenomena, seriously misunderstands transference phenomena or interpretes
transference in a rigid manner as simple repetitions of the past. On a somewhat higher level
the therapist may comment on the relationship, but in a rather superficial way.
Adequate (4) The therapist comments on and attempts to explore -- together with the
patient -- how the patient relates to the therapist during the session and stimulates reflection
on alternative perspectives whenever appropriate.
High (5-7) The therapist shows excellent skill in commenting on and exploring several
aspects of the therapist-patient relationship and links this to themes that are higly relevant for
the patient.
15. Use of countertransference
The technical use of countertransference in MBT borrows heavily on the work of Racker
(Racker, 1957), who distinquished between complementary and concordant countertransference.
Complementary countertransferences are emotions that arise out of the patient's treatment
of the therapist as an object of one of his earlier relationships, and are closely linked to the notion
of projective identification. This leads to countertransference experience of the therapist being
considered as part of the patient’s internal state and technically leads many therapists to place the
experience they themselves are having back to the patient. This is avoided in MBT. Why?
Countertransference experiences are most commonly associated with turbulence in the patient’s
mental state; asking the patient to consider further their feelings in the context of a theoretical
projection of emotion in the therapist will overwhelm their precarious state of mentalizing just at
the time when they need mental support. As in the following examples:
”I am noticing an increasing frustration over our relationship. I think it may be
because you unconsciously want to undermine the therapy and that you therefore behave in a
way aimed at provoking a termination from my part. Then you could leave as a victim, a role
that you seem to be quite comfortable with”.
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The therapist, experiencing himself as becoming confused and then bored, states to the
patient: ‘It occurs to me that you have been feeling confused and are now rather bored so that
you don’t have to remain feeling so confused’.
In contrast concordant countertransferences are empathic concordant responses, based on
the therapist's resonances with his patient. Concordant countertransferences therefore link with
affective attunement, empathy, mirroring and a sense that certain aspects of all relationships are
based on emotional identifications that are not solely projections. Stern's (Stern, 1985) 'affective
attunement' between mother and baby, and, by extension, between patient and therapist, is a
different way of explaining such interaction, involving as it does the ability of the mother
(therapist) to 'read' the patient's behaviour and respond in a complementary manner, which is in
turn 'read' by the child (patient). Technically, in MBT, countertransference experience is used
with this understanding in mind.
Countertransference is stated as the therapists experience, that is it is ‘marked’. It is not
considered initially as a result of projective identification and the therapist must identify the
experience clearly as his. The simplest way to do this is to state ‘I’ at the beginning of an
intervention. Intriguingly this seems to be hard for therapists who understandably worry about
violating boundaries of therapy. Yet we are not suggesting that therapists start expressing their
personal problems or start talking about any feeling that they might have in a session whether
relevant to the process or not. Rather we are maintaining that the therapists current experience of
the process of therapy with the patient has to be a shared openly to ensure that the complexity of
the interactional process can be considered. Patients need to be aware that their mental processes
have an effect on others mental states and that those, in turn, will influence the direction of the
interaction.
There are a number of common countertransference experiences for therapists when
treating patients with BPD which are associated with particular modes of psychological
functioning. Gradually therapists need to become comfortable with managing these states of
mind and be able to express them constructively in the service of extending the patient-therapist
collaboration. Many non-mentalising states of mind are indicated by the actual behaviour of the
therapist who for a considerable period of time may be unaware that his actions are changing.
Therapists who only grunt as the patient talks and clearly lose concentration are often being
affected by pretend mode functioning in the patient; therapists who start to give suggestions
about how to solve problems or who tell the patient what to do without exploration are likely to
be involved in teleological process; the confused therapist who nods wisely is more often than
not struggling with understanding what is being said and is trying too hard to understand psychic
equivalent modes of thought. In all circumstances the therapist, once alerted by a change in his
behaviour, should focus more carefully on his feeling and identify it.
To re-iterate – the expression of the underlying feeling of the therapist as a useful tool in
therapy is done openly and carefully marked. It is ‘owned’ by the therapist to ensure that the
patient is not overburdened with emotional responsibility. Implicitly telling the patient that he
has created the feelings in the therapist increases the mental work required from the patient just
at the time when his mentalizing is in danger of being lost, thereby inadvertently increasing the
likelihood of this outcome.
When it comes to countertransference, it is important to find a form through which this
can be expressed without humiliating the patient. This applies particularly to negative
countertransference. There is no point in uttering: “I am exhausted listening to you”. Rather
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something more like: “I am beginning to notice that I have lost interest in what you’ve been
talking about the past few minutes. I think we need to stop for a second to find out why”.
The use of countertransference can be an extremely powerful tool. Just as with
transference, it is a tool that the therapist should be careful in using in early stages in therapy.
It will become more appropriate as the course of the therapy develops.
Assessment of occurrence
Interventions that are covered in this item include the following:
”That was nice to hear”.
”Yes, you are right about me ending the last session a bit abruptly. I was so captivated
by what you were talking about that I completely forgot the time. How was it for you that you
had to leave while you were still experiencing painful feelings? … I’m sorry about that, I see
that I didn’t deal very well with that situation.”
”If I am disappointed in you? Hm, … no, I don’t think so. I do feel a bit frustrated,
though. I’m frustrated that we weren’t able to find out more together during the last session.
But maybe we both see things a bit more clearly now?”
”If I am irritated? Yeah, you can say that. It has to do with you coming late. We have
discussed it several times, but it doesn’t seem to have had any effect thus far. You continue to
come late. There must be something we have not understood here or there is something I am
not understanding about how to help you with it. Let us go through it again.”
Low competence:
”Yes, I am definitely upset. Psychotherapy is a collaborative effort between two
people. You are not doing your job. It’s about time that you pull yourself together.”
”No, I have a professional attitude about this kind of things. The fact that people hurt
themselves doesn’t affect me anymore.”
“May be it is you who feels bored and that is why I have begun to be bored by the
session”.
Assessment of competence
Low (1-3): The therapist does not mention his/her own feelings or thoughts about the
relationship to the patient during the session, even though this would have been relevant; or
he/she interprets countertransference exclusively as a response to the patient’s way of being in
an attempt to increase the patient’s insight about repetitions of the past. The therapist
comments only superficially on his/her own feelings or thoughts about the relationship in a
situation where an elaboration would have been appropriate.
Adequate (4): The therapist actively uses his/her own feelings and thoughts about the
relationship to the patient and attempts by this to stimulate an exploration of the relationship
between them.
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High (5-7): The therapist uses his/her own feelings and thoughts about the relationship
to the patient as an important component in the process taking place during the session. The
process includes a creative attempt to increase curiosity and exploration on the part of the
patient.
16. Monitoring own understanding and understanding misunderstandings
As mentioned earlier, a central premise of MBT is that mental phenomena are nontransparent and that an interpretive effort is needed to bring these phenomena into a verbal
discourse, whether it be an inner ”conversation” with oneself or a dialogue with someone else.
Interpretations, in the sense of understanding oneself and others, can be more or less precise,
accurate, fair or fitting; and misunderstandings may arise at any stage of the process of
making something comprehensible. A feature of good mentalizing is that one is sensitive to
inner and outer signals that indicate possible misunderstandings and that one tries to clarify if
this is the case, and secondly tries to adjust according to new perspectives or information.
This is otherwise known as “reality testing” ability.
All therapists make errors – they get things wrong. The question that needs answering
is what is to be done when something goes wrong and what has happened to make it go
wrong. Clearly therapists errors range from the mild to the severe and we will discuss here
only those that are misunderstandings rather than those that are boundary violations. Therapist
errors offer opportunities to re-visite what happened and to learn more about contexts,
experiences, and feelings engendered in both patient and therapists as a result of the error.
Therapists should be good role models in terms of checking their own perceptions and show a
willingness to clarify any misunderstandings. These practices are valuable in themselves,
because they contribute to a heightened quality of the therapeutic dialogue. In MBT the
therapist takes initial responsibility for the error until it becomes clearer that there was a
contribution from the patient. The following example illustrates this point:
The therapist was to be away on the day of the patient’s session the following week
and told the patient that he needed to change the session day so that they would not miss an
appointment. The patient said ‘OK. We can sort it out at the end.’ At the end of the session the
therapist (having been so involved in the session – or so he suggested to others afterwards!)
forgot about re-arranging the appointment and the patient did not mention it. The therapist
remembered a minute after the patient had left and ran after her, fortunately catching up with
her before she left the building. At the moment he said to the patient ‘I am sorry I forgot to rearrange the session can you come back for a moment so that we can do it’, the patient said
wryly ‘nearly forgot did we’? Ignoring this, the therapist re-organised the appointment.
The following week the patient quipped ‘this is the session that nearly did not happen!
The therapist apologized and said ‘I wondered what had been going on that meant I
forgot at the end of the session’? I was thinking about it and I am not sure at all.’
Patient: ‘It was because you did not want to see me’
Therapist: I don’t think that had occurred to me but certainly I should have
remembered to re-arrange the session and that was my responsibility.
Patient: I always think that people like me when I am not here.
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Therapist: In what way?
Patient: When I am with them people just feel pissed off with me but when I am not
here they think that may be I am not so bad.
The dialogue continued with the patient expressing a sense that she would have liked
to have missed the session as a result of the therapist’s failure to rearrange it so that she could
feel good. Clearly this needed more exploration as it is not immediately understandable. So
the therapist asked about what she meant. Importantly the therapist took initial responsibility
for what had happened. Only later in the session did the therapist say that he was also curious
about what had stopped the patient asking for the new appointment. Rapidly the patient
became aggressive.
Patient: So now it suddenly becomes my fault does it. It was you who forgot to rearrange it so we should be discussing your problem not mine.
Therapist: I agree that it was my problem and that it was my memory that was the
issue and yet it is intriguing that you don’t feel able to help me with my memory.
Patient: Not my job.
This interaction has the potential to close down the patient’s ability to reflect on his
state and that of the therapist so the therapist task is to ensure that both he and the patient
openly juxtapose their mental states as they consider which aspects of the interaction were
primarily related to the patient and which to the therapist. To do this the therapist has to
balance reference to his own responsibility for something that has happened with stimulation
of the patient’s ability to explore his own contribution. Excessive emphasis in the patient
component will alienate him and increase the likelihood of closing rather than opening his
mind.
Assessment of occurrence and scope
Interventions that fall in under this item include the following:
”Let me first check out if I have understood you correctly.”
”Am I right in thinking that you felt like you were being attacked in that situation?”
”I’m not sure if I really got this right. Is the essence here that you have the opinion that
your mom always favoured your younger sister? Is that so?”
”This is a bit unclear to me. Do you feel that he did it to hurt you?”
”Ok, now it’s making a bit more sense to me. I don’t think I have realised just how
jealous you can get.”
”I’m sorry, I must have misunderstood. It was good that you pointed that out. I thought
that you weren’t very concerned about her and that it didn’t mean anything to you that she
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left. Now I understand that you took it quite hard. Let us first look at how this event affected
you, then we can go back and look at how come that I misunderstood you.”
Poor competence: ”Now I think you are the one misunderstanding me. Are you even
listening to what I’m saying?”
”No, I’m not the one doing the misunderstanding here. You were quite clear a second
ago that you disliked what your mother said to you. You just have problems admitting it.”
Assessment of competence
Low (1-3) The therapist makes a superficial attempt or none at all at checking out
whether his/her understanding of the patient’s state of mind corresponds with the patient’s
own understanding. At clear signs of misunderstanding, the therapist makes no efforts to
correct it. On the contrary, he/she insists that his/her own belief is accurate and that any
disagreement is the patient’s fault.
Adequate (4) The therapist checks out his/her own understanding of the patient’s state
of mind and to what extent this corresponds with the patient’s understanding. Then he/she lets
his/her own understanding be influenced by the patient’s understanding and openly admits to
any misunderstandings whenever they occur.
High (5-7) The therapist examines with great sensitivity his/her own understanding of
the patient’s state of mind, demonstrates clearly how this type of interaction is truly important
in gaining an understanding of the patient’s state of mind and deals with any
misunderstandings in a way that reinforces the ongoing mentalizing process.
17. Integrating experiences from concurrent group therapy
“Classical” MBT is a concurrent treatment consisting of individual and group therapy.
The model calls for the patient’s experiences in the group therapy sessions to be discussed in
the individual therapy sessions. It depends on patient and therapist working together on this
project -- the patient by bringing up topics without having to be asked and the therapist by
devoting space and time to these experiences and also by asking the patient about recent
group experiences.
Assessment of occurrence and scope
Among the interventions falling under this item are the following:
”What happened in the group the last session?”
”It’s a long time since you mentioned anything from the group sessions. …How
should we understand that?”
”Yes, I talk to the group therapists on a regular basis. How do you feel about that?”
”Group therapist X told me last week that you didn’t come to the group session and
that you hadn’t given any notice that you wouldn’t be coming. He asked me to ask you about
it.”
”You refer to Jesper in the group as an idiot. Tell me what happened.”
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”So you think he simply is out to get you. Why would he want that? … Is it possible to
understand it in any other way? … It’s not so easy to bring new members into a group either.
How do you feel about that?”
”So Linda no longer talks to you, what do you think that is about? … Could you
discuss it with her?”
”You should bring it up in the group.”
”So this is happening in the group as well? What’s your part in it, do you believe?”
Poor competence: ”So nobody in the group listened to you. That’s the way it often is
in groups.”
”I don’t think you should have too high expectations of that group. We have seen
before that there are a number of quite sick persons in the group.”
Assessment of competence
Low (1-3) The therapist does not ask about experiences from the group therapy even
though it is relevant; he/she responds only briefly or in a disinterested fashion to the patient’s
account; or he/she demonstrates unwarranted scepticism about the group therapy.
Adequate (4) The therapist stimulates exploration of the patient’s experiences from the
group therapy sessions and helps to integrate the material so that the treatment as a whole is
coherent.
High (5-7) The therapist exhibits a high degree of interest in the group therapy
sessions and explores together with the patient several incidents in which group therapy,
individual therapy and the patient’s most important topics are linked together in a way that
reflects a high level of skill and clinical proficiency.
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MBT adherence and competence scale
Version individual therapy (April 2010)
Rater ID __________________
Date _____________________
Patent ID _____________________ Session no __________________
Therapist ID ___________________
Overall rating of MBT adherence _______
MBT competence __________
Rating targets are the therapist’s interventions. Rating procedures are explained in the Manual for MBT and MBT adherence and
competence scale. Below are the general criteria for occurrence/frequency (adherence) and quality (competence/skill level). The rater takes
notes as the session proceeds (/ versus Ø). High versus low quality can be noted by numbers 1-7 (e.g /3). In addition it is recommended to note
comments.
Each item should be rated according to the criteria. Concerning quality, the number 4 equals en adequate intervention (“good
enough”). The manual contains further examples of low versus high quality.
The overall rating should be performed according to a global assessment, and not as the numeric mean of all items.
If the assessment is performed as a part of supervision, write down on the last page what are the positive aspects of the therapists
style from a MBT perspective and what aspects that can be improved.
Criteria for rating of adherence and extensiveness:
Notations
1
Not at all
The intervention never explicitly occurred
2
A little
The intervention occurred once and was not addressed in any depth
/
3
Infrequently
The intervention occurred twice, but was not addressed in depth or detail
//
4
Somewhat
The intervention occurred one time and in some detail OR the intervention occurred 3-4
times but all interventions were very brief
Ø
///
5
Quite a bit
The intervention occurred more than once in the session, and at least once in some detail
or depth OR the intervention occurred 5-6 times, but all interventions were very brief
Ø//
/////
6
7
Considerably
Extensively
The intervention occurred several times during the session and almost always with
relative depth and detail OR the intervention occurred more than 6 times, but all
interventions were very brief
Ø//Ø/Ø
The intervention occurred many times almost to the point of dominating the session and
was addressed in elaborate depth and detail OR the intervention occurred briefly at such
a high frequency that it became difficult to count
ØØØØ/ØØ
///////
//////////////////
Criteria for rating of quality (skill level):
0
Not at all
The intervention was not observed
1
Very poor
The therapist handled this in an unacceptable, even ”toxic” manner
2
Poor
The therapist handled this poorly (e.g. showing clear lack of expertise, understanding, competence, or
commitment, inappropriate timing, unclear language)
3
Acceptable
The therapist handled this in an acceptable, but less than ”average” manner
4
Adequat
The therapist handled this in a manner characteristic of an ”average”, ”good enough” therapist
5
Good
The therapist handled this in a manner slightly better than “average”
6
Very good
The therapist demonstrated skill and expertise in handling this issue
7
Excellent
The therapist demonstrated a high level of excellence and mastery in this area
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MBT scale
Item name
1. Engagement,
interest and
warmth
Notes adherence
Adherence Notes quality
rating
This item is not
rated for
adherence
2. Exploration,
curiosity and a
not-knowing
stance
Quality
rating
4: The therapist appears genuinely warm
and interested. The rater gets the
impression that the therapist care.
Several concrete comments
communicate this positive attitude
4: The therapist poses appropriate
questions designed to promote
exploration of the patient’s and others
mental states, motives and affects and
communicate a genuine interst in
finding out more about them
To be rated for quality even if specific
interventions are lacking
3. Challenging
unwarranted
beliefs
4: The therapist confronts and
challenges unwarranted opinions about
oneself or others in an appropriate
manner
4. Adaptation to
mentalizing
capacity
This item is not
rated for
adherence
4: The therapist seems to have adapted
to the patient’s mentalizing level and the
interventions are foro the most part
short, concise and unpretentious
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5. Regulation of
arousal
4: The therapist plays an active role in
terms of maintaining emotional arousal
at an optimal level (not too high so that
the patient looses his or her ability to
mentalize; not too low so that the
session becomes meaningless
emotionally)
6. Stimulating
mentalization
through the
process
4: The aim of the interventions clearly
seems to be to stimulate the mentalizing
of experiences of self and others in an
ongoing process and is less concerned
about content and interpretation of
content in order to promote insight
7.
Acknowledging
positive
mentalizing
To be rated for quality even if specific
interventions are lacking
8. Pretend mode
To be rated for quality even if specific
interventions are lacking
4: The therapist identifies and explores
good mentalization and this is
accompanied by approving words or
judicious praise
4: The therapist identifies pretend mode
and intervenes to improve mentalizing
capacity
9. Psychic
equivalence
To be rated for quality even if specific
interventions are lacking
4: The therapist identifies psychic
equivalence functioning and intervenes
to improve mentalizing capacity
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10. Affect focus
4: The interventions focus primarily on
affects, more than on behaviour. The
attention is directed at affects as they are
expressed in the here and now, and
particularly in terms of the relationship
between patient and therapist
11. Affect and
interpersonal
events
4: The therapist connects emotions and
feelings to recent or immediate
interpersonal events
12. Stop and
rewind
13. Validation
of emotinal
reactions
14. Transference
and the relation
to the therapist
4: The therapist identifies at least one
incident in which the patient reacts in a
maladaptive way to an interpersonal
event, then tries to slow down the pace
and find out about the incident step-bystep
4: The therapist expresses a normative
view on the warranted nature of the
patient’s emotional reaction(s) after
these are sufficiently investigated and
understood
To be rated for quality even if specific
interventions are lacking
4: The therapist comments on and
attempts to explore – together with the
patient -- how the patient relates to the
therapist during the session and
stimulates reflections on alternative
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perspectives whenever appropriate
15. Use of
countertransference
To be rated for quality even if specific
interventions are lacking
4: The therapist actively utilizes his/her
own feelings and thoughts about the
relationship to the patient and attempts
by this to stimulate an exploration of the
relationship between them
16. Monitoring
own
understanding
and correcting
misunderstanding
17. Integrating
experiences
from concurrent
group therapy
4: The therapist cheks out his/her
understanding of the patient’s state of
mind and to what extent this
corresponds with the patient’s
understanding. Then he/she lets his/her
own understanding be influenced by the
patient’s understanding and openly
admits to any misunderstanding
whenever they occur
4: The therapist stimulates exploration
of the patient’s experiences from the
group therapy sessions and helps to
integrate the material so that the
treatment as a whole is coherent
Comments for supervision
 Which type of interventions did the therapist make to a greater and/or lesser
extent?
 Which clinical phenomena did the therapist overlook, e.g. ”missed
opportunities”?
 To what degree did the therapist make use of non MBT techniques?
 Which type of interventions had a high versus a low quality from a MBT
perspective?
 Advice formulated to enhance current MBT competence
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7. Reflective functioning scale (RF)
Adapted from Fonagy, Steele, Steele & Target, 1999
RF was developed for research purposes and is an operationalization of a person’s explicit mentalizing
capacity. The most common way to score RF is by using The Adult Attachment Interview (AAI). The interview
subject’s responses to demanding questions such as ”Why do you think your parents did that?” and ”Do you
think they understood that it made you feel rejected?” are particularly relevant. The RF scale (shown below) can
be used for circumscribed responses and as indication of an individual’s overall RF capacity. For RF capacity, it
is the person’s typical tendency that should be specified. The scale below has been adapted for teaching purposes
and is only suggestive of the original RF scale. We refer to the original manual for research applications.
Moderate
to high
RF
9
Full or
exceptional
7
The person exhibits a consistent reflective attitude in most contexts. There
are frequent examples of good reflective functioning that suggest a coherent
psychological model of his/her own and others’ mind. A number of descriptions of
thoughts and feelings – as well as implications for mental states – can be observed,
often within the framework of a developmental (interactional) perspective.
5
The person exhibits an ordinary ability to transform experiences into
meaningful and relevant thoughts and feelings. His/hers implicit model of the mind
(his/her own and others) may be simple, but fairly consistent, personal and coherent.
Marked
Definite or
ordinary
Negative
to limited
RF
The person exhibits a consistently reflective attitude in all contexts.
Comments reflecting exceptional RF are genuine, refreshing, complex and
contextualised, integrated with a developmental perspective when necessary.
3
Questionable
or low
1
Absent, but
not
repudiated
-1
Negative
The responses vary in quality. A mentalizing perspective is present
sporadically, but not consistently. Stories are intermixed with social clichés,
pseudomentalizing, self-centeredness, cockiness and a general impaired ability to see
others’ perspective fairly. There are also mixed feelings and conflicts, a lack of
developmental perspective and a low degree of understanding the opaque character
of mental states. Responses are typically ”splitted”, with a tendency to either idealise
or devalue others.
The person lacks a mentalizing perspective, even though responses may not
be outright hostile or aversive. Responses consistently refer to concrete incidents
and/or social or psychological clichés revealing an inadequate model of the mind.
Most of the responses at this level are coloured by a tendency for distortions of
experiences. The distortions reflect attempts to uphold a certain degree of continuity
in self-presentation (the self), and give the impression of being self-centred in the
sense that they are overly egocentric or self-glorifying with unrealistic and/or
condescending descriptions of others.
The person reacts in a hostile manner to challenging questions and/or
responds in a bizarre or contradictory manner: ”How could I know that, aren’t you
the psychologist here?” or ”You are just trying to make me look bad”.
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8. MBT dynamic formulation
Psychodynamic formulation originated in the short-term psychotherapy tradition.
While psychoanalysis could afford time-consuming therapeutic trajectories and let the
patient’s inner pathogenic scenarios be played out slowly in relation to the analyst
(transference), brief therapy needed focus. An example of a typical dynamic focus for a brief
therapy intervention could be a conflict with authority figures, e.g. defined as the patient’s
“conflicting feelings toward authority figures, which may have resulted in the following
tendencies: 1) submission, 2) self-contempt and 3) passive-aggressive behaviour”. In time it
became more common to use dynamic formulations in long-term therapies (lasting more than
a year) as well.
In reality, all forms of therapy operate with some form of dynamic formulation, but it
may be implicit, held as the therapist’s own understanding of dynamic connections. It
becomes explicit when it is formulated in the medical record or in a research protocol,
reviewed at a case conference or discussed openly with the patient. The formulation is
naturally influenced by the theory guiding the treatment. In classical cognitive therapy, a
dynamic formulation defines the patient’s maladaptive schema, describes situations that
activate the schema and identifies typical response patterns by the patient to such situations.
In Jeffrey Young’s schema therapy (2003), which is intended for patients with
personality disorders, great emphasis is put on completing a detailed ”Schema therapy case
conceptualization form”. The form consists of the following elements:
1) brief description of background
2) relevant schema
3) relevant problems
4) schema triggers
5) severity of schema, coping and mode, risk of decompensation
6) temperament factors
7) development strains
8) most important childhood memory
9) most important cognitive distortions,
10) submissive behaviour
11) avoidance behaviour
12) overcompensating behaviour
13) relevant schema mode
14) relevance for relationship to therapist
In brief dynamic therapy (McCullough et al., 2003), a ”core psychodynamic conflict”
is formulated in relation to the conflict triangle, which focuses on the following affect
variables:
1) Specific affects which the patient attempts to avoid
2) why these affects are avoided
3) defensive behaviour used to avoid these affects
Nancy McWilliams (1999) has written an entire book on ”psychoanalytic case
formulation”, which emphasises:
1) temperament factors
2) upbringing background
3) defensive patterns
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4) central affects
5) identifications
6) relational schema
7) self-esteem regulation
8) pathogenic thought patterns
McWilliams is less schematic than e.g. Young with respect to concrete formulations.
They are formulated in a more oral way and sound like the following: ”One thing that I’ve
noticed about your depression is that you have experienced many losses for which you have
not properly mourned, and that your family has encouraged your avoidance of sad feelings by
criticising you for ‘feeling sorry for yourself’. You might find out that you are harbouring
some anger in relation to this and other experiences that you have had difficulties in
admitting. By opening up to feelings of sorrow and anger, your depression should ease up a
bit. It also seems to me that there is a depressive tendency in your family and that you don’t
seem to have had anyone who could help you find out what brings you down and why. How
do you feel about what I have said to you now?” (McWilliams, 1999, s.43).
Luborsky et al. (1998) has developed a more scientific method, ”The core conflictual
relationship theme method” (CCRT), which is directly linked to Freud’s theory of
transference.
The above-mentioned references make clear that there is not just one generally
acceptable type of dynamic formulation. The formulation must be adapted specifically to each
therapy form. In this context, our starting point is formulations aimed at being discussed
openly with the patient. Some elements will be the same regardless of approach: The
formulation is an attempt to organise the clinical material in such a focussed manner that the
patient and therapist together can define the means and objectives of the therapeutic project
and thereby promote the alliance between therapist and patient. The objective is to build
bridges between the patient’s inner and outer worlds (personality characteristics, relations and
behaviour), and the overall idea is to provide some relevant answers to the questions “why am
I in therapy” and “what needs to be changed and how”. It should be formulated in an easy and
understandable language, but at the same time be one step ahead of the patient’s own
understanding of himself or herself. It must be accepted by the patient, invite an ownership of
the problems and communicate hope about the possibilities for change. It does not represent
any “truths” about the patient, but it should contain well-grounded working hypotheses that
can be changed along the way.
Kassaw and Gabbard provide the following recommendations (Kassaw & Gabbard,
2002):
1) One should not attempt to include everything or describe every single problem the
patient is struggling with. Focus on one or two key themes that seem to be central to the
patient’s difficulties.
2) Illustrate how specific experiences during childhood might have contributed to the
difficulties that have resulted in the patient seeking therapy.
3) Identify stress factors that may have triggered the patient’s symptoms and
distressing feelings.
4) Make use of the patient’s transference reactions and your own countertransference
reactions when trying to understand the patient’s problems.
75
5) Provide likely suppositions about how the patient’s relational patterns may exert an
influence on the therapist-patient relationship and on the course of the psychotherapy.
6) Remember that a formulation is only a hypothesis or a set of hypotheses. The
formulation should be revised in step with new information or changes in therapy.
A mentalisation-based dynamic formulation contains many elements that the reader
may recognize from sources referred to above. The unique aspect is the emphasis on impaired
mentalizing capacity and the combination of individual and group therapies. The approach
encourages a more varied setting (group therapy), and a precondition for progress is a close
collaboration between the various therapists. The formulation is the first invitation to
“socialize” the patient into a mentalization-focussed frame of understanding. The structure of
the formulation may be something like the following:
1. A very short outline of the developmental history that says something about any
traumas, losses, problems with attachment figures, areas of vulnerability, coping
mechanisms and costs associated with these mechanisms.
2. A brief summary of the type and scope of mental problems and how these are played
out interpersonally, particularly with respect to affects and mentalization. The
formulation should contain a description of one or more typical episodes which results
in a significant decline of mentalizing capacity.
3. How the problems might influence the course of the therapy -- in the individual and
group therapy sessions, and recommendations about what the patient himself/herself,
fellow patients and therapist should be aware of.
An MBT formulation should be formulated in writing by the professional who is
responsible for the assessment, discussed in the team and then presented to the patient. If the
patient points out any factual errors, then they should be corrected straight away. If the patient
expresses disagreement in the dynamic understanding, then this should be discussed with the
patient thoroughly until there is a consensus. The following is an example of an MBT
formulation for a patient who was referred to treatment because of work disability, social
isolation, feelings of hopelessness and a history of serious suicide attempts.
”X was born and raised in Northern Norway. His early, formative years were traumatic.
His parents were divorced, and at the age of six he was sent from his mother to live with his
father, who never accepted the boy into his new family. The father was authoritarian and
violent, and X lived in constant fear of beatings. His formative years were characterised by
insecure attachment relationships and unfair treatment by authority figures. Since his early
youth, X suffered from anxieties and fears, and eventually developed oppositional tendencies,
particularly in relation to male authority figures. He was particularly sensitive to issues of
unfairness and injustice, and this caused him problems in the military, at college and later
with employers. A positive side has been his strong involvement in international solidarity
work.
X also experienced problems maintaining close, personal relationships. He is easily
offended and becomes jealous. Another problem is that he is uncompromising in conflicts and
this frequently has resulted in severed relationships and friendships. X’s pride prevents him
from repairing or resolving breaks, and in time this has resulted in him becoming more lonely,
isolated and despondent. Several serious suicide attempts have followed.
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The main problem for X seems to be his sensitivity to insults and his general mistrust of
others. This is understandable in light of his childhood, but it nevertheless has created
problems for him in his adult life. The same pattern is likely to be part of therapy. To start
with, X is likely to be a bit reluctant and wary of opening up in group therapy. This kind of
situation could result in him feeling that others are getting more than him, and he could
interpret this as unfair. In the individual therapy, great emphasis will have to be put on finding
out what X is thinking and feeling about such a development. It is also likely that X will
experience various incidents in group therapy as insulting and humiliating. The first challenge
for him will be to deal with these feelings without withdrawing from treatment.
Communicating his feelings will have to be the first step in dealing with his feelings. If X has
problems talking about his feelings, then he must discuss this with the individual therapist to
find out a means of expression that would be suitable. It is important to look closely at the
situations that make X feel unfairly treated and to try to understand more about how X is
thinking and feeling about himself and others in such situations as well as to help him manage
the feelings themselves. When X gets upset, things quickly become chaotic inside him. In
these situations, it is important for him to be given enough time, space and calm to find the
right words to put to his feelings. X also has problems forgiving others after conflicts and
insults – real or imagined. He quickly becomes uncompromising and bitter and can reject
others ‘for life’. Both X and the group must be aware of the chance of such a development, to
focus on it when it seems to be unfolding in order to understand it better and to try to learn
what prevents X reconciling with people after disagreements and/or conflicts”.
In this formulation, the keywords that should be emphasized are perceptions of injustice
and insult and an unwillingness to forgive or put the past behind him. A schema-focussed
formulation would include details about the various schema activated and what mode the
patient resorts to in stressed situations. In MBT, it is important not to make overly assertive
statements about what is going on in patient’s mind. Instead, there should be an emphasis on
having the patient and therapist(s) work even harder to find out together what is happening
inside the patient and how he interprets himself and others. Again, this means that the
(mentalizing) process itself of finding out about thoughts and feelings is more important than
defining reactions in light of predefined schema and modes.
77