1. Trying to think under fire….
MBT in Secure Settings
Trying to think under fire….
Dr Jon Patrick

2. The Importance of Mentalization
“We will misinterpret people if we misunderstand their motives, become distrusting if we assume people are malevolent, and be unable to love and feel loved if we cannot find ourselves in someone else’s mind.”
Bateman, Brown and Pedder 2010

3. What is Mentalizing?

4. Treatment Vectors in Re-establishing Mentalizing in Borderline/Antisocial Personality Disorder
Impression driven
Controlled
Implicit-
Automatic
Explicit-
Controlled
Mental
interior
focused
Inference
Appearance
Mental
exterior
focused
Certainty of emotion
Doubt of cognition
Affective
self:affect state
propositions
Cognitive
agent:attitude
propositions
Emotional contagion
Autonomy
Imitative
frontoparietal
mirror neurone
system
Belief-desire
MPFC/ACC
inhibitory
system 4

5. Why is Mentalizing important?
Self-awareness and a sense of identity.
Meaningful and sustaining relationships.
Self-regulation and self-direction.

6. Good Mentalizing In relation to others’ thoughts and feelings
Opaqueness
Contemplation and reflection
Absence of paranoia
Perspective-taking
Genuine interest and open to discovery
Forgiveness
Predictability
Opaqueness - an acknowledgement that one often does not know what other people are thinking, yet not being completely puzzled by what happens in the minds of others (eg What happened with Chris made me realise that we can often misunderstand even our best friends’ reactions).
The absence of paranoia - not considering the thoughts of others as in themselves a significant threat and having in mind the possibility that minds can be changed (eg I don’t like it when he feels angry but mostly you can cajole him out of it by talking with him about it).
Contemplation and reflection - a desire to reflect on how others think in a relaxed rather than compulsive manner (eg so they actively contemplate in interview the reasons why someone they know well behaves as they do)
Perspective-taking - acceptance that the same thing can look very different from different perspectives based on individual history (eg a description of an event that was experienced as rejection by one person and genuine attempt made to identify how it came about that they misunderstood it)
Genuine interest - in other peoples thoughts and feelings - not just for their content but also for their style (eg the person appears to enjoy talking about why people do things).
Openness to discovery - the person is naturally reluctant to make assumptions about what others think or feel
Forgiveness - acceptance of others conditional on understanding their mental states (eg the person’s anger about something dissipates once they understand why the other person had acted in the way they did)
Predictability - a general sense that, on the whole, the reaactions of others are predictable given knowledge of what they think and feel

7. Non mentalizing videos 1
Vicky Pollard….. 7

8. Non mentalizing videos 2
Basillllllllllll! 8

9. Non Mentalizing
Excessive detail gets in the way of considering motivations, feelings or thoughts
Focus on external social factors
such as the nursing staff, the clinical team, other patients
self and other in psychotherapy
Focus on physical or structural labels
eg tired, lazy, clever, self-destructive, depressed, short-fuse
Some key indicators pertain to the style of the narrative as well as its content and the attitudes implicit in the patients accounts.
Non mentalising is most commonly revealed in the content of the narrative. For example, in preference to talking about mental states, patients might focus on general external factors, social institutions, the physical environment, the government etc rather than the individuals who are involved and whose mental state is pertinent to the narrative.
Non mentalisation is also revealed in a bias towards generalizations and labelling. For example, circular attributions are sometimes made in what appear to be explanations of behaviour - most commonly behaviour is regarded as accounted for by a diagnosis or a personality. For example, I blew up at him because I have such a short fuse or I failed at these exams because I am very self-destructive.
Not all non mentalising is identifiable in terms of content. Also evident in style and at an implicit level. Non mentalising style may be excessively sparse, or excessively detailed. If its excessively detailed the patient may describe events in such depth that the narrative obscures the states of mind of the participants, for example by endless side stories or excessively detailed description of the physical contents.

10. Non Mentalizing (2) Preoccupation with ‘shoulds and should nots’
Denial of responsibility
Blaming or fault-finding
Expressions of certainty about others’ minds
Always, obviously, never
A preoccupation with rules and roles, obligations and responsibilities, as if these were adequate explanations of behaviour rather than created to short-circuit mentalising, may characterise such narratives.
In others, a sparse narrative characterised by a denial of involvement indicates a reluctance to mentalize and look at ones own and others intentions in a meaningful way.
At an implicit level, poor mentalising is easy to see but may also be easily overlooked. An individual may express inappropriate certainty about the thought and feelings of others, and may speak as if they had no doubt that their model of the mind of another person was the only true perspective. Similarly a lack of curiosity about motives betrays poor mentalisation. In others an attitude of blaming and fault finding indicates a wish to short-cut the genuine possibility of understanding.
*Fawlty Towers DVD clip

11. Non-Mentalizing Features
Inside equals outside
Seeing is believing
Psychic Equivalence
Pseudo- mentalising
Switching off
Teleological

12. Still face video 12 12

13. What goes wrong….. Potentially Premature Fostering So…. Care
Mental illness
Drugs
Resilience

14. Mr X Early trauma and neglect Sexual offence against another minor
Diagnosis of LD (?2ndary to emotional neglect)
Consistent relational problems
Difficulty moving from high to medium security

16. The Antisocial Mind Primitive affects Inadequate affect regulation
Emotions of toddler
envy, shame, boredom, rage and excitement
Lack of guilt, fear, depression, remorse and sympathy 16

17. Mentalizing in ASPD
Antisocial characteristics stabilize non-mentalizing by rigidifying relationships.
Loss of flexibility makes the person vulnerable to sudden collapse in sense of self when their schematic representation of a relationship is challenged.
This exposes feelings of shame, vulnerability and humiliation that cannot be controlled by representational and emotional processing…….but only by violence and control of the other person. 17

18. Joe Pesci’s Teleological Drinks18 18

19. Mentalization and violence
Violence occurs when there is an inhibition in capacity for mentalization.
Mentalization protects against violence.
Violence in ASPD is a defensive response to feelings of shame and humiliation, which have their roots in disorders of attachment.
Sopranos video clip
Pat take over from here 19

21. Aims of MBT To promote mentalizing about oneself
To promote mentalizing about others
To promote mentalizing in relationships
MBT is a psychodynamic treatment rooted in attachment and cognitive theory.
It aims to strengthen patient’s capacity to understand their own and others’ mental states in attachment contexts, in order to address their difficulties with affect, impulse regulation and interpersonal functioning. 21

22. Why is MBT helpful in forensic?
Characterised by complex relationship difficulties
“Giving a language” as difficulties include inability to name affect, thus often get confused and emotional
Mentalizing as a natural process for all!!
Teaching a skill, not a concept or theory
Dual focus/components of our MBT programme
Psychoeducation (MBT-i)
Therapy group
Say something else about CL

23. What is MBT? The mentalising hand Stop – look - rewind
Therapist stance

24. Emerging evidence …
Bateman & Fonagy (1999) – RCT of MBT for BPD vs TAU/control. Sign ↓ hospitalisations, ↓use of medication, ↓suicidal and para-suicidal behaviours
Follow-up study (Bateman & Fonagy, 2001) –gains maintained over 18/12 after treatment completion and continued to show statistically significant improvement
Ongoing - multi-site pilot MBT for violence in ASPD. Refine MBT for ASPD →future RCT
Plus BJPsych 2013 24

25. A pickle!

26. A good result

27. Conclusion Hard work but fun! Important to feel like a team
Liberating – mistakes…great!
Trying to keep each other on-model

28. Q and A