I spoken about mentalization on this site before. Since I’ve lately been on a TED talk kick, mainly watching TED talks about neuroscience, I wanted to post this one from Rebecca Saxe which is called “How we read each other’s minds”. It is basically describing the process of mentalizing and how a certain part of the brain, the Right Temporo-Parietal Junction, is highly specialized for seeking to understand the motivations of others, the essence of mentalization. What is fascinating about this talk is her use of the pirate/cheese sandwich story with children of various ages. She demonstrates how the process of mentalization develops over time. I talked about another mentalization test (which is based on the same principles) in this post. I’d encourage all of my readers to watch this video. Although she doesn’t use the words mentalizing or mentalization, that is what she is describing. Additionally, I suppose that when someone with BPD experiences a “failure to mentalize”, that part of the brain is most likely dimmed.
In DBT, in the distress tolerance module, there is a concept of willingness versus willfulness. I find this concept particularly important and akin to the being right (willfulness) vs being effective (willingness) concept. Here is some information about willingness versus willfulness:
WILLINGNESS
Cultivate a WILLING response to each situation
Willingness is doing just what is effective in each situation, in an unpretentious way.
Willingness is listening very carefully to your WISE MIND, acting from your inner self and your deepest core values.
Willingness is becoming aware of your connection to the universe and to the person you are interacting with.
Willingness engenders listening and mentalizing.
Ask yourself, in 5 years from now, will the situation that causes the distress matter?
WILLFULNESS
Willfulness is like sitting on your hands when action is needed, refusing to make changes that are needed.
Willfulness is about the desire to be right in a situation, regardless of what is needed to get through effectively.
Willfulness causes you to fight any suggestions that will improve the distress and thus make it more tolerable.
Willfulness is being rigid and inflexible.
It is the opposite of doing what works, of being effective. Willfulness is trying to fix every situation or refusing to tolerate the distressful moment.
That last example in willfulness is particularly important to read and consider. Often, I find the loved ones of borderlines to be “fixers” and try to solve each problem for the borderline. Being willing to listen, and really hear what the other person is feeling and going through is usually more effective, despite the distress it may cause, than telling the other person what to do or giving advice.
Adapted from dbtselfhelp.com, with edits and additions by Bon
Often, when speaking with someone who is a close “attachment person,” misunderstandings, assumptions and ineffective modes of thinking creep into the situation. Bateman identifies several “modes” of thinking that inhibit mentalization. These modes are:
Psychic Equivalence – when the world is equivalent to the person’s mind. This is the “feelings = facts” mode. “If I feel sad, there must be someone/something that made me sad.”
Pretend – mental states are not anchored in reality. Pretending “as if” something is true, when external evidence shows the contrary. This is “bullshitting” mode.
Teleological – mental states can only be expressed in action. “If you loved me, you’d buy me a car.” Only tangible actions count, not words or thoughts.
In addition, there are other ways of thinking that inhibit mentalization such as:
Concrete thinking – “But he said he hated me!” Taking something as gospel and ignoring the underlying mental states and their malleability.
Pseudo-mentalizing – seemingly understanding of mental states, but used in a self-serving fashion.
What do you do when the failure to mentalize happens? When a break in mentalization occurs, you must intervene immediately. You cannot let the break go unnoticed or simply “let it go.” You have to be attentive to the level of mentalization in the conversation and stop the flow of the conversation right away. Continue reading A failure to mentalize – Mentalization Information Part 2 →
Basically, mentalization is the connection of mind to mind in a particular exchange. It is about in-the-moment interaction, not about the past or future. It is about communicating and understanding your and the other person’s explicit and implicit expressions and motivations, feelings, goals, etc. It is about accurately expressing yourself and listening to the other person in a search for meaning. It is about internalizing the other’s viewpoint and having the other internalize your viewpoint. A really good example of mentalizing is an inside joke – both you and the other person completely understand the meaning of the joke and have internalized the meaning.
Jerry Holmes, a researcher that works with Anthony Bateman (a co-creator of mentalization therapy), calls mentalization the process of “seeing yourself from the outside and others from the inside.”
Why mentalize?
We mentalize for several reasons. The main one is that mentalization is a “meeting of the minds” in which a personal connection is made. Mentalization encourages the integration of thoughts, desires, feelings, motivations, intentions, goals and all other internal mental elements and the communication and understanding of the same in others. When we mentalize, we are out of “lizard brain” thinking and into the prefrontal cortex. That requires the reflection upon meaning and discourages emotional dysregulation, concrete thinking, bullshitting, dismissive attitudes, blaming and IAAHF.
Mentalization serves to:
Improve trust – others feel that you “get them.”
Improves communication between two people – the meaning is exchanged.
Builds empathy and compassion – you can see the world through the other’s eyes.
Help work on a relationship – people take responsibility for feelings, words, and mental processes.
Decrease misunderstanding and resentment – understanding other person’s intent.
Change viewpoints and assumptions – when alternative meaning is applied to situations, beliefs and assumptions can change.
How does one mentalize?
It is important to remember that mentalization is about NOW. It is not about any other moment than now. Therefore, if you are dragging old issues or future worries into the conversation (or if the other person is) then you are experiencing a “failure to mentalize.”
You mentalize by continually monitoring the progress and state of a conversation. You mentalize by asking questions about the current conversation, the feelings and intention of the other person and monitoring your own feelings and understanding of the current conversation. It is a natural skill and is built into the human mind; however, it is also a difficult skill, because we are often not mindful of the current moment when having a conversation. We are often distracted by our own thoughts and feelings, assumptions and automatic thoughts, history and attachment to the other person. If your mind meanders into these things, you are experiencing a failure to mentalize. Continue reading Mentalization Information Part 1 →
A new research study looks at how adolescents think, how disordered thinking can take root, and how this thought pattern can ultimately lead to an adult personality disorder.
An article from psychcentral about a study indicating that social problems in teens can lead to personality disorders:
Social Problems in Teens Can Lead to Personality Disorders
By Rick Nauert PhD Senior News Editor
Reviewed by John M. Grohol, Psy.D. on September 29, 2011
A new research study looks at how adolescents think, how disordered thinking can take root, and how this thought pattern can ultimately lead to an adult personality disorder.
The study examines the relationship between borderline personality disorder (BPD) traits and “hypermentalizing” in adolescents. Mentalizing is the social intelligence that refers to the ability to infer and attribute thoughts and feelings to understand and predict another person’s behavior.
Dr. Carla Sharp, psychologist at the University of Houston (UH) and lead researcher, believes the results of the data can be used for early intervention, treatment, and identification, of borderline personality disorder (BPD) in adolescents.
This includes improved treatment strategies — such as putting the brakes on “hypermentalizing” — and encouraging a BPD patient to stick to the facts.
“Why does someone with borderline personality disorder key a car, if doing so will not lead to good consequences? What compels her to make that decision?” Sharp said.
“I am trying to understand the development of the disorder and what happens in the brain, and what happens in the minds of these children as they develop to put them on a different trajectory compared to their peers.
“Borderline personality disorder is a condition in which people have long-term patterns of unstable or turbulent emotions about themselves and others. These inner experiences often cause them to take impulsive actions and have chaotic relationships.
“The criteria for BPD includes: excessive anger, affective instability, a clear pattern of self-harm over two years – burning, cutting, suicide attempts, abandonment fears, relationship problems, significant impulsivity – drinking alcohol, drug abuse, eating, anorexia, overeating and illegal activities.
“Clinicians have been reluctant to diagnose BPD in adolescence because there is the notion that personality is not fully developed in childhood and adolescence. We know that the brain is only fully developed by age 25, so how can we diagnose a personality disorder in someone if they don’t have a fully developed brain yet?” said Sharp.
“On the one hand, we are finding in our research that kids do have a stable pattern of interaction with others. Parents will describe their kids to you in terms that remain stable over time.
“Therefore, personality researchers have highlighted the point that teens do not wake up at 19 and have a personality disorder on the first day of their 19th year, so there must be some precursors to the disorders. There’s been a group of people, including myself, advocating that we not necessarily diagnose borderline personality disorder in adolescence, but that we assess for it to make sure that we don’t miss these children.”
The study spanned a two-year period and included 111 adolescent inpatients between the ages of 12 to 17.
A key component was the use of a new tool to assess social cognition in children. The tool is called the Movie for the Assessment of Cognition (MASC) and is used alongside self-report measures of emotion regulation and psychopathology.
In the study, research subjects were presented with actual movie scenes. They were introduced to the characters in the movie: Sandra, Michael, Betty and Cliff, by showing a photo of each. They were instructed to watch the 15-minute film carefully to understand what the characters are feeling and thinking.
They are then asked what the character in the movie might be feeling or thinking, with four options to choose from, forcing a single response prompt for one of the following categories: no mentalizing, less mentalizing, hypermentalizing or accurate mentalization. Continue reading Social Problems in Teens Can Lead to Personality Disorders →
It’s time to reject the notion that people with personality disorders are beyond help, writes Peter Aldhous
FENELLA Lemonsky was 15 when her life disintegrated. She had never been a happy child, but things went from bad to worse in adolescence. Her family had relocated from South Africa to London a few years earlier and she found it impossible to make friends. “I was having mood problems, I was binge-eating and I didn’t know what was happening to me,” Lemonsky recalls. “I would overdose and go to Accident and Emergency. Eventually, I spent time in various psychiatric hospitals, but they didn’t know how to treat me.”
Lemonsky had to wait until her late twenties even to be given a name for the condition that left every aspect of her life in disarray. Then, after one of her suicide attempts came perilously close to succeeding, a concerned doctor got her an appointment with Anthony Bateman at St Ann’s Hospital in London.
Bateman’s unit specialises in treating personality disorders, but Lemonsky didn’t realise that until, sitting in his office, she pleaded for an explanation of her problems. “He said: ‘It’s borderline personality disorder.’ I said: ‘Is it treatable?’ He said: ‘Yes.’”
This simple yet optimistic exchange will surprise many people who have been given the same diagnosis. It may even surprise some psychiatrists. Personality disorders revolve around difficulties interacting with other people. They can be extremely debilitating to those with the condition and those around them, and have been thought to be lifelong afflictions. Borderline personality disorder, in particular, has a terrible reputation, summed up on a cover of Time magazine as “The disorder that doctors fear most.” Even the current edition of psychiatry’s handbook, the Diagnostic and Statistical Manual of Mental Disorders (DSM), perpetuates the gloom by describing personality disorders as “stable and enduring”.
“It turns out that it’s not true,” says John Oldham, a specialist in personality disorders at Baylor College of Medicine in Houston, Texas, and president of the American Psychiatric Association, which publishes the DSM. For despairing families, the encouraging news is that the problems of people with borderline personality disorder subside with age. Recent clinical trials have also shown that specialised psychotherapy can significantly improve their lives. Still, a lingering “untreatable” stigma, combined with the difficulty of securing funding for therapy, means that relatively few people with the condition get the help they need. Continue reading It’s time to reject the notion that people with personality disorders are beyond help →
Q: How do I get my borderline loved one in therapy? What’s the best kind of therapy? How long will it take to cure them?
A: Unless your borderline loved one is a minor or you have a court order, you can’t force anyone into therapy. Therapy must be a choice of the person that needs it. It will probably be much more effective if the person with BPD chooses to go to therapy. Yet, therapy is not like sending your car in for repairs. It’s not as if you send the person in to therapy, he/she gets a new part and comes out fixed. That’s not the way therapy works.
For BPD, the “gold standard” of therapy is Dialectic Behavior Therapy (DBT). It is an “evidence-based” treatment – meaning the therapy has been researched against “therapy as usual” (TAU) and been shown to be more effective than TAU. However, DBT is generally measured on reducing suicidal impulses and self-harm. DBT has been criticized for being most effective with the “lowest functioning” people with BPD. I personally like DBT in that it provides the borderline with essential skills that can make their lives more effective. DBT usually takes at least a year. It took my daughter two years to complete. For more on DBT from this blog, click here. It is also important to note that, in many circumstances, the family members can be more effective if they participate in the DBT treatment by learning the necessary skills to support the treatment.
Recently, a new treatment called Mentalization-Based Treatment (MBT) has come on to the scene – particularly in the UK. I only know of two places in the US that MBT is available. Mentalization-based therapy focusing on the skill of “mentalizing” and is an interactive therapy in which the moment-to-moment relationship between the client and the therapist helps encourage critical, integrative thinking. Mentalizing is a process and it requires participation of each person in a particular conversation. One must try to see the world through the other’s eyes and clearly express one’s own mental aspects including intent, desire, motivation, feelings and aspirations. For more on MBT on this blog, click here.
There are other therapies that can be effective with BPD including schema-focused therapy, STEPPS and transference-focused therapy.
Both DBT and MBT are quite expensive at this time.
My emotionally sensitive daughter has been having a problem with one of her long-time friends. This friend has decided to start hanging out with the “popular” girls in school. Unfortunately, these “popular” girls are also the ones that are dating older boys and using substances (alcohol, pot). My daughter doesn’t like these other girls and doesn’t want to be their friend or be involved with them. The problem is that my daughter is taking this “break” personally. She believes that she did something that made this friend “leave her”. OK, so what do you do? I believe the only way to address this situation is to help my daughter “turn her mind” around the friend’s motivations for going into another social circle. The only way to truly do this is to use mentalization to ask, essentially, “what do you think HER motivation is for hanging out with these other friends?” and not assume that her motivation is the one that my daughter assumes it is. One problem with DBT is that it seems to be all about the client’s feelings and doesn’t usually speculate on motivations of others. Yet, in the case, I feel it is important to actually understand the friend’s motivations. In this case, the friend’s own self-image is driving her into this other social circle. In this case, the friend’s choices are not about my daughter at all. While it hurts to have a long-term friend move away from you (and that pain can be validated), the motivation is not to hurt you. In fact, my daughter’s feelings were not considered at all. Understanding that might hurt a bit too, yet it would seem that it will hurt less knowing that the friend’s choices are not about my daughter’s feelings.
“…BPD is present in about 6% of primary care patients and persons in community-based samples and in 15 to 20% of patients in psychiatric hospitals and outpatient clinics,” writes John G. Gunderson, MD, from the Psychosocial and Personality Research Program, McLean Hospital in Belmont, Massachusetts. “Patients with BPD usually enter treatment facilities after suicide attempts or after episodes of deliberate self-injury. Such episodes result in an average hospital stay of 6.3 days per year and nearly 1 emergency room visit every 2 years, rates that are 6 to 12 times those among patients with a major depressive disorder.”
As you can see BPD has a major financial impact on the health care system, not to mention the distress for the patients and their families.
When reviewing the various treatment options, the author says this about mentalization therapy:
Mentalization-based therapy is a cognitive or psychodynamic therapy including individual as well as group therapy. While assuming a “not-knowing” stance, the therapist insists that the patient “mentalize,” or examine and label his or her own experiences and those of others. This emphasis on thinking before reacting may be a process central to all effective therapies.
That “not-knowing” stance is what I tell the nons that I know: Be a detective, not a judge.
IATROGENESIS, PSYCHOTHERAPY AND BORDERLINE PERSONALITY DISORDER
Pharmacological studies routinely explore the potential harm that a well-intentioned treatment may cause. In the case of psychosocial treatments we all too readily assume that at worst such treatments are inert. However, there may be particular disorders where psychotherapy represents a significant risk to the patient. Whatever the mechanisms of therapeutic change might be, traditional psychotherapeutic approaches depend for their effectiveness on the capacity of the individual to consider their experience of their own mental state alongside its re-presentation by the psychotherapist. The appreciation of the difference between one’s own experience of one’s mind and that presented by another person is key. It is the integration of one’s current experience of mind with the alternative view presented by the psychotherapist that must be at the foundation of a change process. The capacity to understand behaviour in terms of the associated mental states in self and other (the capacity to mentalise) is essential for the achievement of this integration.
Most individuals with no major psychological problems are in a relatively strong position to make productive use of an alternative perspective presented by the psychotherapist. However, those who have a very poor appreciation of their own and others’ perception of mind are unlikely to be able to benefit from traditional (particularly insight-oriented) psychological therapies. We have argued that persons with borderline personality disorder have an impoverished model of their own and others’ mental function (Bateman & Fonagy, 2004). Their schematic, rigid, sometimes extreme ideas about their own and others’ states of mind make them vulnerable to powerful emotional storms and apparently impulsive actions, and create profound problems of behavioural and affect regulation. The weaker an individual’s sense of their own subjectivity, the harder it is for them to compare the validity of their own perceptions of the way their mind works with that which a ‘mind expert’ presents. When presented with a coherent view of mental function in the context of psychotherapy, they are not able to compare the picture offered to them with a self-generated model and may all too often accept alternative perspectives uncritically or reject them wholesale.
Any psychological therapy can generate these divergent responses. Both cognitively based and dynamically orientated therapies offer causal explanations for underlying mental states. These can give ready-made answers and provide illusory stability by inducing a process of pseudo-mentalisation in which the patient takes on the explanations without question and makes them his/her own. Conversely, both types of perspective can be summarily and angrily dismissed as overly simplistic and patronising, which in turn fuels a sense of abandonment, feelings of isolation and desperation. Even focusing on how the patient feels can have its dangers. A person who has little capacity to discern the subjective state associated with anger cannot benefit from being told both that they are feeling angry and the underlying cause of that anger. Such an assertion addresses nothing that is known or can be integrated. It can only be accepted as true or rejected outright, but in neither case is it helpful. The dissonance between the patient’s inner experience and the perspective given by the therapist, in the context of feelings of attachment to the therapist, leads to bewilderment which in turn leads to instability as the patient attempts to integrate the different views and experiences. Unsurprisingly, this results in more rather than less mental and behavioural disturbance.
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