A free eBook – 4X4 for Nons
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An abstract on MBT:
Randomized Controlled Trial of Outpatient Mentalization-Based Treatment Versus Structured Clinical Management for Borderline Personality Disorder
Anthony Bateman, M.A., F.R.C.Psych., and Peter Fonagy, Ph.D., F.B.A.
Objective: This randomized controlled trial tested the effectiveness of an 18-month mentalization-based treatment (MBT) approach in an outpatient context against a structured clinical management (SCM) outpatient approach for treatment of borderline personality disorder.
Method: Patients (N=134) consecutively referred to a specialist personality disorder treatment center and meeting selection criteria were randomly allocated to MBT or SCM. Eleven mental health professionals equal in years of experience and training served as therapists. Independent evaluators blind to treatment allocation conducted assessments every 6 months. The primary outcome was the occurrence of crisis events, a composite of suicidal and severe self-injurious behaviors and hospitalization. Secondary outcomes included social and interpersonal functioning and self-reported symptoms. Outcome measures, assessed at 6-month intervals, were analyzed using mixed effects logistic regressions for binary data, Poisson regression models for count data, and mixed effects linear growth curve models for self-report variables.
Results: Substantial improvements were observed in both conditions across all outcome variables. Patients randomly assigned to MBT showed a steeper decline of both self-reported and clinically significant problems, including suicide attempts and hospitalization.
Conclusions: Structured treatments improve outcomes for individuals with borderline personality disorder. A focus on specific psychological processes brings additional benefits to structured clinical support. Mentalization-based treatment is relatively undemanding in terms of training so it may be useful for implementation into general mental health services. Further evaluations by independent research groups are now required.
http://focus.psychiatryonline.org/cgi/content/abstract/8/1/55
 New "Beyond Boundaries" eBook I published a new eBook called Beyond Boundaries: the advanced guide for loved ones of people with BPD. This 72 page eBook is packed with information and tools for you to gain a more effective and calmer relationship with someone with BPD. It is the culmination of what I have done in When Hope is Not Enough as well as what I have been working on since. It explains (rather tersely) what you can do and how you can get your relationship to be more of a trusting, loving relationship. It also explains when boundaries are helpful and when they are not.
The cost of the new eBook is $18.00. I think you will find that it is worth it. People in NY will have to pay sales tax. Sorry, blame the NY State legislature.
The eBook is available through Google Checkout below:
Beyond Boundaries
 Sometimes the holidays can be stressful Hey all, I haven’t posted much in the way of skills lately, but today, as the holidays are upon us, I think it is helpful to go over some emotional skills and other tools that can help us non-BPD people get through the holidays reasonably unscathed. The holidays are a tough emotional time for everyone. There are expectations that the holidays be “jolly and happy” when, sometimes, the holidays are anything but. The get-together with relatives – many who don’t understand the actions, feelings and behaviors of someone with BPD – can cause huge stress for those with BPD and for the loved ones. Expectations of a low conflict Christmas (or other holiday) are typical, but not often “delivered upon”. Stress and the feeling of being “on-stage” or “good enough” for the family can cause emotional dysregulation and distress. Sometimes an invalidating family can compare the person with BPD with other, less emotional family members. You know, “why can’t you be like your cousin?”
So, in order to skillfully approach the holidays, I’d like to remind non-BPD people and people with BPD alike of the following skills that can help all of us get through. Here we go:
1. Frustration Tolerance. Sometimes we are overcome with frustration. We feel like we “can’t stand it” or “can’t take it anymore.” When you feel that way, I would encourage you to ask yourself some questions that can help build frustration tolerance. Some questions are:
a. Can I really not stand it?
b. Am I really going to explode?
c. How does exploding/raging help me in my relationships?
d. What can I do to decrease the frustration?
2. Mentalizing with yourself in a search for meaning within other people’s actions. Often people jump to conclusions or assume the intent and motivation of others. Sometimes these motivations are assumed to be malevolent, invalidating or uncaring. You can ask yourself the following questions to help understand the intent within yourself:
a. Do I really believe that he/she is being mean?
b. Is there another explanation as to his/her motivations?
c. What would he/she be feeling that could explain this action?
3. Mentalizing with others to understand others’ internal mental states. Be curious. Ask questions. Don’t “load” these questions. That is, ask “can you clarify what you meant, I’m not sure I understand you intention?” vs. “Why are you being so mean to me?”
4. Be validating toward yourself and others. Remember that emotions are a major influence on people’s behavior. Listen to others and validate the emotions. Validation does not equal agreement with behavior. It shows that you have heard the other person’s emotions and that it is ok to feel however one feels. Normalization can also be helpful here.
5. Don’t label people, label events. In other words, rather than saying “he’s an asshole”, say “he did something that bothered me.” This can be used on your own actions as well. Rather than telling yourself you’re a “failure,” you can say “I didn’t do that as I would have liked.”
6. Be mindful of the moment. Monitor interactions actively and in a way that is non-judgmental. Don’t get caught up in past reactions or fear of future reactions.
7. Cheerlead yourself and others. This is not “positive mental attitude” statements. This is encouraging others to be brave and effective. The essence of this skill is “you can do/face hard/difficult things.”
8. Consider the consequences of mind-altering substances. Too much alcohol and/or drugs can create impulsive situations and ones that you may regret later. Think before you drink.
Here’s wishing you all an effective holiday season!
Take good care,
Bon
From the Menninger Clinic… about mentalizing.:
Mentalizing conference call with Drs. Peter Fonagy & Efrain Bleiberg
At the request of participants and the positive response to this November 2009 presentation on the interactive conference call, we are making this tape availalble.
Download conference call
 Mindblindness A little while ago, I was reading through “Mentalizing in Clinical Practice” (a dense read, but worth it IMO) and I was reading the section on Mindblindness. This is a concept that was originally developed with respect to autism. It means that you have the inability to accurately read the intentions, motivations or emotions of another person, based on their behavior. We each develop (around 3-4 years old) the ability to read others motivations based on their behavior. The example they give in the book is a “mind reading” (in the sense of accurately understanding another person’s motivations – internal states – based on behavior) test – it is as follows:
Maxi is helping his mother unload the groceries. He takes the chocolate chips out of the bag and places it in the GREEN cabinet, remembering where he put it with the intention of coming back later and eating some. He goes out to play. While he is outside, his mother opens the GREEN cabinet and takes out the chocolate and uses some for cookies. She places the bag back in the BLUE cabinet and goes down to grab the laundry. While she is gone Maxi returns to get the chocolate. Which cabinet does Maxi open to try to find the chocolate chips?
Most of us would say GREEN, right? People with mindblindness and little children (less than 3-4) say BLUE. Why? Because they already know the chocolate is in the BLUE cabinet – they can’t put their minds in the mindset of MAXI, who doesn’t know the chocolate has been moved.
Why do I bring this up?
Because both people with BPD and Nons do this sort of thing all the time. We attribute motivations to others based on information in OUR minds and not on information in THEIRS. Next time you attribute a motivation to your BP (i.e. “she’s trying to control me!” or “she’s out to get me” or “she’s just trying to get attention”) stop and think about this post. Instead of assuming, ask.
Some time ago I wrote a post about the “myth of the high-functioning BPD.” The point of the post was to facilitate a conversation about whether the categories of high-functioning and low-functioning apply to Borderline Personality Disorder (BPD). My theory was that there was no fixed state in BPD, and a sufferer can swing from high-functioning to low-functioning at the whim of their emotions. Now that I am learning about mentalization, I have a new appreciation for the “high-functioning” state (and it is a temporary state, not a fixed one). It appears to me now to be contextual. Have you ever wondered how a person you love with BPD can be a raging nightmare with you yet perfectly fine in his/her job? Ever wonder how they can “fake it” with others and never show their Mr. Hyde side?
DBT calls this “apparent competence,” which makes sense with respect to the dialectical model (the dialectic side of apparent competence is “active passivity” BTW). The one thing that never made a whole lot of sense to me was how the behavior can generally be “reined in” when with certain people. Most non-borderlines think, “Well, if she can control her behavior with [whomever], this must be completely under her control. So, she needs to start behaving better with me.” Sometimes, it seems as though a person with BPD can turn it on and off at will. However, this is not really the case.
Instead, mentalization explains this through attachment relationships: The closer the attachment, the more at stake for a person with BPD. This is why there is a fear of abandonment in BPD. When it comes to close relationships (such as partner or parent), the attachment is more important to the person with BPD and the fear of losing that attachment, the fear that the other person will judge him/her as wrong or bad (shame), is much larger. Unfortunately, the method of coping with this fear is usually maladaptive and functions to push the other person further away. Sadly, that can lead to a self-fulfilling prophecy of abandonment.
 When Hope is Not EnoughGet the Non-BPD book that is designed for staying and working on the relationship
 Implicit and Explicit When we have a conversation with someone, there are really four “people” trying to communicate. These people are you in your implicit thoughts, feelings, motivations, intent (all things inside your head and unavailable to the other person), you in your explicit expressions, words, body language, actions (all the ways you try and communicate), the other person in their implicit and the other person in their explicit. The most connected conversations are those in which each person can have the other’s “mind in mind.” This state is what complete mentalization is about. It is about understanding the meaning of the other person’s behaviors and words.
In a Non-BP/BPD relationship, this connection is generally broken. There are too many assumptions, too much focus on the content (rather than the meaning/function), too much personalization and too much “baggage” that prevents fully mentalizing. Some of the ways that one can fully mentalize is to approach each conversation from a particular “framework,” the characteristics of which are not a complete list, but a nice first attempt):
- Being curious about the other person’s implicit situation. Ask them how they feel. (“How did you feel when he said that?”)
- Validation for the purpose of understanding implicit understandings. (“Wow, that must have made you feel awful! Why do you think he said that?”)
- Being humble and admitting “fault” where “fault” is warranted. (“Yes, I can see that when I said that it hurt your feelings. That wasn’t my intention.”)
- Being compassionate for the other person’s suffering. (“You seem to be in a lot of pain right now. What do you think would help you feel better?”)
- Seeing the situation through the other person’s eyes.
- Starting afresh in each conversation, without grievances, relationship failures, victimhood, or assumptions that this is the “same” conversation over and over again. (NOT: “Here we go again.”)
- Being fully engaged in the conversation.
- Noticing words, actions and body language that break down engagement. (“When I said that, you seem to have gotten upset. What happened there?”)
- Listen for meaning, rather than just hearing the words.
 Concrete Thinking is a stumbling block One of the biggest stumbling blocks to developing an effective relationship with someone with BPD (and for the person with BPD him/herself) is the issue of concrete thinking. What is concrete thinking? Concrete thinking is the tendency of someone to be unable to generalize about a particular subject. It is the opposite and absence of abstract thinking, in which someone can generalize. Concrete thinking is looking at instance rather than class. What I mean is that a concrete thinker looks at a particular dog and can only speak about that particular dog (instance). He/she is unable to think about dogs, mammals and animals in general (which are classes and subclasses).
I see concrete thinking in Non-BPs all the time, particularly when they first join my email support list or contact me for support. The Non is tied up in the details of their loved one’s behavior and words and is unable to generalize or understand the motivation behind them. Perhaps this line of thinking is related to the idea that Nons often feel at the beginning of the journey to effectiveness that their situation is completely unique: “other people can’t possibly understand what I have been through.” Anyway, whatever the reason for concrete thinking, it causes significant problems in a relationship.
Some sure signs of concrete thinking are:
- The focus on particular behaviors in the person with BPD and bring them up over and over. (“She had an affair and I will never forgive her.”)
- The insistence that whatever is said is unchangeable (“But she told me she hated me!”)
- The insistence that physical or mental health issues are the only cause of behaviors (“It’s PMS”)
- Using extreme, unbending terms such as always, never, etc.
- An insistence on right/wrong, good/bad, morals, responsibility and punishment. (“She’s just evil and deserves what she gets.”)
- Inability to think abstractly, which can lead to inductive, rather than deductive, reasoning (“This dog has fleas, so all dogs have fleas.”).
- Inability to see motivations, especially emotional ones (“She told me to go and I went, but nothing changed.”)
- Focus on content, rather than context (“She is having a fit about the shower not working right.”)
- Categorizing people with a focus on innate, unchangeable traits (“He was born stupid and he’ll never change.”)
- Blame-storming. (“You made me feel that way!”)
Fighting concrete thinking is one of the toughest jobs that I have as an advocate for effective Non/BPD relationships. Many Nons (and people with BPD alike) get stuck in concrete thinking, and are unable to assess the meaning of what is said and done or, perhaps more importantly, the motivation for words and actions. With BPD, the motivation for most words and actions is emotional.
Understanding mental states of others requires abstract thinking and discerning MEANING. It requires an understanding of context, in addition to content. One of the problems with concrete thinking is that people get so caught up in the content, they cease actually discerning what meaning and intention is behind the words and actions.
One of the things I have noticed about Dialectical Behavior Therapy Family Skills versus Mentalization Based Skills is that they operate at a different link on the behavioral chain. In “When Hope is Not Enough” I have a section called “the BPD Dynamic.” What this dynamic outlines is a behavioral chain. That chain goes like this:
Event -> Interpretation -> Emotional/Physical Feelings -> Action Impulses -> Expression and Behavior
DBT-FST seems to me to operate at the Action Impulses to Expression and Behavior link, while validating the Emotional/Physical Feelings link. Don’t get me wrong, the DBT-FST skills are extremely powerful in communicating with someone with BPD. Yet, the change that is requested is at the end of the chain. I have heard that Marsha Linehan is quoted as saying something like, “Just because you feel like a crazy person, doesn’t mean you have to behave like one.” The point here is that DBT is a behavioral therapy and by modifying behavior, that works backwards toward regulating emotion and tolerating distress. In other words, DBT trains you to behave differently based on your feelings. When you gradually learn that your new behavior is more effective than the previous behavior, you break the conditioned chain between Action Impulses and Expression and Behavior. That is the essence of the DBT skill “Opposite Action.” An interesting side note is that by practicing Opposite Action (that is, doing the exact opposite of what your feelings implore you to do – such as engaging when you feel sad, rather than hiding under the covers all day), you actually feel better, because the action does work backward. Dr. Paul Ekman found that configuring one’s face to mimic a certain feeling actually causes that feeling to be experienced. That is the theory behind DBT’s “Half Smile” skill. Ultimately though, by working at that link in the chain, the person still feels the emotion, yet he or she just behaves differently than the emotion originally informed him/her to behave.
MBT on the other hand takes on the on the problem at the Interpretation link. By asking questions and being open to alternative interpretations, the person with BPD is more likely to have a broader view of other people’s behavior and the events in life. DBT never asks about the intent or motivation of the other person and just takes the interpretation as a given in a person with BPD. If a person with BPD says something happens and that something means X, then in DBT it means X. There is very little questioning of the validity of the interpretation X. In MBT, however, the interpretation X can be questioned and alternative interpretations (such as Y or Z) can be examined. The nice thing about this is that when the person with BPD is faced with a similar situation, he/she is less likely to jump to conclusion X and might consider Y or Z.
An example of the differences in the two approaches is as follows:
My daughter comes home from school after being teased by a boy on the playground. My daughter ends up throwing a thermos at the boy’s head.
With DBT, I would validate her anger and ask her how she could behave more effectively the next time this teasing occurs. So next time she will behave more effectively and not throw the thermos.
With MBT, I would validate her feelings and begin to probe with curious and straight-forward questions as to the intent of the boy. Perhaps he actually likes my daughter and that is why he is teasing. Perhaps he is showing off to his friends. If this approach is taken, my daughter is more likely to consider the boy’s motivation for the teasing. If she understands the motivation, she can actually never get angry and risk throwing the thermos.
All of that being said, I believe these skills have to be learned as a “ladder” to effectiveness. You can’t start at point E without going through points A-D. DBT-FST provide the foundation for more advanced skills, like those in MBT.
I am learning mentalization and it shows great promise! Here is a link to Anthony Bateman’s website with info on this technique….
http://www.ucl.ac.uk/psychoanalysis/unit-staff/anthony.htm
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