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Adolescent Mentalization
Based Therapy
Dr Louise Duffy, Consultant Clinical Psychologist
Dr Helen Griffiths, Consultant Clinical Psychologist
NHS Lothian CAMHS / University of Edinburgh
RCP in Scotland Child and Adolescent Faculty Conference.
Nov 2016
With thanks to Anna Freud Centre and UCL for use of some of their
material/slides
What we’ll cover • What mentalization is
• Markers of mentalizing
• Theory of development of mentalizing
• Mentalizing and the adolescent brain
• Application of mentalization
– As a therapy: MBT, MBT-A
• Evidence
• In Lothian CAMHS
– As a general approach:
• Mentalizing stance
• Video clips
• Exercise – using a mentalizing approach to role-play a
discussion with a young person you are finding particularly
challenging.
• Forewarning:
There is nothing new in Mentalizing
What is mentalization?
• A form of imaginative mental activity about
others or oneself
• Perceiving and interpreting behaviour – our own
and others’ – in terms of intentional mental
states (e.g. feelings, beliefs, desires, fears,
hopes)
• When you think about what you are feeling or
wonder what someone else might be thinking or
feeling you are mentalizing. Allen 2005
What is mentalization?
• A ‘bedrock neurodevelopmental capacity’ that is:
• Located primarily in the prefrontal cortex
• Fostered (or rekindled) in the experience of relationship with a
– trusted other, in which one has an iterative experience of
– being accurately mentalized (I find my mind in your mind.)
• Easily overwhelmed by powerful stress/arousal/attachment
What is mentalization?
• When you think about what you are feeling or wonder what
someone else might be thinking or feeling you are mentalizing.
• Having mind in mind
• Seeing ourselves from the outside and others from the inside
• Understanding misunderstanding
• Those psychological skills that allow us to spontaneously and
largely in an intuitive manner make sense of the actions of
oneself and others by reference to mental states such as
beliefs, desires and feelings. Peter Fonagy (2004)
What is mentalization?
• Mentalizing shapes our understanding of self and others.
• Good relationships are based on an ability to understand each other, and ourselves, fairly well. Problems with mentalizing can create difficulties in relationships as people will become unhappy if you’re not aware of their needs and feelings or you misinterpret why they are behaving in certain ways.
The MBT Approach
• The MBT approach is based on a view that a core
problem for many patients, especially those with BPD, is
their vulnerability to a loss of mentalizing.
• This vulnerability becomes associated with interpersonal
sensitivity which triggers dysregulated emotions and
impulsivity
• Mentalization based treatment hopes to address this
vulnerability and in this therapy the aim is on improving
the young person (and families’) mentalizing ability
• The therapy is relational focussed and the therapist is
seen as an active participant and a contributor to
emotional impact on the patient.
Mentalizing as an
Integrative framework
Cognitive Behaviourism: The value of understanding the relationship between my thoughts and feelings
and my behaviour.
Systems Theory: The value of understanding the relationship between
the thoughts and feelings of family members and their behaviours, and the
impact of these on each other.
Psychodynamic: The value of understanding the nature of resistance
to therapy, and the dynamics here-and-now in the therapeutic
relationship.
BIOLOGICAL, SOCIAL and ECOLOGICAL: The value of understanding the impact of context upon mental states: development, deprivation, opportunity, hunger, fear...
COMMON LANGUAGE
MIND BRAIN
When emotion is high....
....mentalizing is in danger
Curiosity I know that I don’t
KNOW what you
must think, boss,
but I can wonder
what that is…
How must it feel
to be you right
now, boss?
Why do I keep
getting into
trouble over my
rabbit habit…?
Is there something
about me and
rabbits that stems
from my childhood, I
wonder…?
Awareness of the impact on others:
Too vigorous,
and
Stuff’ll get spilt
The Opacity of other minds
Perspective-taking
Capacity to Trust
Narrative Continuity
START
X
X
X
How does the capacity for mentalization develop? The caregiver’s emotionally attuned responses to the infant’s states becomes a source of information to the infant about his internal states Theory of Self Development Thinking arises in the context of the relationship with another. The caregiver thinks of the infant as agentive and through this the agentive sense of self is acquired Safe, playful interaction with the caregiver leads to the integration of primitive models of experiencing internal reality (Fonagy & Bateman)
The development of mentalizing
Learning About My Mind, Your
Mind (My mother thinks) I think, therefore I am
Mirroring
Contingent
Marked
Mind in mind
Sam-I-am
Mirroring sadness
Unmarked mirroring Marked mirroring
But the mothers capacity to make sense of the baby’s state is
highly influenced by…….
How she feels about
herself as a mother
How supported she is in
her relationships
How her mother felt
about her as an
infant
What happens when it goes wrong?
• When the parent misperceives the baby’s inner state, the
mirroring would not accurately reflect the baby’s feelings
e.g. when the parent is frightened by a baby’s distress,
what the baby would see and experience is the fear in
the parent, and hence the experience that they would
take into themselves is the experience of: Inner distress
which frightens the other and hence lead to an inner
experience of ‘I am frightening’
Adolescent neurodevelopment
• Brain continues to develop throughout
adolescence into early 20s
• Prefrontal cortex – dramatic changes in
adolescence
• Decline in volume of grey matter
corresponding to synaptic pruning
• ……mentalizing located primarily in
prefrontal cortex
Developmentally, Adolescents are particularly prone to stress-arousal, and low mentalizing
A Developmental trajectory, with high frequency fluctuations:
Mentalization is fragile “Programmed for overwhelm”
Ougrin, D., Tranah, T., Stahl, D., Moran, P., & Asarnow, J. (2015).
Therapeutic Interventions for Suicide Attempts and Self-Harm in
Adolescents: Systematic Review and Meta-Analysis. Journal of the
American Academy of Child & Adolescent Psychiatry., 54(2), 97-107.e2.
MBT outcomes
• Bateman & Fonagy (1999, 2001, 2003): MBT
superior than TAU including at follow-up – MBT: 18-month period with weekly individual and group
sessions, crisis planning and integrated psychiatric care
– Suicidality, diagnostic status, medication, global functioning,
vocational status
• Roussow & Fonagy (2012): MBT superior than
TAU for adolescents who self-harm – MBT: 12 month period with weekly individual MBT-A sessions
and monthly mentalization-based family therapy (MBT-F)
– Self harm behaviour, depression, borderline traits, attachment avoidance, mentalization
Clinical trials register (adolescents)
• Mentalization-Based Therapy to Prevent Suicidal
Behavior in Adolescents With Bipolar Disorder
(Miklowitz, LA)
– Individual and family therapy
• MBT in Groups for Adolescents With BPD or
Subthreshold BPD Versus TAU - the M-GAB
Randomized Controlled Trial (M-GAB) (Emma
Beck, Denmark)
– Case formulation, MBT-I, MBT-G, MBT-P
• Group-based Mentalization Therapy for
Adolescents (NHS Lothian)
– Up to 24 sessions group-based MBT
MBT in Lothian CAMHS
• Different training route – pre MBT-A
• Focus on group therapy
• Tier IV – AMBIT trained
• Early intervention
• Adapted manual, originally developed for adults with
BPD, for adolescents presenting with self harm,
experience of emotional distress and relational
difficulties (i.e at risk of developing BPD)
MBT Skills Training
Small grants to support supervision and further
training:
MBT-AI group
manual: Duffy,
Duffy, Griffiths,
Happer
Initial clinical evaluation • 3 groups: 29 female adolescents, mean age
15.6 years (SD= 1.5)
• Median no sessions attended = 7
• Acceptable to young people
• Pre-post change on a number of variables
showing small-to-medium effect sizes e.g.
reflective function, crisis presentations, emotion
regulation strategies
• RF accounted for variance in outcomes for self-
harm, emotional distress, interpersonal
problems, internal dysfunctional emotion reg
strategies
Lothian MBT RCT
Pilot RCT comparing MBT-A to TAU to determine:
– Effectiveness of recruitment strategies
– Compliance with protocol/procedures
– Trends towards reduced self harm
– Result will inform a future definitive RCT and give an
indication for the potential for wider service
implementation.
Mentalizing ourselves in our work
• We get stressed / upset / anxious / angry
ourselves
• ……..and lose the capacity to mentalize
• ……and when that happens it significantly
affects others’ capacity to mentalize
• This can happen when we are with patients
Fuggle, P., Bevington D., Duffy,
F., Cracknell, L (2016): The
AMBIT approach: working with
hard to reach youth
Griffiths, H., Noble, A., Duffy,
F., Schwannauer, M (2016):
Outcome and service
utilisation in an AMBIT-
Trained Tier IV CAMH
service
Mentalizing
stance
Inquisitive
Terminating
Non-mentalizing
Holding the balance(s)
Highlighting
mentalizing
Video clip
• https://youtu.be/vhPOC-z-3aw
Dickon & girl – exploring argument – example of therapist
stance. 3.19
• Exercise: Spot elements of the stance in this clip
• Client's part played by actor.
Watch the clip and try to spot the elements of the stance that you
notice in this clip.
Feel free to criticise the therapist, too
Video clip
the therapist's mentalizing stance has been
likened to flying as it is described by the
character Buzz Lightyear in the film Toy
Story: "it's just falling... with attitude". The
critical elements of maintaining
inquisitiveness, are to retain awareness of
the extent of one's not-knowing, readiness to
take responsibility for getting it wrong, and
commitment not to get it wrong again in the
same way.
• https://www.youtube.com/watch?v=nyEmI
mJ7ODo
Dickon explaining posture 1.34
THANK YOU FOR LISTENING!
Video clip
• https://www.youtube.com/watch?v=IzBHD
SnR2jk
Anthony – empathic validation 7.13
