Comorbid Antisocial and Borderline Personality Disorders- Mentalization-based Treatment Authors: Anthony Bateman; Peter Fonagy

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Comorbi d Antis ocial and Borderl ine Persona lity

Disorders: Mentalization-Based Treatment m

Anthony BatemanSt. Ann’s Hospital, London

m

Peter FonagyUniversity College London

Mentalization is the process by which we implicitly and explicitly

interpret the actions of ourselves and others as meaningful based on

intentional mental states (e.g., desires, needs, feelings, beliefs, and

reasons). This process is disrupted in individuals with comorbid

antisocial (ASPD) and borderline personality disorder (BPD), who tend

to misinterpret others’ motives. Antisocial characteristics stabilize

mentalizing by rigidifying relationships within prementalistic ways of

functioning. However, loss of flexibility makes the person vulnerable

to sudden collapse when the schematic representation is challenged.

This exposes feelings of humiliation, which can only be avoided by

violence and control of the other person. The common path to

violence is via a momentary inhibition of the capacity for mentaliza-

tion. In this article, the authors outline their current understanding of

mentalizing and its relation to antisocial characteristics and violence.

This is illustrated by a clinical account of mentalization-based

treatment adapted for antisocial personality disorder. Treatment

combines group and individual therapy. The focus is on helping

patients maintain mentalizing about their own mental states when

their personal integrity is challenged. A patient with ASPD does not

have mental pain associated with another’s state of mind; thus, to

generate conflict in ASPD by thinking about the victim will typically be

ineffective in inducing behavior change. & 2008 Wiley Periodicals, Inc.

J Clin Psychol: In Session 64: 181–194, 2008.

Keywords: mentalization; mentalization-based treatment; antisocial

personality disorder; borderline personality disorder; self; violence

Correspondence concerning this article should be addressed to: Anthony Bateman, Halliwick Unit, St.Ann’s Hospital, St. Ann’s Road, London N15 3TH, UK; e-mail: [email protected]

JOURNAL OF CLINICAL PSYCHOLOGY: IN SESSION, Vol. 64(2), 181--194 (2008) & 2008 Wiley Periodicals, Inc.

Published online 9 January 2008 in Wiley InterScience (www.interscience.wiley.com). DO I: 10 .1 00 2/ jc lp .2 04 51



Most personality disorders (PDs) do not present to clinicians in a pure form.

Comorbidity is the rule rather that the exception.

Our focus here is on patients diagnosed with antisocial personality disorder

(ASPD) comorbid with borderline personality disorder (BPD) who have committed

acts of violence. This admixture of personality features complicates the clinicalpicture that is presented to the clinician, who has to take into account the

phenomena of ASPD and the possibility of violence to others in treatment, as well as

the danger of self-harm and suicide common in BPD. There is limited evidence

available about how to treat such individuals and, if we were to start from first

principles, an understanding of the processes underpinning this complex psycho-

pathology would inform treatment innovation, which, in turn, would then be subject

to empirical investigation.

Kazdin (2004) has outlined a sequential program for the development of

psychotherapy based on these principles. The first stage follows from the proposition

that treatment should reflect what we know about the processes that directly bear onthe onset and course of a clinical problem. In violent patients with ASPD/BPD, we

need to understand the interrelationship of the phenomena and if possible,

demonstrate that a specific process or lack of process is present in a sizable

proportion of individuals with this comorbid presentation.

We believe that the process of mentalization is linked to the phenomena of personality

disorder, and in this article we suggest that a focus on mentalizing is relevant to the

treatment of violent patients with complex personality pathology. A clinical vignette

from a group session followed by an associated individual session during treatment of

patients comorbid for ASPD/BPD will illustrate some of our points.

Mentalizing and Personality Disorders

Mentalizing simply implies a focus on mental states in oneself or in others,

particularly in explanations of behavior (Fonagy, Gergely, Jurist, & Target, 2002).

That mental states influence behavior is beyond question. Beliefs, wishes, feelings,

and thoughts, whether inside or outside our awareness, determine what we do.

Explanations of behavior in terms of others’ mental states (mentalizing) are

relatively vulnerable compared with explanations that refer to aspects of the physical

environment (nonmentalizing). The latter are far less ambiguous because the

physical world is less readily changeable. When taking a mentalizing stance the mere

contemplation of alternative possibilities may lead to a change in beliefs. Thus, afocus on mind leads to far more uncertain conclusions than a focus on physical

circumstance because it concerns a mere representation of reality rather than reality

itself. We may act according to wrong beliefs about others’ mental states and

underlying motivations in a particular situation, sometimes with tragic conse-

quences. For example, we may believe that people mean us harm as they run towards

us and react accordingly, when, in fact, they are concerned for our welfare and wish

to push us out of the way of a car we have not seen.

Normal people will, at times, move from understanding themselves and others

according to what is in the mind to explanations based on the physical

environment—‘‘I must have wanted to because I did it.’’ However, we havesuggested that rapid and frequent shifts from mentalizing to nonmentalizing modes

of experience is characteristic of borderline personality disorder (Bateman &

Fonagy, 2004). In this article, we suggest that abnormalities in mentalizing are also a

significant problem in ASPD.

182 Journal of Clinical Psychology: In Session, February 2008

Journal of Clinical Psychology: In Session DOI 10.1002/jclp



The phenomena of ASPD/BPD are a consequence of a shift from mentalistic

modes of function to prementalistic ways of perceiving the world. The prementalistic

modes of organizing subjectivity, which emerge have the power to disorganize

relationships and destroy the coherence of self-experience that the narrative provided

by normal mentalization generates. This move most frequently occurs when theattachment or affiliative system is activated. As soon as emotional states are aroused

in the context of an interpersonal interaction, ASPD/BPD patients become

vulnerable to loss of mentalizing because stimulation of the attachment system

actually inhibits mentalizing itself (Fonagy & Bateman, 2006). The consequence of

the inhibition of mentalizing itself is a reemergence of modes of experiencing internal

reality that antedate the developmental emergence of mentalization, namely psychic

equivalence, pretend mode, and teleological thinking. Nevertheless, in addition,

there is a constant pressure for projective identification—the reexternalization of the

self-destructive alien self (Fonagy & Bateman, 2007).

Psychic Equivalence

Mentalization gives way to psychic equivalence, which clinicians normally consider

under the heading of concreteness of thought. No alternative perspectives are

possible. There is a suspension of the experience of ‘‘as if’’ and everything appears to

be ‘‘for real.’’ This can add drama as well as risk to interpersonal experience, and the

exaggerated reaction of patients is justified by the seriousness with which they

suddenly experience their own and others’ thoughts and feelings. A patient had a

dream about a giant wave destroying thousands of people. When she woke up in the

morning, she heard that there had been a huge tsunami. She became terrified and

believed that she had caused the disaster and eventually took an overdose of paracetamol because she could not cope with her emotional state.

A patient who had been sexually abused by her grandfather had flashbacks of him

coming in to her bedroom. She barricaded her door at night. Even though he had

died a number of years ago, her image of him entering her room was experienced as

current rather than a memory from the past and she reacted accordingly.

Pretend Mode

Conversely, thoughts and feelings can come to be almost dissociated to the point of

near meaninglessness. This is pretend mode. In these states, patients can discussexperiences without contextualizing them in any kind of physical or material reality.

Attempting psychotherapy with patients who are in this mode can lead the therapist

to lengthy, but inconsequential discussions of internal experience that have no link to

their genuine experience. A patient talked about her childhood explaining how it

linked to her suicidal behavior. It seemed logical and understandable, but ‘‘knowing

it’’ did not alter her level of risk or improve her self-destructive patterns. It simply

justified her behavior.

Teleological Mode

Early modes of conceptualizing action in terms of that which is apparent can cometo dominate motivation. This is teleological mode. Within this mode, there is a

primacy of the physical and experience is only felt to be valid when its consequences

are apparent to all. Affection, for example, is only true when accompanied by

physical expression. A patient believed that her new boyfriend did not want to see

183Mentalization-Based Treatment of Comorbid PDs




her anymore because he did not meet her at the agreed time. In teleological mode,

she believed that if he wanted to see her he would have been there. When he

contacted her an hour later to let her know that he had been stuck on an

underground train that had broken down, she swore at him and told him that she

never wanted to see him again. Later she cut her wrists.

Alien Self

Finally, with the dissolution of the self, aspects of oneself that are experienced as

alien are projected and seen as belonging to others. Relationships become rigid and

fixed and the other has to be controlled forcibly to keep hold of alien parts of the self.

The alternative is complete collapse of the self and destruction of the self becomes

preferable. In a teleological mode this is dangerous, i.e., physically, by self-harm and

suicide. The need for the other as a vehicle for the alien self can become

overwhelming as the patient experiences it as a matter of survival and an adhesive,addictive pseudo-attachment to this individual may develop. We assume, as

suggested by Winnicott (1956), that when a child cannot develop a representation

of his own experience through mirroring (the self), he internalizes the image of the

caregiver as part of his self-representation. We have called this discontinuity within

the self the alien self . We understand the controlling behavior of children with a

history of disorganized attachment as persistence of a pattern analogous to

projective identification where the experience of incoherence within the self is

reduced through externalization. The intense need for the caregiver characteristic of

separation anxiety in middle childhood that is associated with disorganized

attachment, reflects the need for the caregiver as a vehicle for externalization of

the alien part of the self rather than simply an insecure attachment relationship. This

method of stabilizing the mind and the self is carried through to adulthood. The

experience of fragmentation within the self-structure is reduced by this process of

externalization. Loss of mentalizing destabilizes the self provoking an uncertainty—

Who am I? Who are they? What do they want? Who am I in relation to them? No

answers are available to the individual and panic ensues. As it does so, the individual

attempts to recapture a sense of self by schematic representation—‘‘I understand this

if he does not like me—he is victimizing me and I am a victim.’’ To manage this state

of mind, individuals’ project aspects of themselves that are destabilizing and see them

in the other. The alien aspects of the self are most dangerous to the individual’s

integrity and narrative structure.

The Self and Violence

A rapid, attachment-dependent movement between these different modes of

experiencing the self and the world is characteristic of BPD, but is modified by the

co-occurrence of violent ASPD. In comorbid ASPD1BPD, the mental processes are

more stable in contrast to the rapidly fluctuating states found in BPD itself. Yet the

patient’s hold on understanding the mental states of others is tenuous and can be

suddenly and catastrophically lost as the attachment system is stimulated. Stability is

maintained by interpreting the world according to teleological understanding muchof the time, but in many instances, we suggest that stabilization of mental processes

arises from the rigidity of the externalization of the alien self. This presents serious

problems for the treating clinician. The rigidity of the system has to be challenged

and yet the challenge might induce violence.





In ASPD/BPD, the alien self is firmly and rigidly located outside—a partner may

be seen as mindless and needing to be told what to do; a system portrayed as

authoritarian and dangerously attempting to subjugate. This stabilizes the mind of

the patient. Threats to these schematic representational structures, which could be a

system being overly nice or pleasant or a partner demanding an unacceptable level of independence, lead to arousal within the attachment system, which triggers an

inhibition of mentalizing, which, in turn, leads to fears of inability to control internal

states and the threat of the return of the alien self.

It has been suggested that threats to self-esteem trigger violence in individuals

whose self-appraisal is on shaky ground because they exaggerate their self-worth

(narcissism). Patients with ASPD/BPD inflate their self-esteem by demanding respect

from others, controlling the people around them, and creating an atmosphere of

fear. This maintains pride, prestige, and status, and ensures the experience of the

external location of the alien self. Loss of status is devastating as the alien self is

returned and reveals internal states that threaten to overwhelm them. Experiencebecomes more firmly rooted in psychic equivalence. Such patients are momentarily

unable to mentalize, to see behind the threats to what is in the mind of the person

threatening them, and so they have no way of keeping out a rapidly lowering self-

esteem and loss of position.

Emotional capacities such as guilt and love towards others and fear for the self

may protect from engaging in violent behavior, but the loss of mentalizing and the

embryonic ability of these patients to experience such feelings prevent mobilization

of these inhibitory mechanisms. Fear for the self is absent and the dangers associated

with violence become secondary. The onset of pretend mode means the risk of being

caught is unreal and an illusory sense of safety and lack of reality is manifest. The

internal state no longer links with external reality—‘‘It happened like in the movies;’’

‘‘it didn’t seem real’’.

Gilligan (2000) creatively and persuasively focused our attention on the regulation

of shame as a key factor in the pathology of ASPD. The shame associated with loss

of self-esteem is also experienced in psychic equivalence mode and is so devastatingly

destructive that the patient has to do something immediate and urgent if he is to

survive. He cannot accept the return of the alien self, which will induce

overwhelming feelings of shame, and so he inevitably attempts to control the

source, which is seen as out there. Aggression towards the source of danger cannot

be limited to nonphysical aggression such as shouting. This can only occur if

mentalizing is retained and awareness of the mental state of the other remains, atleast partially. Recognition of the other person as having a separate mind inhibits

violence; the loss of mentalizing allows a bodily attack as the other person becomes

no more than a body or threatening presence. So it is to violence that we now turn to

understand in more detail this final element to the complex picture.

The common path to violence is via a momentary inhibition of the capacity for

mentalization. Mentalization protects against violence. Some individuals, constitu-

tionally poor at recognizing mental states in others through facial expressions or

vocal tones, may not fully acquire the ability to ‘‘mentalize’’ and thus inhibit their

natural violence. These individuals are callous and unemotional. They remain

unencumbered by the recognition of others mental states and are unaware of theeffects of their actions or expressed desires on others. As a result, they remain

unaffected by negative responses and in line with the terrible threat that such

individuals represent, we dismiss them as ‘‘psychopaths.’’ We are not concerned with

this group here.





Others never had the opportunity to learn about mental states in the context of

appropriate attachment relationships. Or, alternatively, their attachment experiences

may have been cruelly or consistently disrupted. For yet others, a nascent capacity

for mentalization has been destroyed by an attachment figure, who created sufficient

anxiety about his thoughts and feelings towards the child for the child to wish toavoid thinking about the subjective experience of others. It is important to retain an

awareness of the possibility that violence may be rooted in the disorganization of the

attachment system. A child may manifest an apparent callousness that is actually

rooted in anxiety about attachment relationships. Yet, in fact, they are not callous

and unemotional, but terrified and potentially striving for a more reliable

attachment. It is this group that we are more concerned with here as a harsh early

childhood could signal greater future need for interpersonal violence as a means of

expression of underlying mental states. In support of this model are studies (Jaffe

et al., 2004; Shonk & Cicchetti, 2001) that demonstrate that the association between

childhood maltreatment and externalizing problems is probably mediated byinadequate interpersonal understanding (social competences) and limited behavioral

flexibility in response to environmental demands (ego resiliency).

We argue that the group whose aggression is high in early childhood and

continues into adolescence and early adulthood is likely to have had attachment

experiences that failed to establish a sense of the other as a psychological entity. We

propose a synergy between psychological defenses, neurobiological development,

and shifts in brain activity during posttraumatic states such that mentalizing activity

is compromised. The shift in the balance of cortical control locks the person with

maltreatment history into a mode of mental functioning associated with an inability

to employ alternate representations of the situation (i.e., functioning at the level of

primary rather than secondary representations), an inability to explicate the state of

mind (metarepresentation) of the person they face, and a predisposition to enter a

mode of mental functioning associated with states of dissociative detachment, where

their own actions are experienced as unreal or as having no realistic implications.

Treatment has to address all of these facets.

Mentalization-Based Treatment

Mentalization-based treatment (MBT) has been developed for the treatment of BPD

and is fully operationalized for that disorder (Bateman & Fonagy, 2006). It has been

shown to be effective in randomized controlled trials in a partial hospital program(Bateman & Fonagy, 1999) and is currently being investigated in an intensive

outpatient format. It is now being adapted for patients with ASPD. The primary

aims of MBT are to create a therapeutic environment in which mental states of self

and others become the focus of concern. To this extent, it may be especially suited to

the abnormal processes associated with ASPD/BPD patients who need to extend

their ability to maintain mentalizing when self-esteem is threatened by developing

some mental functioning at a secondary level of representation.

Clinical Modes of Mentalization-Based Treatment

Mentalization-based treatment is offered to patients in the form of combined groupand individual treatment. Patients are seen every 2 weeks, but sessions alternate

between individual and group modes. Group therapy is an excellent context in which

to address the difficulties presented by patients who disregard normal social

processes and fail to take into account common interpersonal sensitivities.





It provides the possibility for them to develop a better understanding of their role in

social processes, and how their interactions with others can provoke distortion in

social understanding and interpersonal interaction. As we have already suggested,

if a person feels angry with someone or feels misunderstood or treated unfairly, he or

she has to manage his or her mind rather than rid themselves violently of the physicalcause of the discomfort. The dangers of mentalizing group psychotherapy with

ASPD/BPD become obvious when we consider the aim is to promote serious and

detailed consideration of the motives of self and other when emotions are aroused

and to find ways of managing the alien self without resorting to control through

violence. Once rigidly held schematic representations are challenged or even

questioned, violence will not be far off.

Patients with both ASPD and BPD find group therapy problematic partly because

of their compromised ability to understand the motives of others, but our current

experience is that they can attend regularly for a prolonged period of time if the

sessions are interspersed with individual sessions in which they review their role andbehavior in the group as well as addressing other personal concerns. In the following

illustrative clinical vignette, we report a group session in which the patients form an

agreed understanding of a violent event. Their understanding is temporarily accepted

without question by the cotherapists. This clinical material will be discussed in

relation to our earlier outline suggesting that it is the loss of mentalizing processes

that lead to violence in patients with ASPD/BPD. Although this is not addressed

fully in the group, it is considered further in the subsequent individual session with

the patient who again reported the episode of violence.

Case Illustration

Group Session

The group is formed by 6 patients, all of whom have a diagnosis of comorbid ASPD

and BPD. They are aware of their diagnosis and have been attending the group and

individual sessions for 6 months. One patient, Kieren aged 28 years, is absent. The

group members are aged between 25 and 36. All have been in prison in the past for

violent offences. Steve and Patrick are currently on probation having been released

from prison early for good behavior. John is 32 years old and was brought up in a

rough part of Northern England. He presented with depression and indicated that he

wanted to change himself so that he could have a better relationship. He had beenviolent to his partner on a number of occasions and was currently living separately

from her. Steve is 28 years old and has spent most of his life dealing in stolen goods

and sometimes in drugs. He also has a number of offences for fraud. He presented

for help because he was drinking too much and it was getting him into too many

fights. He had also been involved recently in extortion and blackmail. He lives with

his mother and father who themselves have a criminal history. Patrick is 36 years old

and has a number of children by different partners. He asked for help because he and

his current partner had recently had a baby boy. He stated that he wanted to be a

‘‘better person’’ for his son. Michael is 25 years old and is the only member of the

group to work. He works in a warehouse and his employer suggested he seek help forhis anger. Following an anger management course, he was referred for further

treatment because he had many problems related to his childhood including sexual

abuse and physical violence while in care homes. His parents had abandoned him

when he was 4 years old. Peter, who is 31 years old, had similar problems, but was

187 Mentalization-Based Treatment of Comorbid PDs




more depressed at presentation to the services. The group began with John talking

about an incident that had occurred a few days ago.

John (J): I stabbed someone the other night. He was causing me a lot of problems

and so he had it coming to him.Steve (S): What did he do?

J: He was in my flat. I had let a number of the young people on the estate come

into my flat to use it as a cooch (drug den). They know that I let them do it

sometimes and I quite like it. Anyway, I told them it was late and so they had

to leave. Then one of them said that I had pinched his cigarettes. I said ‘‘What

did you say?’’ He repeated himself and so I told him that I had not and he had

better leave. He then started swearing at me and told me that I was a thief. I

warned him that he should shut up and get out.

Patrick (P): You warned him then?

J: Yes.P: That was good. You had done what you should. After that, it is up to him.

J: I warned him again actually. Because he continued to accuse me of stealing his

cigarettes so I said again that if he didn’t shut up and get out he was getting

what was coming to him.

P: Then he deserves everything that was coming to him if he carried on.

J: He then started to go, but as he was still talking when he packed his things I

picked up the kitchen knife and went for him. His mates got hold of me and

held me back so I couldn’t reach him. They thought that he was out of the

flat, and so let me go but when he got outside he started to shout back at me

that I was a thief and cheat. So at that point, I ran out and stabbed him.

Couldn’t help it. He had crossed a line.

Therapist (TA): What line are you referring to?

Michael (M): That’s obvious, isn’t it? He had warned the guy and he carried on. You

can’t allow that to go on.

TA: Can you say more about what ‘‘that’’ is?

M: Well, he had warned him and he just carried on. That’s disrespectful.

Steve (S): Yes, you need to understand that these people were in his flat and you

can’t be disrespectful like that. If you let that go, there would be real trouble.

Peter (P): Yes. Big trouble.

TA: I am beginning to understand that there is something about this that you all

understand, but I am not quite there yet.J: Look, they were in my flat with my permission, but that does not allow them to

do what they want, does it?

TA: I understand that, but in this situation it leads to someone being stabbed and

my concern is how circumstances can lead you to do that—you suggested that

you could not help yourself so something pretty important had happened in you.

S: It’s obvious to me. If you let someone get away with that you never know what

will happen next time. They will assume that they can do anything. He gave

him his chance to get out gracefully, but he did not take it. John followed the

rules, but the other guy broke them and you can’t allow that.

TA: Can you help me with a bit more about the rules?J: Well, if you disrespect someone and they warn you, you should get out or

expect a fight. I don’t care when someone warns me, although I know that they

have given me a chance, but I stay and go for it. If I lose, I accept that but I

don’t care what happens to me, so I usually win. Most other people worry a bit





about what happens to them and so they don’t go quite as far as I do. But the

rules are the rules.

Therapist (TB) to J: As I understand it, then this man disrespected you and then

behaved a bit like you do and stayed to challenge you, which

you couldn’t allow. Can you say what the challenge to you is?J: If I let him get away with what he was saying and his accusations, the other people

would have told everyone around the estate and then people would think that I

was weak. I wouldn’t have any respect from anyone then.

P (interrupting): Yes, you have to understand the sort of place we live in. If you

didn’t deal with situations like this, people would laugh at you

and that would be you finished as a person.

TA: Can anyone say what Patrick means by being finished as a person?

M: I know what he means. If you don’t stand up for yourself then you are nothing.

TB: Nothing?

M: Yeah, nothing. You would be nobody and people might even start to takeadvantage of you. People are frightened of me and so keep away. I am

someone. Everyone knows that they cannot mess with me and I want to be

left alone. If I am not left alone then something happens. The other day

someone didn’t move out of the way when I was walking along. At first, I left

it and stepped aside, but as he passed I just felt that I couldn’t let that

happen. He was challenging me, and so I ran back and smacked him in the

face. He won’t do it again. But he was treating me like I was nothing and that

is not on.

TB: Can you just say what it is like to suddenly feel in danger of being nothing?

(silence)

S: You don’t wait to feel it, you just sort out what you have to sort out.

TA: What if someone doesn’t know the rules or if their mind is elsewhere—for

example, that this person you hit for not standing aside when you were

walking along. Maybe his mind was elsewhere. (silence)

TA: I realize that none of us have mentioned the person who was stabbed. It seems

that we have forgotten about him. Was he OK?

M: He’s not important. He had it coming to him. I don’t think about people after

something has happened unless I have a score to settle. Then I keep it and plot

to get my own back later. I don’t do remorse stuff. It does your head in.

S: It’s no good being guilty about it all. Anyway, both these guys deserved what

they got.TA: Being punched in the head for not moving aside?

S: Depends on the circumstances. This guy was probably giving him that look that

says he is defying you and so he shouldn’t do that. (The group continued with

some discussion about the ‘‘look,’’ what it was and what it meant.)

John describes a context in which he has invited young people into his flat to use

drugs. Here he is in charge, they are in his debt, and he has their gratitude. He can

feel safe in the knowledge that all those around him accept his superior status in a

hierarchy. The moment that an individual challenges him by accusing him of theft,

his anxieties are aroused and he feels threatened. The therapists attempt initially toexplore this challenge and what feelings it induces in him (a common mentalizing

technique), but the other patients quickly start to ask him if he kept to an accepted

code of conduct, in this case a warning that something will happen unless the

challenge is withdrawn. The revelation that two warnings were given is reason

189 Mentalization-Based Treatment of Comorbid PDs




enough to suggest that the act of violence is probably justified. The underlying

feeling state is initially avoided; the discussion focuses on the importance of respect.

All members of the group consider respect as necessary for survival. A return to the

theme is indicated by their unease about ‘‘the look’’ which, in essence, is one of

disrespect. However, it is just before the return to the theme of disrespect that there isan indication of what is of most alarm to John and to the rest of the group—

becoming nothing.

John expresses concern about ‘‘losing respect,’’ Patrick about being ‘‘finished as a

person,’’ and Michael as being ‘‘nothing.’’ It is clear to them all that loss of face is

not an option, and they have to rid themselves of the cause of the threat to maintain

their sense of pride, dignity, honor, and, in the end, their own self. Indeed, they ask

the therapists to understand the world in which they live—which is unforgiving,

talionic, and where it is a daily struggle for survival. This seems to be accepted by the

therapists who gradually become bystanders in the discussion of the violent act,

seemingly agreeing with the patients about the responsibility of the victim forwhat happened. The perpetrator is seen as being within his normal mind when

stabbing him.

To this extent, we believe that the mentalizing capacity of the therapists is

temporarily switched off by patients who present horrifying material without

concern. The therapists become identified with the aggressor rather than placing

themselves in identification with the victim. To do so would leave the therapists

themselves concerned about being the recipients of violence and yet at the same time,

they cannot completely identify with the violent patient as that too is dangerous.

The patients seek to control the alien self, in this case, a torturing and humiliating

self, by developing a nonmentalizing explanation. The victim ‘‘deserved’’ it because

he was warned and you have to do this sort of thing otherwise you do not get

the respect you should. He cannot countenance any such feeling of humiliation

in himself.

At the same time, the group disrupts the mentalizing of the therapists using a

‘‘power dynamic’’ that fuels the victim–victimizer–therapist interaction, through the

impact of conscious and unconscious coercion. The roles of John, the victim, and the

therapists can be seen from this perspective as representing a dissociating process;

the victim is dissociated from the group as ‘‘not us’’—‘‘He was warned and he knows

the rules. It is his choice if he ignores them’’— by John and the group. The therapists

are warned that they have to understand the culture that is inherent in the way they

live. The therapists then abdicate their role for a brief time by colluding with the ideathat the problem lies with the victim. The task of the therapists as observers of the

process is to maintain mentalizing as much as possible and to avoid this risk as well

as the risk of schematically representing the perpetrator as a demon and the victim as

a helpless innocent. This is equally nonmentalizing.

The therapists in this vignette attempt to maintain a mentalizing stance and ask

for clarification and understanding from members of the group to identify the

meaning of words which are implicitly accepted as having an agreed definition—‘‘the

rules,’’ ‘‘disrespect,’’ ‘‘finished as a person,’’ ‘‘being nothing.’’ To explore these areas,

the therapists recruit other patients to expand on the relatively underdeveloped

statements that are made. This is characteristic of mentalizing groups in whichtherapists try to stimulate a process of understanding between members of the group

about what they understand is going on in the minds of each other. The therapists

also participate actively: in this vignette by expressing their uncertainty about the

explanation of events. Finally, they briefly indicate that something intolerable had





taken place in John, but he does not explore it further. As a matter of principle, we

ask therapists to explore more explicitly such affective change in more detail.

Although this group session allowed the patients to identify the role of respect, the

importance of hierarchy, their recognition of avoiding ‘‘becoming nothing,’’ it did

not address the underlying dynamics involved in the violence. In part, this wasrelated to the problems the therapists had in actively maintaining their mentalizing

stance, but it was also related to recognition that to insist on too much exploration in

the group might have been experienced as forcibly returning the humiliating alien

self. The group protected John from this perhaps because they were unconsciously

aware that not to do so could lead to further violence. In MBT, it is commonly in the

individual session that some of these serious actions can be explored in more detail,

and this was done in this case.

Individual Session

The individual therapist was aware of the content of the group and so at thebeginning of the session, in line with our normal practice, he told John what he knew

about what had been discussed.

Therapist: I understand from Dr A that you reported stabbing someone since I last

saw you. It might help if we can talk about that a bit more, although I

understand that you talked quite a bit about it in the group.

J: Yes, well, I told the group that he deserved it. I warned him and he took no notice

so he had it coming to him. Rules are rules.

T: You have mentioned the ‘‘rules’’ to me before. It sounds like you feel he broke the

rules.

J: He did. He knows the rules. He was in my place as well, so he should have been

more careful about it. I don’t know what happened anyway.

T: Tell me a bit more about what it is that you didn’t know.

J: I keep trying not to do these things. If I keep doing them, I won’t be allowed to see

my kids. The f ______ social worker will just see me as dangerous. I am not

dangerous. These things just happen.

T: From my perspective that seems to be what is dangerous—these things just

happen. Can you help a bit to see what it is that does happen? (John then

reiterates some features of the events already discussed in the group.)

T: What is it about all that which you feel is the most significant bit?

J: Don’t know.T: Can you push it a bit?

J: Well, I think it is something to do with worrying about how people will see me. If I

let people call me names and tell me what I am, then I won’t be treated as I

should be.

T: I can see that you felt that not to respond would be seen as weak and it might give

you more trouble in the future as far as you could see. What is that like to feel

weak?

J: I can’t live like that. I have to have people respect me. Otherwise, I don’t know

that I could live there. You don’t know what it is like to live in these places. I

wouldn’t be able to go out and some of my mates would avoid me. I am not atroublemaker, but other people do stuff and then trouble happens.

T: I can see that you try to avoid trouble most of the time, but you find it difficult

at these times when you don’t know what happens. I am still curious about

what changes at these points.





J: I just see them looking at me and that starts it.

T: There’s that look again (referring to earlier discussion of a look). It really does

something to you.

J: They think that they have got one over you (colloquial for winning a personal

competitive interaction) so you have to show them that they have not.T: One over what?

J: (sighs) I don’t know. (silence)

T: What is it like in you when someone seems to be getting one over you?

J: It is not good. My mind goes at that point, and I know I have to do something

about it. It all just happens. ( pretend mode)

T: Yes, it seems that it is at those times that you struggle. What happens to your

mind?

J: It goes blank and that is it.

T: To my way of understanding, you see a look which is a challenge, and it is that

challenge that you have to win. If the other person doesn’t respond in the wayyou want, you start feeling that they might win something and then your mind

goes blank.

J: It is not always like that. Sometimes I can ignore it, but this time it was in my

house and so it was more of me that he was going for. I think that the group

therapists thought that I was a troublemaker and that I shouldn’t have done it.

Do you?

T: I am not sure how your mind moved on to that. Where did the group therapists

suddenly come into it?

J: They seemed to think that I was causing some of it and being the trouble and

shouldn’t have done it. Do you?

T: I don’t think you should have done it, but you have helped me begin to

understand that you felt you had no choice. But I think that the most important

part is seeing if we can help you manage whatever happens when the look

happens without having to attack someone. That leads you into trouble when

you are trying to avoid it. It occurred to me to ask if you had ever felt that I was

giving you the look.

J: Oh, no. You are my doctor. It is here that I am trying to sort it out.

T: Perhaps if it happens though, you can let me know.

J: Hmm. Anyway, I wasn’t sure that I wanted to go back to the group really. The

others were quite helpful, but I thought that the therapists didn’t really

understand.T: Tell me more about that.

J: Being in the group just made me feel that it was my fault that this thing happened.

I don’t want to feel like that. It is wrong anyway. So the best thing is not to go

back to the group.

T: It sounds like you are wondering if I am going to make you go back to the group.

J: You can’t, but do you think I should?

T: Yes, I do. You see, I guess that by staying away ( teleological response to a feeling)

you want to make sure that you don’t have to feel anything more about what

has happened, but if you can work out what is going on it might help another

time so that your mind does not just go blank (encouraging mentalizing).

This clinical dialogue is a transcript from a tape recording made as a part of an

ongoing pilot project into treatment for ASPD and so is highly accurate. It illustrates

a number of points about mentalization-based treatment. First, the therapist is active





about his investigations of the events related to a violent episode. It is not left to the

patient to bring up the topic. We explore violent acts in the same way as we explore

acts of suicide and self-harm in our treatment for BPD.

Second, the therapist clarifies that he is aware that the topic has been discussed in

the group therapy, indicating that the confidentiality is between members of thetreatment team rather than held with any one therapist. This policy is known by the

patients prior to treatment and should not be a surprise to them. Patients with ASPD

seem to have little concern about it, which is in contrast to patients with BPD who

have complained on a number of occasions about the lack of confidentiality in

individual sessions.

Third, the therapist tries to maintain the focus on the action and is not easily

deflected from his task. The patient is helpful in this regard, as he does not really

attempt to move away from the topic. Should he do so, the mentalizing therapist will

try to ‘‘stop and stand’’ and maintain the focus for as long as possible.

Fourth, the therapist tries to move to a consideration of the detail of mental statesand internal feelings of the patient. However, this is hard for the patient who finds it

difficult to identity his feeling states.

Fifth, many of the therapist statements are inquisitive, but always balanced

with some supportive and validating component. In MBT, we commonly try

to see things from the patients’ point of view while asking them to stretch their

minds to other perspectives Gradually, we hope to be able to move to more detailed

work within the treatment session itself. This therapist attempts to do this

towards the end of the vignette by referring again to ‘‘the look,’’ but the patient

moves away quickly. In doing so, he illustrates a nonmentalizing response to the

extent that he gives a specious explanation about why the look could not occur

within the session.

The patient’s rapid move away from any consideration of the therapist to a

discussion about the group therapists exemplifies the difficulty these patients have

with transferential experience, which is in marked contrast to patients with BPD who

rapidly invoke the patient–therapist relationship in discussing their problems.

Patients with ASPD tend to avoid the intensity of the relationship itself and

therapists have to respect this while not avoiding it completely.

Finally, the therapist also states his point of view when asked a direct question by

the patient rather than placing it back to him to explore. Patients who operate in

psychic-equivalent mode find exploring other people minds in fantasy provocative

and thoughts can rapidly become facts, leaving the therapist vulnerable toaccusation. It is better to inform the patient what is on your mind in a way that

encourages further dialogue about the focus of discussion.

Clinical Issues and Summary

Although we have increasing evidence for positive outcomes using MBT with

patients with BPD, we have little information on outcome for those with concurrent

ASPD and BPD. In this pilot project, the overall aim was to reduce violent episodes

by helping patients maintain mentalizing at the point at which is it likely to be lost.

Certainly, a focus on mentalizing engages the patients in treatment who haveattended regularly over a year. Therapists can expect a reduction in violence if the

group and individual therapy facilitate greater flexibility in the patient’s rigid

mentalizing. This cannot be done in the short term and so treatment is for 1 year, but

even that might be overoptimistic and a longer period may be required.





We have always emphasized that the application of MBT for personality disorders

requires not only a focus on techniques that facilitate the development of mentalizing,

but also an avoidance of those that decrease it. In patients with concurrent ASPD and

BPD, therapists have to focus on the more stable aspects of the mind found in ASPD

rather than concern themselves with the rapidly fluctuating states of mind of BPD,which are hidden within the stability of the ASPD. Patients with ASPD do not have

mental pain associated with the others state of mind; thus, to generate conflict in ASPD

by thinking about the victim will typically be ineffective in inducing behavior change.

It would only be of help if that type of conflict was aversive to them.

In the act of violence described in this article, there was no consideration of the

victim’s state of mind, and not a single patient expressed any concern about what

happened to him or what was going on in his mind that made him behave in the way

he did. The inability of the patient with characteristics of ASPD not to experience

psychic pain in this way suggests that they will not respond to aversive interventions,

such as time out, contracts, or punishment, but might begin to respond towithdrawal of positive reinforcement of their self-regard. Most mentalizing

interventions contain within them some aspect that helps patients feel that the

therapist is trying to understand what is happening in their mind rather than

attempting to make them to conform to some predetermined way of living. The

overall aim is to engender a mentalizing process about events that ‘‘just happen’’ and

about inner experiences that are perplexing.

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Documents

Comorbid Antisocial and Borderline Personality Disorders- Mentalization-based Treatment Authors: Anthony Bateman; Peter Fonagy