The treatment of personality disorders presents a unique challenge to therapists. These disorders are characterized by persistent, inflexible, and maladaptive patterns of thinking, interacting, and behaving. Unfortunately, the deeply ingrained nature of these patterns makes them particularly resistant to change, which is usually the primary goal of psychotherapy.
Of all the personality disorders, the one that is most frequently seen in therapist’s offices, mental health clinics, and psychiatric hospitals is borderline personality disorder (BPD). Individuals with BPD typically have chaotic lives, a long history of rocky relationships, erratic and intense mood fluctuations, and frequent incidents involving self-mutilation or suicidal behavior, threats, or gestures. Combine the latter with impulsivity and a heightened vulnerability to substance abuse, and you have particularly high risk therapy client.
Over the past few decades, several new therapies have been developed to treat borderline personality disorder specifically. One of the more recent therapies is Mentalization Based Therapy (MBT). An effective treatment for individuals with BPD, Mentalization Based Therapy was developed and manualized by Peter Fonagy, a clinical psychologist and psychoanalyst, and Anthony Bateman, a psychiatrist and psychotherapist. It is a long-term, psychodynamic approach to therapy that incorporates Bowlby’s attachment theory as the primary basis for its approach.
Attachment Theory and BPD
Attachment theory is based on the idea that we’re born with an innate need to attach to our primary caregiver. As infants, we used various behaviors to get our caregiver to respond to us. For example, we cried when we were hungry, frustrated, or had a wet diaper, and we smiled and giggled when we were happy and content. If our caregiver typically responded empathically to our needs and attachment behaviors (e.g. by feeding us, soothing us, changing our diaper, and smiling back), we developed a healthy, secure attachment. However, if our caregiver frequently failed to respond empathically, we developed an insecure attachment. This negatively impacted our ability to learn how to comfort ourselves (self-soothe) and manage our emotions and behaviors in healthy, effective ways.
Individuals with BPD often grow up in chaotic and / or unpredictable environments that thwart their ability to form secure attachments. As a result, they develop an insecure, hyperactive attachment. This results in a destructive “push-pull” relationship pattern (i.e., one minute they want to be close and the next minute they want their space) that causes significant problems in their relationships with others. This is one of the main reasons individuals with borderline personality disorder typically have very intense and rocky relationships. Those closest to them often feel manipulated, frustrated, and confused, while the borderline individual is usually completely oblivious to the adverse impact of his or her behavior.
The disorganized and insecure attachment is also one of the reasons they have such a difficult time managing their emotions. Individuals with BPD are easily overwhelmed by intense feelings. When this occurs it often results in impulsive reactions, volatile outbursts, self-harm behavior, and unhealthy attempts to self-soothe.
The Concept of Mentalization
Mentalization refers to the insightful and intuitive ability to understand our own, as well as others’, behaviors and feelings by considering one’s state of mind. For example, if someone says something hurtful to you when he’s frustrated or upset, your ability to mentalize allows you to understand the connection between his mental or emotional state and his behavior. In order to develop fully, our ability to mentalize must continue to be nurtured by healthy, close relationships – secure attachments – with others.
Mentalization Based Therapy is based on the theory that this adaptive ability to mentalize stems from the development of a secure attachment in early childhood. Unfortunately, individuals who aren’t able to form secure attachments early in life don’t develop this. As a result, they develop BPD or some other type of serious psychopathology by or even before they reach adulthood.
Interpersonal problems – and difficulties mentalizing that often accompany them – frequently play a major role in the development of mental health disorders. Since mentalization involves the ability to interpret the behaviors of others as well as our own, it’s no surprise that a fundamental element in all forms of mental health issues is a misinterpretation that manifests in maladaptive behaviors, emotions, and coping mechanisms.
As humans, the ability to mentalize is vital to our wellbeing as well as our relationships with others because it enables us to:
- Create something meaningful from adversity
- To be flexible
- Handle conflicts with others in a healthy and effective manner
- Have genuine empathy
- Feel compassion toward ourselves and others
- Feel connected to others
- Consider our role in relationship problems whenever they occur
- Self-soothe in healthy (rather than destructive or maladaptive) ways when we’re experiencing negative emotions such as sadness, anger, boredom, or frustration
- Make constructive changes in our behavior when needed
- Experience the sense of mastery that stems from taking responsibility for our actions
- Communicate more effectively
- Express emotions openly
- Process and try to make sense of troubling or confusing situations and experiences
- Have a strong sense of purpose
- Have a hopeful, positive outlook
- Be supportive and also be open to accepting support from others
- Experience and share a broad range of emotions
How MBT Works
The primary goal of MBT is to help individuals with borderline personality disorder develop the skill of mentalization. As they develop this skill it improves their ability to have more stable and gratifying relationships, exert more control over their behaviors, regulate their emotions more effectively, and experience more fulfillment and satisfaction in life as they pursue goals that are important to them.
In order to develop the skill of mentalization, the MBT therapist utilizes the client-therapist relationship to a significant degree Thus, one of the key components of MBT is establishing a strong, empathic therapeutic alliance. The therapist functions largely as a coach throughout the process. The therapist encourages clients to consider their interactions with the therapist during sessions as well as their day-to-day interactions with others in outside of therapy. Clients’ relationship with the therapist inevitably activates their underlying attachment issues, which can be used to gently facilitate the development of mentalization in the safety of the therapeutic setting.
Although mentalization is often addressed to some degree in other forms of psychotherapy, it is the primary focus in Mentalization Based Therapy. All of the interventions used in MBT are geared towards helping therapy clients reflect on their own and others mental states. One of the ways a therapist can promote this type of reflection is by assuming a position of not-knowing. In other words, MBT therapists refrain from presuming to know and then attempting to interpret what a client is thinking or feeling in the session. This gives the client an opportunity to practice and improve his or her ability to mentalize. It also enables the therapist to model a reflective stance for the client as they talk in therapy sessions.
Mentalization and Various Mental Health Issues
Posttraumatic Stress Disorder and Unresolved Trauma – A traumatic event can quickly unhinge our sense of safety and security in the world. If you’re unable to adequately process the trauma, symptoms of PTSD may develop. When this occurs, it’s a strong indicator that your ability to mentalize was seriously damaged or insufficiently developed or utilized to effectively process the trauma. A hallmark symptom of PTSD is a recurring “reliving” or re-experiencing of the trauma itself. This often occurs in the form of nightmares or flashbacks of the trauma. Although you’re not actually reliving the trauma again – as nightmares and flashbacks, troubling and unpleasant as they are, don’t present any actual danger or threat. They’re just memories of the trauma playing out vividly in your mind. But without the ability to mentalize, you’re unable to make that distinction. In your mind, the “threat” you felt during the nightmare or flashback was every bit as real as it was when the trauma actually occurred. As you regain the ability to mentalize, you’ll be able to shake off the bad dream or flashback, and acknowledge it for what it was.
One of the reasons your ability to mentalize shuts down during and after a significant trauma is because your frontal cortex – the area of the brain in which mentalization occurs – is often deactivated by hyper-arousal. Fortunately, you can learn or regain the ability to mentalize when you’re experiencing intense anxiety. Doing so will help you manage the post-trauma symptoms.
It should be noted that many individuals with borderline personality disorder experienced at least some form of trauma in childhood, such as sexual, physical, or emotional abuse – often at the hands of a caregiver, family member, or someone close to the family. The impact of the trauma itself may also be a contributing factor in their inability to mentalize.
Depression – Individuals in the throes depression at least temporarily lose some or most of their ability to mentalize. One of the ways this is evidenced is in the dark, bleak shadow a depressed mood casts on everything. When you’re depressed, your thinking becomes distorted and irrational. You misinterpret your own behavior as well as the actions of others. For example, if a friend doesn’t return a phone call in a timely fashion, your depression leads you to assume the worst; “She’s mad at me” or “He’s tired of my depressed mood”. In actuality, your friend had viable reason for not getting back to you, such as an unusually hectic week or a family crisis. However, your unfounded assumptions exacerbate your feelings of worthlessness. Your depression hinders your ability to mentalize and understand the connection between the irrational thoughts and your depression.
You limited capacity to mentalize also has a negative impact on the way you interact with others. Rather than considering why others are behaving in a certain way, you’re wrapped up in your own emotional pain. Over time, this can end up alienating others who naturally prefer a relationship that includes more give and take, rather than one that’s become one-sided and all about you. And of course, as they pull way, it adds to your feelings of worthlessness.
Personality Disorders – The inability to mentalize is particularly noticeable in personality disorders. One of the classic characteristics of all personality disorders is the failure to recognize the negative impact the person with the disorder has on others. For example, individuals with narcissist personality disorder regard others as objects rather than people. They have little to no empathy for the feelings of anyone, and fail to see how their own actions and words cause problems in their relationships. Instead, they blame those problems on the other person. If you’ve ever dealt with a narcissist, his or her inability to mentalize is abundantly obvious.
Another prominent characteristic of personality disorders is the inability to have (or desire to have) healthy, close relationships that involve things such as mutual respect, flexibility, genuine intimacy, and give and take. Instead, individuals with personality disorders either have little to no desire for connection with others (e.g. schizoid personality disorder), or have relationships that lack any real semblance of harmony. At best, their relationships are fraught with problems due largely to the maladaptive characteristics the personality disordered individual brings to the table.
Healthy, mutually satisfying relationships require a reasonable capacity for mentalization in both parties. Both individuals must possess a strong degree of self-awareness, as well as a genuine awareness of and empathy for the other person’s experience in the relationship. That’s why a relationship with someone who has a personality disorder (and who hasn’t benefitted from psychotherapy) is destined to have significant problems from the start.
Substance Use Disorders and Addictions – Individuals who abuse or are addicted to substances or activities (e.g. sex, gambling, or viewing pornography) exhibit a diminished or severely under-developed ability to mentalize. If you have ever dealt with an addict, you know how totally and completely pre-occupied they become in their quest for a “fix”. They don’t care how their addictive behavior adversely affects others or damages their relationships. Nor do they consider the serious consequences their behavior has on their health, finances, career, and other aspects of their life.
The tricky thing with addictive behavior is that the lack of mentalization may be directly due to the effects of the addiction (e.g. the impaired judgment and dulled awareness of an alcoholic or junkie), or the individual may be using the substance or activity to purposefully avoid having to think about or feel anything unpleasant. Also, their inability or poorly developed capacity to mentalize likely played a prominent role in the development of their addiction. If individuals with an addiction enter into rehab and the mentalization issue isn’t adequately addressed in treatment, the chances of a lasting recovery are limited.
Interestingly, and not surprisingly, individuals with borderline personality disorder often battle depression, substance abuse and other addictive behaviors, and have a history of trauma (as mentioned above). It’s not uncommon for them to meet the criteria for a comorbid diagnosis of major depression, PTSD, or substance use disorder. This is another example of how an insecure attachment and the inability to mentalize can lead to a host of psychological problems and disorders.
Research on MBT
Studies have been done that validate the efficacy of MBT as a treatment for borderline personality disorder. Two randomized clinical trials – one conducted in 1999 involving 19 patients, and one involving 134 patients conducted in 2009 (both published in the American Journal of Psychiatry) – found the following positive results in those who received Mentalization Based Therapy as part of their treatment:
- Significant improvement in mental health symptoms
- Decrease in depressive symptoms
- Fewer self-harm behaviors
- Less impulsivity
- Better overall functioning compared to patients in the control group
- Improved social functioning
- Improved overall functioning
- Decrease in suicidal behaviors and attempts
- Fewer hospitalizations
More research needs to be done, of course, but the results of these clinical trials strongly suggest that MBT is a strong alternative to other treatments for BPD.
Finding a Mentalization Based Therapy Practitioner
Currently, MBT is not as prominent in the U.S. as other forms of treatment for borderline personality disorder. Finding a qualified mental health professional who offers it may be a challenging task unless you live near a major metropolitan area where the odds of finding one is greater. Two of the best ways to locate a provider are 1) by contacting therapists or programs (such as DBT programs) that specialize in treating BPD and asking if they or someone they know offers MBT, and 2) doing an online search for “mentalization based therapy” or “mentalization based treatment” in your city.
Mentalization based therapy may be the missing piece for anyone with BPD who has already had specialized treatment, such as Dialectical Behavior Therapy, or another type of psychotherapy, but didn’t make as much progress as they’d hoped as a result of the treatment. MBT’s focus on mentalization may be the aspect that was missing. It’s an effective therapy that’s definitely worth considering for anyone with this complex and challenging disorder.