Peter Fonagy Lecture at IPMH I: Mentalization Based Therapy

MBT (Mentalization Based Therapy) focuses on how the person feels now, rather than on the past. Imagine yourself talking to a client. Try to think about how you would think about the situation the person is describing. When the other person isn’t making sense, it is because he is not bearing in mind the person he is talking to – you. That means he isn’t “mentalizing”.

The therapist makes “simple sound-bite” interventions that are affect-oriented (related to love, desire, hurt, catastrophe, excitement), and focus on the patient’s mind, not on his behavior, nor on his past. MBT relates to a current event or activity, and identifies non-mentalizing as getting in the way of the patient’s stated goals.

Technically, the therapist in MBT notes breaks in the patient’s mentalizing – when the patient starts to talk as if the world is against him and he is the helpless victim, for example – and rewinds the conversation to the moment before the patient stops mentalizing. Suppose the patient is explaining a disagreement with her boss and then says that her boss treats her the way all men treat her, in fact the way you, the therapist, is treating her right now – by not ‘hearing’ her! In fact, she should leave right now since she is just wasting her time in this therapy!” You might then go back to what the boss said to her that morning and explore how it feels the same as what is going on now between you. How is she feeling ‘not heard’ by you? You accept responsibility for contributing in some way you do not yet understand, for generating this terrible feeling in the patient.

In MBT the mind of the patient becomes the focus of the treatment. Your job as therapist is to help the patient learn about the complexities of his thoughts and feelings about himself and others, how that relates to his responses, plus how “errors” in his understanding of himself can lead to actions that cause problems for him. It is not your job to tell the patient how he feels, what he thinks, how he should behave, or what the underlying reasons are. Instead, you are helping him build new competencies for maintaining a self-reflective mind even under the stress of intense affect. Peter recommends adopting a “not knowing” stance, conveying to the patient a sense that mental states are opaque.

In the therapy, the therapist first of all helps the patient become better regulated. That sounds familiar, doesn’t it? You want to lower arousal as much as possible. Then you validate the patient’s perceptions. Finally, you begin the painstaking work of trying to get the patient to see the situation from another person’s point of view – that is “mentalizing”. Suppose the patient says, “I am just a bad mother.” That is not mentalizing. You stay with what she is saying right here, recognize the self critical feelings are flooding back, and do not turn your attention to the past. If she is not mentalizing when she tells you about herself as a mother, go to another subject and help her regain her more mature perspective, then return to her distress as a mother.

Peter talks about how therapy “activates the attachment system”. That is what we mean when we talk about “transference”, though Peter does not prefer that term, at least not in this context. You always start by being supportive; only then do you ask for clarification and elaboration, and gently challenge the patient’s reasoning. Remember to stay with a focus on affect, for example, asking the patient what her child (the one she is a “bad mother” to) felt.

You assume that you cannot “cure” your patients. In your assumption of a humble position, you can admit to being confused (as a matter of fact, this is one of the techniques Peter demonstrates) – “Hang on a sec, let me think about it. I’m getting confused. What I’m getting is this. Am I right”? In this therapeutic model, the therapist and patient sit side by side instead of face to face. The therapist’s interventions are meant to be supportive and empathic, respectful of the patient’s narrative, positive but curious and questioning, and always demonstrating a desire to know and understand though you are currently “unknowing”.

Peter talked about “the non-mentalizing hand”. By this he means that you stop non-mentalizing whenever you see it. He uses a technique of holding up his hand as if to stop something, for example, “This time that we have together is so important. I don’t want to repeat things that we’ve heard before.” You try to provoke curiosity about motivations (which is what “mentalizing” competency does – link actions to motivations). You try to elicit feeling states and while recognizing mixed emotions, probes for feelings other than the first the patient mentions. Be open about your emotional experience as it links to your relationship with the patient, and connect the patient’s current affective state to the therapeutic work within the session itself. For example, “I can see that you are getting frustrated with me right now, perhaps because I am not “hearing” you, the way you experience your boss (or your daughter) as not hearing you.”

I will write more about Peter’s lecture and give references in the next posting.



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