MBT in Secure Settings

Dr Jon Patrick

Trying to think under fire….

The Importance of Mentalization

• “We will misinterpret people if we

misunderstand their motives, become

distrusting if we assume people are

malevolent, and be unable to love and feel

loved if we cannot find ourselves in

someone else’s mind.”Bateman, Brown and Pedder 2010

What is Mentalizing?

Implicit-Automatic

Explicit-Controlled

Mentalinterior focused

Mentalexterior focused

Cognitiveagent:attitudepropositions

Affectiveself:affect statepropositions

Imitativefrontoparietalmirror neuronesystem

Belief-desireMPFC/ACCinhibitorysystem

Impression driven

Appearance

Certainty of emotion

Treatment Vectors in Re-establishing Mentalizing in Borderline/Antisocial Personality Disorder

Controlled

Inference

Doubt of cognition

Emotional contagion Autonomy

4

Why is Mentalizing important?

1. Self-awareness and a sense of identity.

2. Meaningful and sustaining relationships.

3. Self-regulation and self-direction.

Good Mentalizing

• In relation to others’ thoughts and feelings– Opaqueness– Contemplation and reflection– Absence of paranoia– Perspective-taking– Genuine interest and open to discovery– Forgiveness– Predictability

• Vicky Pollard…..

7

Non mentalizing videos 1

• Basillllllllllll!

8

Non mentalizing videos 2

Non Mentalizing

• Excessive detail gets in the way of considering motivations, feelings or thoughts

• Focus on external social factors – such as the nursing staff, the clinical team, other

patients– self and other in psychotherapy

• Focus on physical or structural labels– eg tired, lazy, clever, self-destructive, depressed,

short-fuse

Non Mentalizing (2)

• Preoccupation with ‘shoulds and should nots’

• Denial of responsibility

• Blaming or fault-finding

• Expressions of certainty about others’ minds– Always, obviously, never

Non-Mentalizing Features

TeleologicalSeeing is

believing

Pseudo- mentalising

Switching off

Psychic Equivalence

Inside equals outside

Still face video

12

What goes wrong…..

So….

Premature

Fostering

Care

Drugs

Mental illness

Potentially

Resilience

Mr X

• Early trauma and neglect• Sexual offence against another minor• Diagnosis of LD (?2ndary to emotional neglect)• Consistent relational problems• Difficulty moving from high to medium security

The Antisocial Mind

• Primitive affects

• Inadequate affect regulation

• Emotions of toddler» envy, shame, boredom, rage and excitement

• Lack of guilt, fear, depression, remorse and sympathy

16

Mentalizing in ASPD

• Antisocial characteristics stabilize non-mentalizing by rigidifying relationships.

• Loss of flexibility makes the person vulnerable to sudden collapse in sense of self when their schematic representation of a relationship is challenged.

• This exposes feelings of shame, vulnerability and humiliation that cannot be controlled by representational and emotional processing…….but only by violence and control of the other person.

17

Joe Pesci’s Teleological Drinks

18

Mentalization and violence

• Violence occurs when there is an inhibition in capacity for mentalization.

• Mentalization protects against violence.

• Violence in ASPD is a defensive response to feelings of shame and humiliation, which have their roots in disorders of attachment.

Aims of MBT

• To promote mentalizing about oneself

• To promote mentalizing about others

• To promote mentalizing in relationships

Why is MBT helpful in forensic?• Characterised by complex relationship difficulties

• “Giving a language” as difficulties include inability to name affect, thus often get confused and emotional

• Mentalizing as a natural process for all!!

• Teaching a skill, not a concept or theory

• Dual focus/components of our MBT programme

1. Psychoeducation (MBT-i)

2. Therapy group

What is MBT?

Therapist stanceThe mentalising

handStop – look

- rewind

Emerging evidence …• Bateman & Fonagy (1999) – RCT of MBT for BPD vs

TAU/control. Sign ↓ hospitalisations, ↓use of medication, ↓suicidal and para-suicidal behaviours

• Follow-up study (Bateman & Fonagy, 2001) –gains maintained over 18/12 after treatment completion and continued to show statistically significant improvement

• Ongoing - multi-site pilot MBT for violence in ASPD. Refine MBT for ASPD →future RCT

• Plus BJPsych 2013

A pickle!

A good result

Conclusion

Hard work but fun!

Important to feel like a team

Liberating – mistakes…great!

Trying to keep each other on-model

Q and A