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Mentalization Based Therapy : Dr Linda Treliving Consultant psychiatrist in psychotherapy, NHS Grampian

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Page 1: Mentalization Based Therapy : Dr Linda Treliving Consultant psychiatrist in psychotherapy, NHS Grampian

Mentalization Based Therapy :

Dr Linda Treliving

Consultant psychiatrist in psychotherapy, NHS Grampian

Page 2: Mentalization Based Therapy : Dr Linda Treliving Consultant psychiatrist in psychotherapy, NHS Grampian

Why mentalization based therapy?

• Evidence based• Psychodynamic treatment• Rooted in attachment and cognitive therapy• Requires limited training with moderate levels of

supervision • Implemented by generic mental health

professionals• MBT skills accessible to non mental health staff

and is simple intervention for complex group

Page 3: Mentalization Based Therapy : Dr Linda Treliving Consultant psychiatrist in psychotherapy, NHS Grampian

Mentalization

• the capacity to recognise and understand the existence of minds, both one’s own and those of others.

• to recognize that human behavior is motivated by mental states–by things like thoughts, beliefs, feelings, and desires.

Page 4: Mentalization Based Therapy : Dr Linda Treliving Consultant psychiatrist in psychotherapy, NHS Grampian

Mentalization

• Everybody will struggle to mentalize at times but people with borderline PD and other diagnoses have more consistent difficulty and can account for signs and symptoms

• Underpins clinical understanding, the therapeutic relationship and therapeutic change regardless of modality of therapy

Page 5: Mentalization Based Therapy : Dr Linda Treliving Consultant psychiatrist in psychotherapy, NHS Grampian

What does good mentalizing looklike?

• Perception of own mental functioning– appreciation of changeability– developmental perspective– awareness of impact of affect

• Self-presentation – consistency in sense of self

• General values and attitudes – tentativeness and moderation

Page 6: Mentalization Based Therapy : Dr Linda Treliving Consultant psychiatrist in psychotherapy, NHS Grampian

What does non-mentalizing look like?

»Excessive detail to the exclusion of motivations, feelings or thoughts.

»Focus on external social factors, such as the school, the council, the neighbours.

»Focus on physical or structural labels.»Preoccupation with rules, responsibilities.»Denial of involvement in problem.»Blaming or fault-finding.»Expressions of certainty about thoughts or feelings of

others.

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Page 7: Mentalization Based Therapy : Dr Linda Treliving Consultant psychiatrist in psychotherapy, NHS Grampian

Prementalizing modes of cognition

• psychic equivalence - the equation of one’s mental states with reality

• pretend mode - the dissociation of mental states from reality

• teleological – only action that has physical impact can alter mental state in self or others

Page 8: Mentalization Based Therapy : Dr Linda Treliving Consultant psychiatrist in psychotherapy, NHS Grampian

Attachment Theory

Attachment theory is about proximity,

an experience of safety and the

consequential development of robust,

flexible psychological processes that

protect the individual from the stresses of

human interaction and everyday life

(Bowlby,1969, 1973, 1980).

Page 9: Mentalization Based Therapy : Dr Linda Treliving Consultant psychiatrist in psychotherapy, NHS Grampian

Development of affect regulation and a positive sense of self

– the infants states are noted by the caregiver – carer communicates their understanding of

the infants emotional experience to the infant not merely an expression of the carers own conflicts or an exact copy of the infants distress.

Page 10: Mentalization Based Therapy : Dr Linda Treliving Consultant psychiatrist in psychotherapy, NHS Grampian

The hyperactivation ofattachment in BPD

• The attachment system in BPD is hypersensitive and triggered too readily

• Indications of attachment hyperactivity in core

symptoms of BPD– Frantic efforts to avoid abandonment– Pattern of unstable and intense interpersonal

relationships– Rapidly escalating tempo moving from acquaintance

to great intimacy

Page 11: Mentalization Based Therapy : Dr Linda Treliving Consultant psychiatrist in psychotherapy, NHS Grampian

Attachment provocation in clinical situations

• In the ward– Stimulation of attachment system in admission– Changing shifts– Discussing discharge

• At interview– Clinician lowering voice– Increasing intimacy– Responding/refusing to demands– Boundary violation however small

Page 12: Mentalization Based Therapy : Dr Linda Treliving Consultant psychiatrist in psychotherapy, NHS Grampian

BPD and attachment

• Borderline patients have a history of disorganized attachment (94%) which leads to problems in affect regulation, attention and self control

• These problems are mediated through a failure to develop a robust mentalizing capacity

Page 13: Mentalization Based Therapy : Dr Linda Treliving Consultant psychiatrist in psychotherapy, NHS Grampian

“The development of an attachment based treatment programme for borderline

personality disorder”

The mediator between the genotype and the phenotype is the attachment process…..

Anthony Bateman and Peter Fonagy

Bulletin of the Menninger Clinic

(2003) , 67,3:pp187-211

Page 14: Mentalization Based Therapy : Dr Linda Treliving Consultant psychiatrist in psychotherapy, NHS Grampian

Mentalization based therapy

• Aims to strengthen patients’ capacity to understand their own and others mental states in attachment contexts in order to address difficulties with –– Affect regulation– Impulse regulation– Interpersonal functioning

Bateman and Fonagy 2009

Page 15: Mentalization Based Therapy : Dr Linda Treliving Consultant psychiatrist in psychotherapy, NHS Grampian

Mentalization based stance – what does it look like?

• Therapist adopts a stance of inquisitive, not knowing

• Alert to patients mentalizing and level of arousal in session – Intervenes to restore mentalizing– Maintains arousal at optimal level

• Collaborative, normal human relationship

Page 16: Mentalization Based Therapy : Dr Linda Treliving Consultant psychiatrist in psychotherapy, NHS Grampian

Interventions: Spectrum

Supportive/empathic

Clarification, elaboration

Basic mentalizing and challenge

Mentalizing the relationship

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Page 17: Mentalization Based Therapy : Dr Linda Treliving Consultant psychiatrist in psychotherapy, NHS Grampian

Supportive and Empathic

Respectful of the patients narrative and expression

Positive/hopeful but questioning Constantly check-back your understanding

– ‘as I have understood what you have been saying is…

Spell out emotional impact of narrative based on common sense psychology and personal experience

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Page 18: Mentalization Based Therapy : Dr Linda Treliving Consultant psychiatrist in psychotherapy, NHS Grampian

Clarification, elaboration,

• Make behaviour explicit– extensive detail of actions

• Trace action to feeling • Re-construct the events in affective and mental

state terms

challenge• Surprise the patient’s mind; trip their mind back

to a more reflective process• Use humour when possible

Page 19: Mentalization Based Therapy : Dr Linda Treliving Consultant psychiatrist in psychotherapy, NHS Grampian

Interventions: Spectrum

Supportive/empathic

Clarification and elaboration

Basic mentalizing and challenge

Mentalizing the relationship

Mos

t in

volv

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ast

invo

lved

Page 20: Mentalization Based Therapy : Dr Linda Treliving Consultant psychiatrist in psychotherapy, NHS Grampian

Mentalizing the relationship

• Using the feelings between the patient and therapist to understand how each others minds work.

• Point out feelings where possible

• Comment on recurring life patterns

• Link these experiences to here and now

• Pay attention to feelings engendered in the therapist

Page 21: Mentalization Based Therapy : Dr Linda Treliving Consultant psychiatrist in psychotherapy, NHS Grampian

Anthony Bateman, Peter Fonagy

Mentalization based therapy.

Weekly group plus individual sessions

• Am. J. Psychiatry 1999; 156:1563–1569

18-Month Follow-Up

• Am. J. Psychiatry 2001: 158:36-42

8 year follow up

• Am. J. Psychiatry 2008: 165: 631,

Page 22: Mentalization Based Therapy : Dr Linda Treliving Consultant psychiatrist in psychotherapy, NHS Grampian

Results:

Five years after discharge MBT vs TAU continued to show clinical and statistical superiority.

• suicidality (23% versus 74%)• diagnostic status (13% versus 87%)• service use (2 years versus 3.5 years of psychiatric outpatient treatment)• use of medication (0.02 versus 1.90 years taking three or more medications)• global function above 60 (45% versus 10%)• vocational status (employed or in education 3.2 years versus 1.2 years )

Page 23: Mentalization Based Therapy : Dr Linda Treliving Consultant psychiatrist in psychotherapy, NHS Grampian

Why mentalization based therapy?

• Evidence based• Psychodynamic treatment• Rooted in attachment and cognitive therapy• Requires limited training with moderate levels of

supervision • Implemented by generic mental health

professionals• MBT skills accessible to non mental health staff

and is simple intervention for complex group.

Page 24: Mentalization Based Therapy : Dr Linda Treliving Consultant psychiatrist in psychotherapy, NHS Grampian

MBT Scotland

MBT skills, 2 day course

MBT basic, 3 days

MBT practitioner certificate

Plus supervision of cases

Plus supervision of cases

Plus supervision of cases and CPD

Page 25: Mentalization Based Therapy : Dr Linda Treliving Consultant psychiatrist in psychotherapy, NHS Grampian

MBT Scotland

Thank you for listening

For more information contact [email protected]