Mentalisation Based Therapy (MBT) with Melbourne Psychologists

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Mentalisation-Based Treatment (MBT)

Mentalisation-Based Therapy (MBT) is a type of psychotherapy designed to help individuals understand and interpret the mental states of themselves and others. MBT originated from the work of Peter Fonagy, Anthony Bateman and his colleagues as they were researching the role of attachment and mentalisation in the development of personality disorders in the 1990s. Findings from this initial research indicated that individuals with Borderline Personality Disorder (BPD) often had difficulties with mentalisation, particularly in emotionally charged situations. These difficulties were linked to early attachment disruptions, which could impair the development of a stable sense of self and the ability to regulate emotions.

Fonagy and Bateman developed MBT as a structured approach to help individuals improve their mentalising capacity. This therapy integrates principles from attachment theory, cognitive-behavioural therapy (CBT), psychodynamic therapy, and systemic therapy to create a multifaceted treatment approach. MBT practitioners play a crucial role in establishing a secure therapeutic relationship and creating a safe environment where clients can explore their personal emotions and those of others, ultimately improving mentalisation and emotional regulation.

Mentalisation-Based Treatment (MBT) emphasizes the importance of understanding mental states to maintain healthy relationships and improve psychological resilience. The therapy aims to help patients develop a better understanding of their own and others’ mental states, which can lead to more effective emotional regulation and interpersonal functioning.

What is Mentalisation?

Mentalising, or mentalisation, refers to the ability to make sense of actions by inferring the mental states that underlie them. It involves understanding that behaviour is driven by thoughts, feelings, and intentions.

The capacity to mentalise develops over time, influenced by early attachment relationships and social experiences. Secure attachment in childhood provides a foundation for healthy mentalising, as caregivers model and support the understanding of mental states. Conversely, disruptions in attachment can impair the development of mentalising capacities. Therapists often monitor emotional arousal levels to ensure clients can maintain mentalising without becoming overwhelmed.

When individuals can mentalise effectively, they are better able to manage their emotions, understand the perspectives of others, and respond adaptively to social situations. However, disruptions in the capacity to mentalise can lead to significant interpersonal difficulties and emotional dysregulation, which are common features of a number of disorders. Recognising and regulating emotional distress is crucial for fostering better mentalising capabilities and interpersonal relations.

Dimensions of Mentalising

Mentalising is considered to be multi-dimensional, and each dimensions encompasses an aspect that contributes to how effectively an individual can mentalise. Here are the key dimensions of mentalising:

1. Automatic vs. Controlled Mentalising

  • Automatic Mentalising: This involves the rapid, intuitive understanding of mental states without conscious effort. It occurs spontaneously and is often used in everyday social interactions. Automatic mentalising allows individuals to quickly read social cues and respond appropriately.

  • Controlled Mentalising: This involves a more deliberate and reflective process, requiring conscious effort and attention. Controlled mentalising is used in complex or ambiguous social situations where intuitive understanding may not be sufficient. It allows for deeper exploration and analysis of mental states.

2. Cognitive vs. Affective Mentalising

  • Cognitive Mentalising: This dimension refers to the intellectual ability to understand one’s own and others’ thoughts, beliefs, intentions, and motives. It is often described as “theory of mind” – the capacity to attribute mental states to oneself and others and to predict behaviour based on those states.

  • Affective Mentalising: This dimension involves understanding and empathising with one’s own and others’ emotions and feelings. It is the emotional component of mentalisation, enabling individuals to connect with others on an emotional level and respond with appropriate empathy and compassion.

3. Self vs. Other Mentalising

  • Self-Mentalising: This involves reflecting on and understanding one’s own mental states. It includes self-awareness, self-reflection, and the ability to regulate one’s own emotions and behaviour based on this understanding.

  • Other-Mentalising: This involves understanding or at least guessing the mental states of others. It includes perspective-taking, empathy, and the ability to anticipate and interpret others’ thoughts, feelings, and behaviours.

4. Internal vs. External Mentalising

  • Internal Mentalising: This dimension focuses on internal mental states, such as thoughts, feelings, and intentions. It involves looking inward to understand the psychological experiences of oneself or others.

  • External Mentalising: This dimension focuses on observable behaviours and external cues that provide information about mental states. It involves interpreting facial expressions, body language, and actions to infer what someone might be thinking or feeling.

Balancing Dimensions

These dimensions of mentalising often interact and influence one another. For example, effective mentalisation typically requires a balance between cognitive and affective components, as well as the ability to shift between automatic and controlled processes depending on the context. Similarly, understanding oneself can enhance the ability to understand others, and vice versa.

The key to effective mentalising is balancing these dimensions and much of the work in MBT is on understanding and developing flexible capacity to mentalise by working on these various dimensions.

Non-Mentalising Modes

Non-mentalising modes (or mentalising failures) are cognitive and emotional states where an individual fails to adequately understand and interpret their own and others’ mental states. These modes can lead to misunderstandings, emotional dysregulation, and interpersonal conflicts. Identifying and addressing non-mentalising modes is also crucial component of MBT. Here are 3 non-mentalising modes:

1. Psychic Equivalence Mode

Individuals experience thoughts and feelings as absolute realities, leading to a lack of differentiation between their internal and external worlds. Feelings tend to be experienced as overwhelming and indisputable facts.

Examples:

  • A parent gets angry at their child. The child thinks they must be inherently bad or a failure, rather than understanding the parent might be stressed for other reasons.
  • A person experiences a mild headache. They start to feel anxious and are convinced that something is terribly wrong and that they have a brain tumour.

2. Teleological Mode

Individuals focus on physical actions and tangible outcomes as the only way to verify internal states. There is a reliance on concrete evidence or external validation to prove thoughts, feelings, or intentions.

Examples:

  • A person assumes their partner doesn’t love them when they don’t respond to their text messages quickly enough.
  • A person posts on social media. They don’t feel they are worthwhile unless they get a certain number of likes/comments.

3. Pretend Mode

Individuals disconnect from reality and engage in superficial or fantasy-based thinking. This mode involves a dissociation from true emotional experiences, leading to an inauthentic or detached engagement with oneself and others.

Example:

  • An individual reports to their therapist that they feel “on fire” in social situations and that others “hang off their every word”, whilst actually feeling deeply anxious or sad inside.

Addressing Non-Mentalising Modes in Therapy

1. Psychoeducation: Understanding the different modes of non-mentalising and how they impact thoughts, emotions, and behaviours.

2. Reflective Practice:  Encouraging people to reflect on their experiences and recognise when they are in a non-mentalising mode.

3. Mindfulness: Using mindfulness techniques to help people stay present and connected to their authentic emotional experiences.

4. Perspective-Taking: Practicing perspective-taking exercises to help people consider multiple viewpoints and develop a more nuanced understanding of mental states.

5. Validation and Empathy: Providing validation and empathy to help people feel understood and supported, fostering a safe environment for exploring mental states.

Understanding non-mentalising modes is crucial for improving mentalisation skills and fostering healthier relationships. By identifying and addressing these modes, therapeutic approaches like MBT can help individuals develop a more balanced and accurate understanding of their own and others’ mental states.

Effectiveness of MBT for Borderline Personality Disorder

Research has shown that MBT can be highly effective in treating BPD and other conditions characterized by difficulties with mentalisation. MBT has also been shown to reduce depressive symptoms and self harm incidents among patients treated for BPD. Studies have found that MBT can lead to significant improvements in symptoms of BPD, including emotional instability, impulsivity, and interpersonal difficulties. Patients who undergo MBT often report better relationships, greater emotional stability, and a stronger sense of self.

Evidence-Based Support

Numerous clinical trials and studies support the effectiveness of MBT. For example, a randomised controlled trial conducted by Bateman and Fonagy found that patients who received MBT showed significant improvements in BPD symptoms compared to those who received treatment as usual. These improvements were maintained at follow-up, indicating the long-term benefits of the therapy. Comparative studies have shown that while both MBT and dialectical behaviour therapy (DBT) are effective in treating BPD, they differ in their approaches and techniques. The therapeutic relationship in MBT is crucial, as empathetic statements and support strengthen the rapport between therapist and client, enhancing the client’s capacity to mentalise and effectively address the complexities of BPD.

Application to Other Conditions

While MBT was initially developed for BPD, its principles can be applied to other conditions characterised by difficulties with mentalisation, such as depression, anxiety, and eating disorders. Research is ongoing to explore the effectiveness of MBT in these contexts, and preliminary findings are promising. Patients treated with MBT often show significant improvements in symptoms and overall mental health compared to those receiving standard care.

Mentalising is a complex and multi-dimensional capacity that plays a crucial role in social cognition and emotional regulation. By understanding and enhancing the various dimensions of mentalising, therapeutic approaches like MBT can help individuals improve their relationships, manage emotions, and lead more fulfilling lives.