Anthony W. Bateman - Peter Fonagy - Handbook of Mentalizing in Mental Health Practice-American Psychiatric Publishing (2011)

HANDBOOK OF
Mentalizing
in Mental Health Practice
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HANDBOOK OF
Mentalizing
in Mental Health Practice
Edited by
Anthony W. Bateman, M.A., F.R.C.Psych.

Peter Fonagy, Ph.D., F.B.A.
Washington, DC
London, England
Note: The authors have worked to ensure that all information in this book is accurate at the
time of publication and consistent with general psychiatric and medical standards and that infor-
mation concerning drug dosages, schedules, and routes of administration is accurate at the time
of publication and consistent with standards set by the U.S. Food and Drug Administration and
the general medical community. As medical research and practice continue to advance, however,
therapeutic standards may change. Moreover, specific situations may require a specific therapeu-
tic response not included in this book. For these reasons and because human and mechanical er-
rors sometimes occur, we recommend that readers follow the advice of physicians directly
involved in their care or the care of a member of their family.
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Library of Congress Cataloging-in-Publication Data

Handbook of mentalizing in mental health practice / edited by Anthony W. Bateman, Peter Fonagy.
— 1st ed.
p. ; cm.
Includes bibliographical references.
ISBN 978-1-58562-372-3 (alk. paper)
1. Psychotherapy—Handbooks, manuals, etc. 2. Awareness—Handbooks, manuals, etc.
3. Social perception—Handbooks, manuals, etc. I. Bateman, Anthony. II. Fonagy, Peter, 1952–
[DNLM: 1. Psychotherapy—methods. 2. Awareness. 3. Social Behavior. 4. Social Perception.
WM 420]
RC480.5.H2766 2012
616.89′14—dc23
2011015575
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Contents
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
Disclosure of Interests . . . . . . . . . . . . . . . . . . . . . . .xiii
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . xxiii
Part I
Clinical Practice
1 Introduction and Overview . . . . . . . . . . . . . . . . . . . . .3

Patrick Luyten, Ph.D.
2 Assessment of Mentalization . . . . . . . . . . . . . . . . . .43

Benedicte Lowyck, Ph.D.
Rudi Vermote, M.D., Ph.D.
3 Individual Techniques of the Basic Model . . . . . . . . . 67
4 Group Therapy Techniques. . . . . . . . . . . . . . . . . . . . 81

Sigmund Karterud, M.D., Ph.D.
5 Mentalization-Based Family Therapy. . . . . . . . . . . . 107

Eia Asen, M.D., F.R.C.Psych.
6 Mentalization-Informed Child Psychoanalytic

Psychotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
Jolien Zevalkink, Ph.D.
Annelies Verheugt-Pleiter, M.Psych.
7 Brief Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . 159

Jon G. Allen, Ph.D.
Flynn O’Malley, Ph.D.
Catherine Freeman, M.A.
8 Partial Hospitalization Settings . . . . . . . . . . . . . . . 197

Dawn Bales, M.Sc.
9 Outpatient Settings . . . . . . . . . . . . . . . . . . . . . . . . 227

Morten Kjolbe, M.D.
10 Psychodynamically Oriented
Therapeutic Settings . . . . . . . . . . . . . . . . . . . . . . . 247
Bart Vandeneede, M.A.
Part II
Specific Applications
11 Borderline Personality Disorder . . . . . . . . . . . . . . . .273

12 Antisocial Personality Disorder . . . . . . . . . . . . . . . .289

13 At-Risk Mothers of Infants and Toddlers . . . . . . . . .309

Nancy Suchman, Ph.D.
Marjukka Pajulo, M.D., Ph.D.
Mirjam Kalland, Ph.D.
Cindy DeCoste, M.S.
Linda Mayes, M.D.
14 Eating Disorders . . . . . . . . . . . . . . . . . . . . . . . . . .347

Finn Skårderud, Prof. Dr. Med.
15 Depression . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .385
Alessandra Lemma, B.Sc., M.A., M.Phil. (Cantab.), D.Clin.Psych.
Mary Target, Ph.D.
16 Trauma. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .419
Jon G. Allen, Ph.D.
17 Drug Addiction . . . . . . . . . . . . . . . . . . . . . . . . . . .445

Björn Philips, Ph.D.
Ulla Kahn
18 Adolescent Breakdown and Emerging Borderline
Personality Disorder . . . . . . . . . . . . . . . . . . . . . . . 463
Efrain Bleiberg, M.D.
Trudie Rossouw, M.B.Ch.B., F.F.Psych.
Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 511
References. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 519
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 571
Contributors
Jon G. Allen, Ph.D.
Helen Malsin Palley Chair in Mental Health Research and Professor of Psychiatry,
Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of
Medicine; Senior Staff Psychologist, The Menninger Clinic, Houston, Texas

Visiting Professor, Psychoanalysis Unit, University College London; Consultant
Psychiatrist, Marlborough Family Service, London, United Kingdom
Dawn Bales, M.Sc.

Clinical Psychologist/Psychotherapist and Manager, MBT Unit and Expertise
Center, De Viersprong Center of Psychotherapy, and Viersprong Institute for
Studies on Personality Disorders, Halsteren, the Netherlands

Consultant Psychiatrist in Psychotherapy, Halliwick Unit, St. Ann’s Hospital,
Barnet, Enfield, and Haringey Mental Health Trust; Visiting Professor, Univer-
sity College London; Visiting Consultant, The Menninger Clinic and Menninger
Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine,
Houston, Texas

Professor and Vice Chair, Menninger Department of Psychiatry and Behavioral
Sciences, and Director, Child and Adolescent Psychiatry, Baylor College of Med-
icine, Houston, Texas
Cindy DeCoste, M.S.

Research Associate, Department of Psychiatry, Yale University School of Medi-
cine, New Haven, Connecticut; The Mothers and Toddlers Program, New Ha-
ven, Connecticut

Freud Memorial Professor of Psychoanalysis and Head of Department, Research
Department of Clinical Educational and Health Psychology, University College
London; Chief Executive, Anna Freud Centre, London, United Kingdom; Train-
ing Analyst and Fellow, British Psychoanalytic Society
ix
x Handbook of Mentalizing in Mental Health Practice

Psychoanalytic psychotherapist in private practice and clinical consultant on per-
sonality disorders, London, United Kingdom
Ulla Kahn
Consultant Psychiatrist, Licensed Psychotherapist, Center for Dependency Disor-
ders, Stockholm County Council, Sweden

Adjunct Professor of Social Work and Family Research, Faculty of Social Sci-
ences, University of Helsinki; Adjunct Professor of Music Education, Sibelius
Academy; Senior Researcher, Folkhälsan Research Center, Helsinki, Finland

Professor, Faculty of Medicine, University of Oslo, and Medical Director, Depart-
ment for Personality Psychiatry, Oslo University Hospital, Oslo, Norway
Morten Kjolbe, M.D.

Chief Consultant Psychotherapist, Clinic for Personality Disorders, Aarhus Uni-
versity Hospital, Risskov, Jutland; Associated Professor, Department of Commu-
nication and Psychology, Aalborg University, Jutland, Denmark

Director, Psychological Therapies Development Unit, Tavistock and Portman
NHS Trust, London; Visiting Professor, Psychoanalysis Unit, University College
London; Visiting Professor of Psychological Therapies, School of Health and Hu-
man Sciences, Essex University, Essex, United Kingdom

Psychotherapist and Researcher, University Psychiatric Hospital Kortenberg,
University of Leuven, Leuven, Belgium

Associate Professor, Department of Psychology, University of Leuven, Leuven,
Belgium; Senior Lecturer, Research Department of Clinical, Educational, and
Health Psychology, University College London, London, United Kingdom
Linda Mayes, M.D.

Arnold Gesell Professor of Child Psychiatry, Pediatrics, and Psychology, Yale
Child Study Center, Yale University School of Medicine, New Haven, Connect-
icut; Chair, Directorial Team, Anna Freud Centre, London, United Kingdom

Associate Professor, Menninger Department of Psychiatry and Behavioral Sci-
ences, Baylor College of Medicine; Program Director, Compass Program for
Young Adults, The Menninger Clinic, Houston, Texas
Contributors xi

Child Psychiatrist and Senior Researcher, Department of Child Psychiatry, Uni-
versity of Turku, Turku, Finland; Senior Researcher, Folkhälsan Research Center,
Samfundet Folkhälsan, Helsinki, Finland

Psychotherapy Coordinator, Center for Dependency Disorders, Stockholm City
Council, Stockholm, Sweden; Postdoctoral Fellow, Department of Clinical Neu-
roscience, Karolinska Institutet, Stockholm, Sweden; Lecturer, Department of
Behavioral Sciences, Linköping University, Linköping, Sweden

Consultant Child and Adolescent Psychiatrist, North East London Foundation,
London, United Kingdom

Professor, Research Center for Child and Youth Competence Development, Lille-
hammer University, Lillehammer, Norway; Senior Psychiatrist, Regional Services
for Eating, Oslo, Norway

Associate Professor, Department of Psychiatry and Yale Child Study Center, Yale
University School of Medicine, New Haven, Connecticut
Mary Target, Ph.D.

Professor of Psychoanalysis, University College London; Professional Director,
The Anna Freud Centre, London, United Kingdom

Psychotherapist and Researcher, University Psychiatric Centre, University of
Leuven, Belgium

Psychotherapist and Psychoanalyst, Child Psychotherapy & Analysis and Adults
sections, Dutch Psychoanalytic Institute, Amsterdam, the Netherlands

Associate Professor, Departments of Medicine and Psychology; Head, Treatment
Unit on Psychoanalytic Lines for Personality Disorders, University Psychiatric
Centre, Campus Kortenberg; Head, Postgraduate Psychoanalytic Psychotherapy
Training, University of Leuven, Leuven, Belgium

Department Head, Research and Quality Assurance, Netherlands Psychoanalytic
Institute, Amsterdam, the Netherlands; Lecturer, Developmental Psychology,
Radboud University, Nijmegen, the Netherlands
Disclosure of Interests
The following contributor reported receiving research support from the sources listed below:
Linda C. Mayes, M.D.—Current and ongoing research support from the U.S. Department of Health
and Human Services under the following grants: National Institute on Alcohol Abuse and Al-
coholism, R21 AA017685; National Institute of Child Health and Human Development,
R01 HD044796 (Principal Investigator [PI]), R01 HD057947; National Institute on Drug
Abuse, P01 DA022446, P50 DA016556, R01 DA026437, R21 DA027737 (PI), R21
DA029445, RL1 DA024856.
The following contributors reported having no competing financial interests in relation to work
published in this volume:
Jon G. Allen, Ph.D.
Dawn Bales, M.Sc.
Cindy DeCoste, M.S.
Ulla Kahn
Alessandra Lemma, B.Sc., M.A., M. Phil., D.Clin.Psych.
Trudie Roussow, M.B.Ch.B., F.F.Psych.
Mary Target, Ph.D.
xiii
Preface
This book is about mentalizing, a concept that has captured the interest and imagi-
nation of an astonishing range of people from psychoanalysts to neuroscientists, from
child development researchers to geneticists, from existential philosophers to phe-
nomenologists. The concept’s ability to be useful to proponents of apparently disparate
areas of knowledge partly explains the term’s somewhat surprising popularity and
widespread use. More significant, however, is the fact that mentalizing lies at the very
core of our humanity—it refers to our ability to attend to mental states in ourselves and
in others as we attempt to understand our own actions and those of others on the basis
of intentional mental states. Without mentalizing, there can be no robust sense of self,
no constructive social interaction, no mutuality in relationships, and no sense of per-
sonal security. Throughout this book, we and our coauthors attempt to refine this def-
inition further and to chart the daunting territory that the concept of mentalizing now
embraces.
This book follows two earlier attempts to establish mentalizing as a developmental
and clinical concept. Affect Regulation, Mentalization, and the Development of the Self
(Fonagy et al. 2002a) summarized the relationship between attachment and mentaliz-
ing, suggesting that the process of mentalizing should be given central importance in
child development. A link between abnormal development of social cognition during
childhood and adult psychopathology was postulated as being mediated through men-
talizing; this has been confirmed in the last 5 years. At the same time, the book de-
scribed how a focus on mentalizing process could enhance clinical practice. A second
book, Psychotherapy for Borderline Personality Disorder: Mentalization-Based Treatment
(Bateman and Fonagy 2004), finally established mentalizing as a core psychological
process worthy of focus when treating major psychiatric disorders and mentalization-
based treatment (MBT) as a psychotherapeutic orientation sitting somewhere between
psychodynamic and cognitive therapy.
Unlike other integrative approaches such as interpersonal psychotherapy, MBT
has a theoretical frame of reference that includes a developmental model, a theory of
psychopathology, and a hypothesis about the mechanism of therapeutic action. The
xv
xv i Handbook of Mentalizing in Mental Health Practice
process of identifying specific therapeutic techniques that could be used to foster the
capacity to mentalize was slower, but these techniques were eventually summarized in
relation to the treatment of borderline personality disorder (BPD) in Mentalization
Based Treatment for Borderline Personality Disorder: A Practical Guide (Bateman and Fon-
agy 2006a). Although this book outlined a specific manual for treatment, we suggested
that mentalization-based treatment for BPD was novel only in the way that the com-
ponents were woven together and in the rather dogged manner in which the therapist
attempts to enhance mentalizing. The latter remains the single most important factor
distinguishing mentalizing therapies from other psychotherapies.
The aim of a mentalizing therapy has to be to enhance a mentalizing process, ir-
respective of the context in which it is being delivered. The mentalizing therapist is not
engaged in cognitive restructuring, is not working to provide insight, and does not at-
tempt to alter behavior directly. The focus is on mental processes. It is inaccurate to
state that cognitive and behavioral changes do not happen in MBT or that patients in a
mentalizing therapy do not recognize underlying meanings or identify reasons that
they are as they are. The evidence indicates that these things do occur, but the changes
occur almost as an epiphenomenon. They are consequences of the change in mental-
izing, rather like positive side effects, and also of the concept itself being broad, almost
an umbrella term for a group of basic psychological processes.
Initially, the breadth of the concept encouraged us to see mentalizing as one of many
common factors in psychotherapy. All psychotherapies, whatever their focus, share the po-
tential to re-create an interactional matrix of attachment in which mentalization develops
and sometimes flourishes. Positive changes in mentalizing, stimulated as a by-product of
interventions, act as a catalyst for further change in cognitions, emotions, and behavior, ir-
respective of the therapeutic target; mentalizing begets mentalizing and healthier psycho-
logical functioning. This is not to claim that mentalizing is the mechanism of change in a
wide range of therapies, although this may be the case, but to suggest that a perspective of
having a patient’s mind in mind will make any therapeutic effort more efficient. This is not
a radical suggestion—a patient who feels that his or her subjective states of mind are un-
derstood is more likely to be receptive to therapeutic intervention.
The catalyst model of mentalizing, however, may sell MBT somewhat short for sev-
eral reasons. First, evidence indicates that individuals who have specific deficits in men-
talizing in the context of attachment relationships may be those who are currently
defined as having a personality disorder. This was our original suggestion about BPD,
and it now looks as though the fifth edition of the DSM classification of mental disorders
may use problems in reflective capacity and sense of self as a potential common factor
across all personality disorders. In the proposed DSM definition, personality disorder is
defined as a failure to develop a sense of self-identity and capacity for interpersonal func-
tioning, suggested, for example, by having poorly integrated representations of others,
which is a key facet of mentalizing. Thus, a disordered sense of self and dysfunctional in-
terpersonal relationships, driven by problems in mentalizing, may be powerful criteria
for personality disorder itself and well beyond the restricted domain of BPD.
Preface xvii
Second, mentalizing is a developmental construct. This raises questions about the

variability not simply of mother-child interaction but also of families and the signifi-
cance of developmental milestones, particularly the importance of the move from
childhood to adolescence. Distortions in the development of mentalizing are therefore
likely to go beyond personality disorder, and there may be other individuals who can
benefit from having their mentalizing problems addressed directly. The idea that prob-
lems in mentalizing are a source of developmental crisis has epidemiological conse-
quences (see Chapter 18) and may account for the increasing incidence of several
disorders such as eating disorders, conduct disorder and antisocial personality disorder,
and depression. This opens up the possibility of preventive work during childhood,
which is discussed by Zevalkink et al. in Chapter 6.
Third, mentalizing is a fundamental psychological process and so interfaces with
all major mental disorders. It is therefore no more surprising that mentalizing treat-
ments may have the potential to improve well-being across a range of disorders than
that the use of reinforcement or other general psychological principles has generic ap-
plicability. Whatever the source of pathology, whether mentalizing is central or not,
disordered mental processes will affect or be affected by the capacity to think and to
represent states of mind. For example, depression, discussed by Luyten and colleagues
in Chapter 15, is not a disorder of mentalizing; however, once an individual is de-
pressed, his or her ability to mentalize will be lost, and this will affect the course of de-
pression because of the impact this has on the individual’s sense of self and relationships
with others; in addition, the mental capacity necessary to allow escape from depression
is removed. Trauma, discussed by Allen et al. in Chapter 16, is another example. We are
not suggesting that trauma represents a partial failure of mentalizing, but because
trauma has such a pervasive impact on a range of psychological processes, it inevitably
interfaces with mentalizing, and that interface is a critical area that needs to be ad-
dressed whatever the treatment techniques and method.
On the one hand, our claims for mentalizing continue to be modest, but on the
other hand, we make rather more expansive claims for its importance as a unifying
mental process that interfaces with a wide range of psychological functions. We suggest
that regardless of whether a formal mentalizing approach is adopted in treatment, there
is a need for any practitioner to see the world from the patient’s perspective, and that
whenever that focus on the patient’s internal mental process is dominant, there is in-
trinsic value in this powerful commitment to the patient’s subjectivity. This consistent
focus on the subjective reality of the patient is shared in all the chapters of this book.
The book itself is divided into two parts. In both parts of the book, the clinical fo-
cus leads the authors to constantly explore the treatment implications of taking a men-
talizing perspective. Generally, the evidence does not suggest MBT as a preferred
approach for disorders but rather that working to enhance the patient’s mentalizing ca-
pacity can make other approaches more effective.
The first part of the book is a comprehensive review of ways in which a mentalizing
perspective affects the treatment of patients in different psychotherapy contexts. The
xv ii i Handbook of Mentalizing in Mental Health Practice
focus is partly on technique when it is delivered in a particular psychotherapy frame-

work or modality, such as individual, group, and family work, and partly on how men-
talization can be used in various settings, such as outpatient, partial hospital, and
inpatient facilities. Before instigating treatment in any of these contexts or settings, the
therapist must have a good understanding of an individual’s mentalizing capacity and be
able to assess it in a systematic and reliable manner. Only then can mentalization be-
come a central focus of treatment for both patient and therapist.
We therefore begin the book by introducing the concept itself and providing a de-
tailed discussion of its multiple facets or dimensions in Chapter 1. Taking this perspec-
tive on mentalizing has implications for assessment, which Luyten et al. discuss in
Chapter 2. The authors suggest that assessing mentalizing means identifying a “men-
talizing profile” across a range of facets, all of which are affected differentially in a va-
riety of contexts. Thus, the assessment of mentalizing is not a process of defining a
singular attribute of an individual but more a detailed process of defining a matrix in
which different facets of mentalizing are influenced to a greater or lesser extent by a va-
riety of circumstances, including interpersonal, social, and emotional interactions and
more specific contexts.
In Chapters 3–9, the authors describe how a mentalizing focus can be implemented
in common psychotherapy modalities. The approach is best developed and documented
in relation to individual psychotherapy (Bateman and Fonagy, Chapter 3) and so we have
used this chapter to clarify areas of individual MBT that have caused some confusion
rather than repeating material covered elsewhere. Although individual therapy is often
both patients’ and therapists’ preferred context for therapy, it has its drawbacks. First, the
extent to which a patient can benefit from the representation of his or her mind offered
by a single therapist is limited, however sensitive and well attuned that therapist might
be. Second, for some patients, exclusive focus on themselves in individual therapy be-
comes too stressful and undermines their capacity to mentalize. By contrast, group ther-
apy, discussed by Karterud and Bateman in Chapter 4, strengthens a person’s competence
in mentalizing by harnessing the impact of the representation of an individual’s mind by
a number of people. This is not only because more people are reflecting on the patient’s
subjective experience but also because the patient has an opportunity to reflect on the ex-
perience of many others, most importantly in the context of trying to understand how
one mind affects another mind in a relationship that does not directly involve him or her
and is between other members of the group. The group replicates the historical and de-
velopmental context within which mentalizing is normally acquired. Going back to pre-
historic times, a group of 50 or more people were collectively concerned about the state
of mind of a child, but this evolutionary task has been passed on to the family in Western
society. Families struggle to keep one another’s mind in mind consistently. Not feeling
understood, subjectively not being appreciated, is a highly aversive state, so families who
find it difficult to adopt a mentalizing stance toward one another, particularly parents to-
ward their children, will experience psychosocial stress creating psychological distur-
bance. This in itself becomes a threat to mentalizing in the family and a cause of further
Preface xix
stress. This cycle of nonmentalizing makes the family an ideal framework for interven-
tion in a range of disorders presented by children and caregivers, and this is discussed by
Asen and Fonagy in Chapter 5. But clinical experience has shown that some children and
some families are not accessible to this approach, and the children therefore need to be
seen individually, with or without input to the parents. In Chapter 6, Zevalkink et al. de-
scribe the application of a mentalizing therapeutic frame and therapeutic approach to
children with relatively severe problems.
The authors then move on to discuss different contexts in which mentalizing ther-
apeutic approaches are being applied. Long-term treatments are not a practical alter-
native for many people who need input from psychosocial treatments. We have evolved
a brief version of mentalizing therapy, particularly suitable for groups and originally
initiated as part of short-term inpatient treatment programs, which can serve to pre-
pare the patient for longer-term treatment and can be used as a mechanism for self-
selection for the model and clinical selection for other treatment programs. In
Chapter 7, Allen et al. describe how this brief treatment is done. By contrast, some in-
dividuals with severe disorders require treatments that support and protect them over
significant periods of months. In Chapter 8, Bales and Bateman present a model for us-
ing mentalizing in the context of a partial hospital program and the setting of the initial
randomized trial of MBT. Vermote et al., in Chapter 10, present a model for using
mentalizing in the context of an inpatient setting. In both of these contexts, more than
in an outpatient setting (discussed by Kjolbe and Bateman in Chapter 9), the clinician
needs to be acutely aware that the closed, intense interactive environments and persis-
tent focus on the therapeutic milieu could potentially cause harm to patients, especially
borderline patients, as well as provide possible substantial benefits. We suggest that a
focus on mentalizing can reduce the risk of negative outcomes in these therapeutic set-
tings.
The second part of the book takes the perspective of the patient. We use diagnostic
categories as a starting point to discuss more specific mentalizing problems for each
group and identify effective techniques regardless of the context in which treatment
takes place. In Chapter 11, Bateman and Fonagy advance the treatment of BPD, clar-
ifying areas of technique that were less developed in the original treatment manual and
providing further ideas about the role of the therapist in treatment. Less well supported
by clinical evidence and more experimental is the adaptation of MBT to antisocial per-
sonality disorder. In Chapter 12, Bateman and Fonagy describe an innovative mental-
izing-based approach to adults with severe, long-standing antisocial problems. The
intervention is based on the assumption that mentalizing problems leave the individual
unable to recognize the emotional impact of his or her actions; this, combined with a
genetic and an environmental vulnerability, releases aggression. We describe a pro-
gram that aims to enhance mentalizing in the context of group therapy, which appears
clinically to be potentially successful. The establishment of relationships among the
members of the group combined with low-intensity individual treatment serves to re-
duce violent criminality.
xx Handbook of Mentalizing in Mental Health Practice
Our understanding of the development of antisocial personality disorder takes us

back to early childhood. Longitudinal studies provide good evidence linking a disor-
ganized, hostile, abusive early environment with later aggression. This justifies, if such
justification were needed, intervening with mothers, who are often the primary (sole)
caregivers in high-risk families, to support them in developing a mind-minded bond
with their infant and young child. In Chapter 13, Suchman and colleagues describe a
remarkable early intervention package for people facing a level of social adversity that
makes mindful caregiving almost impossible. This preventive work points to exciting
avenues for the future development of mentalizing as a powerful clinical tool.
In Chapter 14, Skårderud and Fonagy explore aspects of eating disorders in the
context of multiple failures of mentalizing. The treatment of eating disorders remains
a challenge, with current therapies such as cognitive-behavioral therapy and interper-
sonal therapy achieving only moderate effects. The authors suggest that an exaggerated
focus on the body may be a by-product of a vulnerable sense of self, which is enfeebled
by limited capacity for mentalizing. Addressing this limitation may be helpful for this
extremely challenging group of patients and may bring additional benefits to other
therapies. MBT for eating disorders is currently the focus of a randomized controlled
trial. A characteristic of this and other clinical groups is how mentalizing difficulties
may create an exaggerated focus on the body as a vehicle for unexpressed and unexpe-
rienced states of mind and how this exclusive focus undermines a consistent experience
of self. In Chapter 15, Luyten and colleagues adopt a similar approach to understand-
ing the difficulties of individuals with depression, viewing their cognitive distortions,
often consequent to adverse life experience, as acquiring overwhelming potency be-
cause of mentalizing failure. In both depression and eating disorders, we suggest that a
failure of mentalizing is not so much a trigger for the condition but is more likely to be
a process that plays a significant role in the maintenance of the problems and their well-
known resistance to therapeutic approaches. When mentalizing is enfeebled, the effect
of any therapeutic techniques inevitably will be muted. In Chapter 16, on trauma, Allen
et al. show a further example of this dynamic. The issue here is less one of devising new
forms of treatment than of understanding how excellent treatment can be made more
effective. Trauma is conceived, both by us and by other experts, as a social experience
that directly affects the mental capacities that normally would be available to process
that experience. The distortion of subjectivity associated with trauma causes the stress-
ful traumatic experiences to be experienced not as memories and associated thoughts
and feelings but as physical reality. Understanding of this disruptive effect of the loss of
mentalizing may aid treatment in patients presenting with the chronic effects of
trauma. In Chapter 17, Philips et al. deal with substance abuse or dependency, a further
example of a disorder that causes disruption of social cognition leading to substantial
interference with the capacity to establish therapeutic relationships. In this chapter, the
authors discuss the underlying biology of substance abuse, which brings us back to at-
tachment because of the shared neurobiology of attachment and processes of addiction.
This connection is not well understood, but the link brings addiction into the mental-
Preface xxi
izing domain via the relation between mentalizing and attachment. In Chapter 18,
Bleiberg et al. integrate all the previous chapters on particular disorders and focus on
adolescence, the phase of development when personality disorder, depression, eating
disorders, substance abuse, and other disorders first present. The authors outline a
range of approaches that are specific to adolescents and might help reduce subsequent
morbidity. The chapter underscores the importance of recognizing adolescence, a
phase underpinned by rapid biological brain developments such as myelination and
synaptic pruning, as a critical period when robust development of mentalizing can be
established or undermined. It highlights both the vulnerability that late development in
mentalizing capacity can create and the value of a focus on prevention.
We hope that this book reflects the current state of knowledge about mentalizing
and is a fair summary of its current use clinically. Certainly, we do not claim to offer the
last word. We leave that to others, taking some pleasure that we, along with our many
colleagues, have stimulated debate about and constructive scrutiny of the contempo-
rary understanding of the mind.

Acknowledgments
For their help in our endeavors, we would especially like to thank all our colleagues
who have contributed to this volume. In addition, the book would not have been
possible without the ideas of a wide range of people, including Efrain Bleiberg, Lois
Choi-Kain, Pasco Fearon, George Gergely, John Gunderson, Jeremy Holmes, Robin
Kissell, Patrick Luyten, Linda Mayes, Carla Sharp, Mary Target, and the staff of the
Halliwick Unit at St. Ann’s Hospital in London. We especially thank Jon Allen for his
permission to adapt the glossary from our book Mentalizing in Clinical Practice (Allen
et al. 2008), of which he was the primary author. Finally, we would like to thank Liz
Allison for her sensitive redrafting of many of the chapters, Rose Palmer for her edi-
torial assistance, and in particular her extremely thorough work on the bibliography,
and Alexandra Bateman for her careful scrutiny of the whole manuscript and her edi-
torial suggestions. Without them and the other staff of the Psychoanalysis Unit at Uni-
versity College London and the considerable patience of American Psychiatric
Publishing, this book would never have come about.
xxiii
Part I
Clinical Practice
CHAPTER 1
Introduction and
Overview
M entalizing is a term that has been introduced simultaneously into neuroscience

and clinical thinking to denote the remarkable and pervasive human tendency to look
beyond the visible shell of the body in understanding behavior and seeking descrip-
tions and explanations in terms of states of mind. In Mentalizing in Clinical Practice
(Allen et al. 2008), we boldly invited clinicians to consider mentalizing as a foundation
of psychotherapeutic treatments, arguing that this apparent audacity was justified be-
cause mentalizing addresses the fundamental human capacity to apprehend our own
and others’ minds as minds. Dysfunctional mentalizing leading to disorders of self-
experience occurs in all severe conditions that lead to referral for psychological ther-
apy. Psychotherapists across modalities necessarily use this capacity to mentalize, re-
gardless of whether they conceptualize it explicitly in their theories about what they
do, and good outcomes may be conceptualized in terms of improvements in mentaliz-
ing ability. Beyond this generic reach, a range of psychological techniques can be used
specifically to enhance mentalizing, and clinicians from a range of orientations now ap-
ply these mentalization-focused approaches in everyday clinical practice, especially in
3
4 Handbook of Mentalizing in Mental Health Practice
Europe and the United States. Psychotherapy informed by the mentalizing perspective
is now practiced in many different contexts and is used to treat a wide range of psycho-
logical conditions. In this book, we aim to provide a guide to this wide range of appli-
cations of mentalizing theory and technique in current mental health practice.
Mentalizing is a form of social cognition. It is the imaginative mental activity that
enables us to perceive and interpret human behavior in terms of intentional mental
states (e.g., needs, desires, feelings, beliefs, goals, purposes, and reasons) (Allen et al.
2008; Bateman and Fonagy 2006a; Fonagy and Target 2005). A rudimentary version of
a mentalization-focused clinical approach was advanced more than 20 years ago (Fon-
agy 1989), and we have attempted to refine and test a mentalization-based approach to
the treatment of psychological disorders in the light of empirical observations by others
as well as our own work.
In previous works (Bateman and Fonagy 2004; Fonagy et al. 2002a), we have con-
sistently argued the following:
1. Understanding the behavior of others in terms of their likely thoughts, feelings,

wishes, and desires is not entirely a constitutional given but to some degree a de-
velopmental achievement.
2. The acquisition of this capacity depends on the quality of attachment relation-
ships—particularly, but not exclusively, early attachments, as these reflect the ex-
tent to which our subjective experience was adequately mirrored by a trusted other.
3. The quality of affect mirroring affects the development of affect regulative pro-
cesses and self-control (including attention mechanisms and effortful control) and
the capacity for mentalization.
4. Disruptions of early attachment and later trauma have the potential to disrupt the
capacity for mentalizing and, linked to this, the development of a coherent self-
structure.
5. The capacity to mentalize has both “trait” and “state” aspects that vary in quality in
relation to emotional arousal and interpersonal context.
6. Mentalizing and the associated capacities for affect representation, affect regula-
tion, and attentional control normally obscure forms of subjectivity that develop-
mentally antedate mentalization.
7. The failure of mentalizing, in combination with profound disorganization of self-
structure, may provide a comprehensive account for core features of borderline
personality functioning. In particular, we have argued in the past that borderline
personality functioning can be understood as the consequence of the following:
a. The loss of mentalizing in emotionally intense relationship contexts
b. The reemergence at these times of modes of thinking about subjective experi-
ences that antedate full mentalization
c. The constant pressure for externalization of internal states (projective identi-
fication), which we consider the reexternalization of disorganized, intolerably
painful self-states (the self-destructive alien self)
Introduction and Overview 5
In several publications, we have reviewed evidence in support of these contentions

(Bateman and Fonagy 2004; Fonagy and Bateman 2006a, 2007, 2008; Fonagy and Tar-
get 2006; Luyten et al., submitted 2011c). In essence, we have argued that impairments
in social cognition, and particularly a compromised capacity to understand oneself and
others in terms of mental states, play an important role in the development of various
psychiatric disorders that involve pathology of the self (Sharp et al. 2008)—most specif-
ically, borderline personality disorder (BPD; Bateman and Fonagy 2004), antisocial per-
sonality disorder (Bateman and Fonagy 2008a), and eating disorders (Skårderud 2007b,
2007c). Therapeutic interventions that focus on the patient’s capacity to mentalize in the
context of attachment relationships can be helpful in improving both behavioral and af-
fective aspects of their conditions. Over the last decades, several prevention and treat-
ment programs for a variety of disorders and problem behaviors have been developed
(Bateman and Fonagy 2004; Fearon et al. 2006; Skårderud 2007a; Twemlow et al. 2001),
and some have been evaluated in randomized controlled trials (Bateman and Fonagy
2007, 2008b; Fonagy et al. 2009). Several other controlled trials are currently under way
(Bateman and Fonagy 2007; Fearon et al. 2006; Sadler et al. 2006).
In this introductory chapter, we present an expanded version of the mentalization
framework for understanding psychological disorders based on recently accumulated
data. We begin by summarizing our theory of the development of social cognition. We
reexamine the mentalization construct in the light of current neuroimaging findings
and suggest a four-component model that might help us to specify the relation between
mentalizing and linked concepts more clearly and offer a framework for its assessment
(Luyten et al., submitted 2011c). We argue that different neurocognitive systems are
involved in different components or aspects of mentalizing, and thus impaired mental-
izing capacity will have different characteristics depending on the particular neuro-
cognitive circuits affected. We discuss the complex relation of attachment and mental-
ization and outline a biobehavioral switch model that links temporary loss of
mentalization with stress, affect regulation, and attachment on the basis of recent psy-
chosocial and neurobiological research. Finally, we discuss the principles of treatment
that the model implies.
Need for a Transactional Model

of Development
In considering the role of dysfunctions of mentalization in all severe conditions that lead to
referral for psychological therapy, we try to take a dynamic developmental view (e.g., Crick
et al. 2005; Hughes and Ensor 2008b). This view entails the following assumptions:
1. That symptoms of the disorder will manifest differently at different developmental

periods (heterotypic continuity)
2. That a specific influence may be critical at a certain stage of development but mat-
ter less at others
3. That the effect of a specific deficit will relate to the child’s stage of development
4. That a complex function such as mentalization will have multiple components (de-
velopmental precursors, alternative mediating mechanisms, and strategies for
compensating for a deficit)
5. That contextual determinants will moderate the relation of risk factors and patho-
genic outcomes so that atypical development can be identified only by considering
the difficulties in negotiating developmentally appropriate, normative tasks
6. That the dynamic model must explain not only the emergence of disease but also
the process of spontaneous recovery that may sometimes occur
From our standpoint, the ideal developmental model describes the emergence of
both the capacity to mentalize and the failures of this function characteristic of various
psychological disorders. Such a developmental model will always be a transactional
one, even if data are rarely available that speak to models of that degree of complexity.
Individual difference models that are based on genetic and biological parameters, en-
vironmental models that focus on stressful or traumatic experience, and interaction
models (e.g., diathesis-stress model) that identify individual vulnerabilities to particular
types of environmental challenges are all inadequate to the task. Transactional models
have the potential for change built into them because they consider the effect that in-
dividuals have on their environment, which can change the characteristics of both the
person and the environment in ways that could alter the nature of future interactions
between the two (Cicchetti and Rogosch 2002; Steinberg and Avenevoli 2000). Of
course, transactional models have well-known difficulties with linear causality. The
analogy of two hands clapping has been suggested as a metaphor to illustrate the pa-
thology of interaction between person and environment, in which the lack of sound
may indicate no clapping, but it is not easy to surmise which hand is not cooperating
(Baird et al. 2005).
The transactional nature of development is probably key to understanding the
emergence of most complex mental health problems. BPD offers a particularly strong
example. For instance, disorganization of the attachment system may cause a child to
be increasingly manipulative and controlling of his or her environment, but these con-
trolling actions may undermine the caregiver’s capacity to provide his or her young
child with a normative playful environment that has the potential to facilitate the de-
velopment of social cognition.
Development of Social Cognition

We have elaborated elsewhere a detailed developmental model specific to BPD (Bate-
man and Fonagy 2004; Fonagy et al. 2002a, 2003). Our account focused on the devel-
opment of the social affiliative system, which we consider to drive many higher-order
social cognitive functions that underpin interpersonal interaction, specifically in an at-
tachment context. Four of these functions are of primary importance in understanding
not only BPD but also many other severe psychological disorders:
1. Affect representation and the related affect regulation

2. Attentional control, which also has strong links to the regulation of affect
3. The dual arousal system involved in maintaining an appropriate balance between
mental functions undertaken by the anterior and posterior portions of the brain
4. Mentalization, a system for interpersonal understanding that is particularly rele-
vant within the attachment context
Because these capacities evolve in the context of the primary caregiving relationships
experienced by the child, in addition to the child’s constitutional vulnerabilities, they
are vulnerable to extremes of environmental deficiency as exemplified by severe ne-
glect, psychological or physical abuse, childhood molestation, or other forms of mal-
treatment.
Severe psychological disorders can all be conceptualized as representing different
types of failures in the mind’s capacity to represent its own activities and contents. Man-
ifestations of such failures might include disorders of thinking (including ruminations,
cognitive distortions, delusions, and the classic thought disorder that is detectable in
speech); disorders of memory (such as posttraumatic stress disorder, in which traumatic
memories persist in clear consciousness); disorders of consistency and integrity of self
(as commonly described in BPD); disorders of self-concept and self-image (which are
most notably found in eating disorders but also may be a result of sexual abuse); and dis-
orders of self-recognition (which are found in extreme forms in disorders such as
Capgras’ syndrome but may be one generator of self-harming behaviors). Disorders of
a social or relational self may be localized to one form of relationship (usually intimate
dyads) or may be more global (as is seen in antisocial personality disorders). All these in-
stances have in common a state of confusion on the part of a mental agent over the
meaning, significance, or value of its own activities. If, as we contend, unstable or psy-
chogenically/defensively reduced mentalizing capacity is a core feature of many psycho-
logical disorders, any successful treatment will have mentalization as one of its foci or, at
the very least, will stimulate development of mentalizing as an epiphenomenon arising
from other therapeutic initiatives. We briefly review the key aspects of this model.
Affect Regulation
To achieve normal self-experience, the infant requires his or her emotional signals to be
accurately or contingently mirrored by an attachment figure (Gergely and Watson
1996). In mirroring the infant, the caregiver must achieve more than contingency (in
time, space, and emotional tone). The mirroring must be “marked” (i.e., exaggerated or
slightly distorted) if the infant is to understand this display as part of his or her own
emotional experience rather than an expression of the caregiver’s (Fonagy et al. 2002a;
Gergely 2004). This will enable infants to internalize the representation of the reflec-
tion of their experience and thus generate a representational system for internal states
(a kind of social biofeedback system) (Gergely and Watson 1996). We speculated that
the absence of marked contingent mirroring experience in infancy creates a vulnera-
bility to affect dysregulation, probably through less robust second-order representa-
tions of internal states of emotional arousal, which both limit the capacity for control
and create the possibility of generating unpredictable qualities and intensities of emo-
tional experience. Developing a second-order representation implies an ability to give
definition and meaning to internal states and to impute to another individual inten-
tions, beliefs, and emotions that may be different from one’s own. It is this capacity that
may be compromised.
Although this model emphasizes the caregiver’s role in achieving affect regulation,
the transactional model discussed earlier calls for us to consider contributions from the
infant’s side. For example, in some instances, observed disturbances of affect regulation
may be the result of deficit on the infant’s side of the parent-infant dyad; such deficits in
infant reactivity make the establishment of contingent responding challenging or even
impossible. For example, abnormal hippocampal and hyperactive amygdala function-
ing (Herpertz et al. 2001; Schmahl et al. 2003; Tebartz-van Elst et al. 2003; Vermetten
et al. 2006) in children who are at risk for later developing BPD may cause highly anx-
ious and emotionally labile infant behavior and thus an infant who is not able to benefit
from the regulating qualities of the attachment relationship. This constellation might
well create disorganized attachment relationships, principally driven by the child’s con-
stitutional characteristics (see suggestive evidence for this in Lakatos et al. 2000, 2002).
Attentional Control
We also have suggested that disorganized attachment histories will disrupt agentive
self-development and that long-term problems in effortful control (Ellis et al. 2004;
Posner and Rothbart 2000) may be a consequence (Fonagy 2001b). The failure to di-
rect attention voluntarily appears to link directly to the problems of unstable affect we
considered earlier. Inappropriate control of attention combined with affect regulation
difficulties is probably sufficient to directly or indirectly undermine an individual’s ca-
pacity to function adequately in interpersonal contexts. Particularly when exposed to
social stress, such individuals may have great difficulty in allocating adequate process-
ing capacity to understanding their social context. They may appear to act rashly be-
cause they give insufficient consideration to their social partner’s thoughts or feelings,
or alternatively, they cannot exclude from consideration a range of hypotheses about
the thoughts and feelings of others for which little evidence exists and which most peo-
ple would be able to set aside. Self-regulation may be taught (or more accurately, mod-
eled) by the caregiver’s regulation of the infant’s activity. In a study of almost 1,000
children, Jay Belsky and Pasco Fearon (Belsky and Fearon 2002; Fearon and Belsky
2004) found a positive relation between the quality of infant-mother attachment at age
14 months and attentional performance at 54 months when a Continuous Performance
Test (CPT) was used to measure attentional capacity at the latter age. Findings indi-
cated that children with secure attachment appeared to be protected from the effects of
cumulative social contextual risk (and male gender) on CPT attentional performance
relative to their insecure counterparts (Belsky and Fearon 2002; Fearon and Belsky
2004). The longitudinal work of Kochanska and colleagues (2008a, 2008b) has shown
that both self-control and the internalization of the capacity to regulate affects appear
to be rooted in mutual parent-infant responsivity. In brief, we see organized attachment
to the primary caregiver as protective against influences that are likely to undermine
self-control, rooted in the capacity to coordinate and regulate internal states using at-
tention. By inference, and suggestive empirical data, we would argue that such internal
control relates to a sense of autonomy and the ability to undertake responsible inter-
personal interaction (Weinstein and Ryan 2010).
Arnsten’s Dual Arousal Systems

Importantly, studies suggest that the impact of emotional arousal is different in the an-
terior and posterior systems of the brain. While stress or arousal has been shown to fa-
cilitate automatic mentalization, it inhibits neural systems associated with controlled
mentalization (Lieberman 2007; Mayes 2006). Mild to moderate arousal is conducive
to optimal prefrontal functioning and the employment of flexible mental representa-
tions and response strategies. As task complexity increases, the optimal level of arousal
decreases. Mentalizing interactively, as for example in holding an emotional conversa-
tion, is among the most complex cognitive tasks and is therefore highly vulnerable to
hyperarousal in our patients and in ourselves.
The arousal system is not unimodal and is not based in a single neural system. Mul-
tiple interactive neural systems with different neurochemical substrates regulate spe-
cific and different aspects of prefrontal and posterior cortical and subcortical functions.
Activation is not generalized but reflects a differential balance of excitation and inhi-
bition. The prefrontal cortex–mediated executive functions (including planning, work-
ing memory, and anticipatory responding) and the posterior cortex–mediated functions
of vigilance (automatic responding, selective attention) are regulated by two neuro-
chemically distinct arousal systems (Arnsten 2000). As level of cortical activation in-
creases through mutually interactive norepinephrine alpha-2 and dopamine D1
systems, prefrontal cortical function improves on effortful control, planning and orga-
nization, and working memory. With excessive stimulation, norepineprhine alpha-1
and dopamine D1 inhibitory activity increases. The prefrontal cortex goes “offline”
and posterior cortical and subcortical functions (more automatic functions) take over.
These findings may clarify aspects of the heightened emotional sensitivity noted in
BPD patients. When they are in a state of emotional arousal, BPD patients typically
lose their explicit mentalizing capacity almost completely. Paradoxically, however, at

the same time they often seem to become particularly attuned to the states of mind of
individuals around them. This can be explained by their lower threshold for activation
of the automatic mentalizing system. Nevertheless, because of the inhibition of their
explicit mentalizing system, they are likely to be massively handicapped in their at-
tempts to explain their own and others’ states of mind.
Mentalization
Mentalization (a psychological self-narrative) normally maintains an agentive sense of
self (Fonagy and Target 1997). In social contexts when mentalization is impaired, some
indications of a failure of self-organization become apparent. Here we are considering
self not as a representation but rather as a process with specific qualities that are closely
related to the notion of autonomy, a consciously accessible sense of regulating one’s
own behavior. Many constructs cover more or less the same ground (see Choi-Kain and
Gunderson 2008), such as reflectiveness (Bleiberg 2001), mindfulness (Brown and
Ryan 2003), and coherence of “self-narrative” (Westen and Cohen 1993). The lack of
a self-narrative creates characteristic gaps or discontinuities in self-experience. Al-
though our emphasis is on the process of self rather than its representation, changes in
the phenomenology of the self are invariably associated with the temporary failure of
mentalization. In the face of negative affect, patients may feel unable to experience
themselves as authors of their actions, leading not only to a sense of temporally diffused
identity (Kernberg 1983) but also to experiences of inauthenticity or painful incoher-
ence, feelings of emptiness and inability to make commitment, disturbances of body
image, and gender dysphoria (Akhtar 1992). These findings are borne out by factor-
analytic studies of data from clinically experienced informants for adult patients
(Wilkinson-Ryan and Westen 2000) and for adolescent patients (Betan and Westen,
unpublished manuscript, 2005). Ultimately, failure of mentalization is marked by a ten-
dency to misread minds, both one’s own and those of others. Individuals with this dif-
ficulty consequently perform dramatically badly in social contexts, not only upsetting
people whom they wish to befriend (King-Casas et al. 2008) but also showing deficits in
social problem solving (e.g., Hughes and Ensor 2008a). This tendency could be con-
sidered a general marker of psychopathology, and studies of schizophrenia (e.g., Chung
et al. 2008), depression (e.g., Uekermann et al. 2008), and autism (e.g., Stichter et al.
2010) all suggest diagnosis-specific anomalies of mentalization. When mentalization
fails, prementalistic modes of organizing subjectivity described emerge, and these have
the power to disorganize interpersonal relationships and destroy the coherence of self-
experience that the narrative provided by normal mentalization generates (see the sec-
tion Consequences of Inhibited Mentalization later in this chapter).
To help explain some of these anomalies, it may be helpful to extend our develop-
mental perspective to the context in which the ability to mentalize normally emerges,
which is (at least in Western society) in the relationship with the primary caregivers.
Attachment and Mentalization

Children naturally start to wonder about minds in the context of their relationships
with members of their family—parents, siblings, and grandparents. It first becomes ob-
vious to children that behavior is based on mental states as they attempt to understand
the actions of those physically closest to them. The family, and more specifically the at-
tachment relationships of the child, offers a natural context for learning about minds. In
fact, the attachment strategies adopted by a child may indicate the quality of attention
shown by the caregiver to the child’s mental states. Greater interest and understanding
are likely to be indicative of a resource-rich environment in which mental states are re-
spected, and thinking about them may pay dividends in an evolutionary sense. When
sensitivity to the child’s mind takes second place to ensuring survival, the child may well
feel that resources are better used in optimizing his or her physical abilities and may
show only limited concerns with mentalizing. If these speculations have validity, we
would expect a positive association between mentalizing ability and security of attach-
ment. Research literature over the last decades suggests that this may well be the case.
Quality of attachment and early mentalization. A relation between attachment in

infancy and early social understanding was first reported by Bretherton et al. (1979),
who found that children who were securely attached at 12 months used more proto-
declarative pointing at 11 months than did other infants. Bowlby (1969, p. 368) clearly
recognized the significance of the developmental step entailed in the emergence of “the
child’s capacity both to conceive of his mother as having her own goals and interests
separate from his own and to take them into account.” Several studies have since re-
ported associations between the quality of children’s primary attachment relationship
and the passing of standard theory of mind tasks somewhat earlier (e.g., de Rosnay and
Harris 2002; Fonagy and Target 1997; Fonagy et al. 1997; Harris 1999; Meins et al.
1998; Ontai and Thompson 2002; Raikes and Thompson 2006; Steele et al. 1999; Sy-
mons 2004; Thompson 2000). Given the weak and unreliable association between at-
tachment and measures of mentalization, it is unlikely that the pathway connecting the
two is a direct one. Secure attachment and mentalization may both be facilitated by as-
pects of parenting. The strongest evidence for this comes from observations that the
inclination of mothers to take a psychological perspective in relation to their own ac-
tions or in relation to their child, including maternal “mind-mindedness” (an ability to
read accurately the mental states governing infant behavior) ) and “reflective function”
as they interact with or describe their infants, is associated with both secure attachment
and mentalization (Fonagy and Target 1997; Meins et al. 2002, 2003; Peterson and
Slaughter 2003; Sharp et al. 2006; Slade 2005).
What qualities of parenting appear to facilitate the establishment of strong men-
talization?
Precocious understanding of false beliefs has been associated with more reflective
parenting practices (Ruffman et al. 1999), the quality of parental control (Astington
1996; Cutting and Dunn 1999; Dunn et al. 1991b; Ruffman et al. 1999; Vinden 2001),
parental discourse about emotions (Denham et al. 1994; Meins et al. 2002), the depth of
parental discussion involving affect (Dunn et al. 1991a), and parents’ beliefs about
parenting (Baumrind 1991; Ruffman et al. 1999; Vinden 2001). Parenting of this kind
is likely to be strongly associated with the child’s acquisition of a coherent conceptual
apparatus for understanding behavior in mentalistic terms. It is not difficult to under-
stand why parents whose disciplinary strategies focus on mental states (e.g., a victim’s
feelings or the nonintentional nature of transgressions) should have children who suc-
ceed in understanding the importance of mental states earlier, because this capacity is
reflected in theory of mind tasks (Charman et al. 2002; Sabbagh and Callanan 1998). By
contrast, one might well expect power-assertive parenting (including spanking and
yelling) to retard the understanding of false beliefs (Pears and Moses 2003). However,
in line with the transactional model we advocate, we should consider the possibility of
child-to-parent causation (that children with less mentalizing capacity are more likely
to elicit controlling parenting behavior) as well as the parent-to-child causation in
which more mindful or reflective parenting facilitates both attachment security and the
development of mentalization.
Ability to tolerate negative affect could be a shared characteristic of secure attach-
ment and a family environment facilitating mentalizing. For example, family-wide talk
about negative emotions, often precipitated by the child’s own emotions, has been shown
to predict later success on tests of emotion understanding (Dunn and Brown 2001), and
reflecting on intense emotion without being overwhelmed is a marker of secure attach-
ment (Sroufe 1996). Thus, secure mother-infant attachment may not directly facilitate
the development of mentalization, but it is an indicator of an approach the caregiver
takes to the child that may have a direct facilitative effect. Perhaps more crucially, secure
infant attachment means that aspects of parental behavior that might have undermined
mentalization are not present. Preliminary evidence that the capacity for change in at-
tachment organization decreases as development proceeds underlines the danger that
persistent trauma will lead to long-term disorganization of attachment, with attendant
poor development of social cognition and substantially raised risks of psychopathology
(Kobak et al. 2006). However, we are not suggesting that parental mind-mindedness
(Meins et al. 2003) is inevitably helpful for the children’s emotional development. Mind-
mindedness is likely to be one of those parental attributes that is most adaptive in mod-
eration. Evidence on this issue is still lacking, but on the basis of our clinical observations,
we have proposed that maladaptive aspects of parental mentalizing of a child can be ei-
ther deficient (concrete and stimulus-bound) or excessive, that is, hypermentalizing
(necessarily going beyond the data, often quite distorted, and sometimes paranoid)
(Fearon et al. 2006; Williams et al. 2006). In the research referred to earlier, the measure
of maternal mind-mindedness was confounded with the accuracy in the scoring; low
scorers could be either deficient or excessive mentalizers because both would be rated as
failing to reflect the child’s mental state with what we may refer to as grounded imagination
(Allen 2006). However, regardless of the confounding of accuracy and concreteness in
assessments of parenting, the literature suggests that it is not attachment per se but cor-
related features of parenting, particularly an adult mind taking an interest in a child’s
mental state, that may be critical for the consistent establishment of mentalization.
Oxytocin may turn out to be a primary mediator of the association between mental-
ization and attachment (Heinrichs and Domes 2008). Intranasally administered oxytocin
appears to improve performance in mentalizing tasks in experimental studies (Domes et al.
2008; Guastella et al. 2008). Oxytocin is present at significantly elevated levels in women
around childbirth and during breast-feeding (Macdonald and Macdonald 2010), when psy-
chological attunement with the infant is particularly important. Emerging evidence, pri-
marily from studies of women, indicates that secure attachment is associated with high
levels of maternal oxytocin (Buchheim et al. 2009; Strathearn et al. 2009a), and trauma and
maltreatment appear to reduce oxytocin levels (Fries et al. 2005; Heim et al. 2008b).
Figures 1–1 and 1–2 display our provisional speculative model of the developmen-
tal roots of mentalizing, based on these findings. We suggest that in the case of secure
parental attachment, increased oxytocin levels while the parent is in the presence of the
infant will ensure a more mentalizing parental stance characterized by marked and con-
tingent responses to the infant when the latter is in a state of high emotional arousal.
This stance increases the likelihood of strong symbolic representations of self-states
being created in the child’s mind. Second-order representations of constitutional self-
states ensure better affect regulation in interpersonal interactions. This ability will con-
tribute to creating a social environment around the child that facilitates the develop-
ment of mentalizing. Ultimately, the infant may show increased resilience to stressful
social experience.
By contrast, insecure parental attachment linked to reduced oxytocin levels in the
parent may lead to nonmentalizing (unmarked, noncontingent) parental responses to
distress expressed by the infant. We see such responses as undermining the natural pro-
cess of maturation for mentalizing by violating the infant’s and young child’s expecta-
tion of basic principles of reciprocity, fairness, and rational action. The infant’s failure
to internalize self-states through interactions with the parent creates a potential vul-
nerability. Mentalizing can more readily go awry for these individuals, particularly un-
der conditions of high arousal and threats to attachment. Mental states then will be
enacted rather than experienced. Such actions will have a destructive effect on the
child’s social environment. The individual’s actions can disrupt and distort social inter-
actions, potentially undermining future opportunities for the development of mental-
izing. This may be a source of concern in situations in which the child’s mentalizing
resources are particularly called upon when caregivers and others are behaving in ways
that violate healthy expectations. The child needs extra resources to understand the
motivations, thoughts, and feelings of those who expose him or her to interpersonal ad-
versity (i.e., attachment trauma; Allen 2004).
Extreme attachment experiences and attachment trauma. Maltreated children are

by definition deprived of expectable attuned social input. This could be argued to cause
Insecure, disorganized maternal attachment
Reduced maternal oxytocin while with infant
Nonmentalizing (unmarked and noncontingent) response to infant distress

undermines natural process for the maturation of mentalization
Infant fails to internalize representation of self-state
Mentalizing goes awry more frequently, particularly under conditions of high

arousal and attachment activation; mental states are enacted
Destructive effect on social interactions undermines further opportunities for

development of mentalizing vulnerability to trauma
FIGURE 1–1. Provisional model of the developmental roots of mentalization with

insecure, disorganized maternal attachment.
a distortion and deficit in mentalization in abused or maltreated children. Reasonable

evidence links the maltreatment of young children with problems of mentalization. We
know that maltreated children engage in less symbolic and dyadic play (Alessandri
1991), and they may fail to show typical empathic responses to distress in other chil-
dren. They manifest a range of problems indicative of difficulties in processing emo-
tional expressions. This adds up to a social cognitive vulnerability that might, with
other environmental and personal characteristics, predispose them to severe psycho-
logical disorder in adulthood.
Limited evidence exists for delayed theory-of-mind understanding in maltreated
children (Cicchetti et al. 2003; Pears and Fisher 2005). But this could be a function of
the broader intellectual delays experienced by many maltreated children (Macfie et al.
2001). Maltreated children, especially physically or sexually abused children, were
shown to manifest more dissociation, disruptions of identity, and incoherence of pa-
Secure maternal attachment
Increased maternal oxytocin while with infant
More mentalizing (marked and contingent) response to infant distress
Infant generates a second-order representation of self-state
Improved affect regulation enhances interpersonal interactions
Facilitative effect of social interaction on development of

improved mentalization resilience
FIGURE 1–2. Provisional model of the developmental roots of mentalization with

secure maternal attachment.
rental representations and had limited reflective function on the Child Attachment In-
terview (Ensink 2003). We would see all this as indicative of the potential failure of
mentalizing capacities (Fonagy et al. 2002a). Maltreatment affects mentalization by
compromising the unconstrained, open reflective communication between parent and
child or between child and child (see review by Fonagy et al. 2007). Maltreatment un-
dermines the parent’s credibility in linking internal states and actions. This limitation
in communication is easy to comprehend and is anticipated if the maltreatment is per-
petrated by a family member. Even when the maltreatment is not perpetrated by a fam-
ily member, the centrality of the maltreatment experience for the child coupled with
the oversight by the parent of maltreatment that the child encounters outside the home
could serve to invalidate the child’s communications with the parent about the child’s
subjective state. Thus, apparently reflective discourse will not correspond to the core of
the child’s subjective experiences, and this will moderate or reduce the facilitative effect
of mentalizing in generating the sense of an agentive self. The formulations advanced
here imply that general characteristics of family function rather than maltreatment per se
generate vulnerability to loss of mentalization under stress. Thus, preventive interven-

tions should aim to engage maltreated children in causally coherent psychological dis-
course within appropriate contexts.
The mentalization-based treatment model does not attribute a central role to
trauma. Nevertheless, we anticipate that in individuals who have already been made
vulnerable to stressful psychosocial experiences (particularly in an attachment context)
by inadequate early mirroring and disorganized attachment, maltreatment can play a
key role in shaping psychopathology. In our view the effect of trauma is most likely to
be felt as part of a more general failure to consider the child’s perspective. This failure
is manifested through neglect, rejection, excessive control, relationship incoherence,
and confusion, which, taken together, can devastate the experiential world of the de-
veloping child and leave deep scars that are evident in terms of distortions of social-
cognitive function and behavior.
However, aggression and cruelty directly focused on the child, if present, will often
have specific effects in addition to the nonspecific influences referred to earlier. These
effects may be due to the defensive inhibition of the capacity to think about others’ ma-
levolent thoughts and feelings about the self. We have suggested elsewhere that the re-
luctance to consider mental states on the part of maltreated individuals might be
understandable given the frankly hostile and malevolent thoughts and feelings the
abuser must realistically hold to explain his or her actions against a vulnerable young
person (e.g., Fonagy 1991). Consistent with this assumption, forms of maltreatment
that are most clearly malevolent and clearly target the child (i.e., physical, sexual, and
psychological abuse) have the greatest effect on mentalization.
Factors Triggering the Failure of Mentalization

Arousal and mentalizing. Mentalizing is likely to fail to dominate behavior in the
context of intense emotional arousal as the fight-or-flight response is activated. Arnsten
(1998) described this process in the title of her article, “The Biology of Being Fraz-
zled.” In understanding the relation between emotional arousal and mentalizing, it is
essential to go beyond a unitary concept of arousal (Robbins 1997). Key neuromodu-
lators, for example, contribute to different forms of arousal: norepinephrine contrib-
utes to alerting, vigilance, and controlled attentional processing in the face of stress;
dopamine energizes approach behavior in response to potentially rewarding incentives;
and serotonin modulates arousal in the norepinephrine and dopamine systems (Pliszka
2003). Furthermore, the effects of arousal in any of these systems vary not only with the
extent of transmitter secretion but also with the receptor subtype activated (Arnsten
1998; Arnsten et al. 1999; Mayes 2000). Through dynamic changes in patterns of ex-
citation and inhibition, these intertwined arousal systems modulate the relative balance
of activity in various cortical and subcortical areas.
To understand arousal-provoked impairments in mentalizing, it is vital to appre-
ciate that because of what can be construed as a neurochemical switch associated with
escalating levels of emotional stress (Arnsten 1998; Mayes 2000), patterns of brain
functioning can shift from flexibility to automaticity—that is, from relatively slow ex-
ecutive functions mediated by the prefrontal cortex (PFC) to faster habitual and in-
stinctual behaviors mediated by posterior cortical (e.g., parietal) and subcortical
structures (e.g., amygdala, hippocampus, and striatum). Concomitantly, mentalizing
appears to disappear as self-protective physical reactions (fight-flight-freeze) come to
dominate behavior. This is “normal.” It has the presumed evolutionary value of pro-
moting immediate adaptive responses to danger. However, in situations of interper-
sonal stress, when complex cognitive-emotional functioning (i.e., mentalizing) may be
helpful, the loss of mentalization may be, to say the least, a significant inconvenience.
Thus, the degree of arousal generated by interpersonal situations is critical. More gen-
erally, there will be situational variations when social stress triggers the threshold for
switching from executive (mentalizing) to automatic (fight-or-flight) responding. We
also assume, following Arnsten and Mayes, that the threshold for switching can be low-
ered as a result of exposure to early stress and trauma. Situational, within-person vari-
ation may be related to particular emotional contexts or even time of day. This also may
be a domain in which genetic influences make themselves felt.
Simultaneous activation of attachment and deactivation of mentalization. Neuro-

imaging studies have further linked some attachment phenomena to the deactivation of
mentalizing. Rodent research on the neurobiology of attachment has linked the attach-
ment system to the mesocorticolimbic dopaminergic reward circuit, which probably
also plays a key role in mediating some chemical addictions (Insel 1997; MacLean 1990;
Panksepp 1998). Ironically, attachment could be construed as an addictive disorder (In-
sel 2003) in the sense that falling in love, which is stimulated by social and sexual ac-
tivity, entails the activation of an oxytocin- and vasopressin-sensitive circuit within the
anterior hypothalamus linked to the ventral tegmental area and the nucleus accumbens
shell (Insel 2003). Human functional magnetic resonance imaging studies also tend to
indicate specific activation of these reward-sensitive pathways in the brain of somebody
seeing his or her own infant or partner as compared with another familiar infant or
other people’s partners (Nitschke et al. 2004). Early deprivation affects the vasopressin
and oxytocin systems, which are critical for the establishment of social bonds and the
regulation of emotional behavior (Fries et al. 2005).
In two separate imaging studies, Bartels and Zeki (2000, 2004) reported that the ac-
tivation of areas mediating maternal and romantic attachments appeared simulta-
neously to suppress brain activity in several regions mediating different aspects of
cognitive control, including those associated with making social judgments and with
mentalizing. Bartels and Zeki (2004) suggested grouping these reciprocally active areas
into two functional regions. The first of these systems includes the medial prefrontal,
inferior parietal, and medial temporal cortices, mainly in the right hemisphere, and the
posterior cingulate cortex. These areas are part of the circuitry specialized for attention
and long-term memory (Cabeza and Nyberg 2000), and they also have variable involve-
ment in both positive (Maddock 1999) and negative (Mayberg et al. 1999) emotions. It
is argued that these areas may be specifically responsible for integrating emotion and
cognition (e.g., emotional encoding of episodic memories; Maddock 1999). In addition,
lesion studies suggest a role in judgments involving negative emotions (Adolphs et al.
2000). As projections from the affect-oriented limbic and paralimbic regions modulate
the activity of these areas, they could subserve mood-mediated inhibition or enhance-
ment of cognitive processing (Mayberg et al. 1999). These areas also may play a role in
recalling emotion-related material and generating emotion-related imagery (Maddock
1999), which may be relevant to understanding the typology of attachment.
The second set of brain areas observed to be deactivated by the activation of at-
tachment concerns included the temporal poles, parietotemporal junction, amygdala,
and mesial PFC. The authors argued that activation of these areas is consistently linked
to negative affect, judgments of social trustworthiness, moral judgments, theory of
mind tasks, and attention to one’s own emotions. This system probably constitutes part
of the primary neural network underlying the ability to identify and interpret mental
states (both thoughts and feelings) in other people (Frith and Frith 2003; Gallagher and
Frith 2003) as well as in the self (Gusnard et al. 2001). These structures are also thought
to be associated with intuitive judgments of moral appropriateness (Greene and Haidt
2002) and of social trustworthiness based on facial expressions (Winston et al. 2002).
We assume that the arousal of the attachment system, beyond more general interper-
sonal stress-induced arousal, brings with it a general loss of mentalization. Any trauma
arouses the attachment system (i.e., protection seeking), and attachment trauma may
do so chronically.
Trauma history may have a part to play. Trauma-related rapid triggering of fight-
flight may account for the inhibition of mentalization, but more specifically, hyperac-
tivation of the attachment system sometimes may be a consequence of maltreatment in
an attachment context. The coincidence of trauma and attachment could create a bio-
logical vicious cycle. Trauma normally leads a child to try to get close to the attachment
figure. This generates a characteristic dependency on the maltreating figure, with the
real risk of an escalating sequence of further maltreatment, increased distress, and an
ever-greater inner need for the attachment figure. Attachment trauma probably hyper-
activates the attachment system because the person to whom the child turns in a state of
anxiety is the one who is causing fear in the first place. There is no resolution of the
anxiety; looking for reassurance and protection generates more fear through the (men-
tal) proximity of the maltreating figure. The historical effect of attachment trauma is
the combined result of the inhibition of mentalization by attachment and the hyperac-
tivation of the attachment system by trauma. The ready triggering of the attachment
system in BPD may be a residue of trauma history and manifests both as the rapidly ac-
celerated tempo of intimacy in interpersonal relationships and as the vulnerability to
the temporary loss of mentalization.
In summary, there are several possible routes to the suppression of mentalization.
First, psychological defenses may protect the individual from thinking about the men-
tal states of those who harbor malevolent thoughts toward a vulnerable individual. Sec-
ond, arousal-related shifts in brain activity may “switch off” mentalizing, and this may
happen more readily in traumatized individuals. Third, hyperactivation of the attach-
ment system associated with an experience of lack of safety may drive the individual to
seek proximity to an abusive attachment figure.
The failure of mentalizing is problematic not only because it makes appropriate so-
cial relatedness in an attachment context difficult but also because of the reemergence
of prementalistic ways of thinking about self and others that can lead to powerful com-
plications and profound disturbances. We will deal with these after considering the di-
mensions of mentalizing that may be affected to various degrees in circumstances that
compromise personality development.
Mentalization:
A Multidimensional Construct
A key feature of the mentalization-based approach to treatment presented in this book
is that therapeutic interventions, at each stage in the therapeutic process, must be tai-
lored to the individual patient’s mentalizing abilities (Bateman and Fonagy 2006a). The
concept of mentalization has been appropriately criticized as a marker of a specific form
of psychopathology such as BPD because in its original formulation the theory offered
a construct that was too broad and multifaceted to be operationalized (Choi-Kain and
Gunderson 2008; Holmes 2005; Semerari et al. 2005). It is essential to realize that
mentalization is not a static and unitary skill or trait. Rather, it is a dynamic capacity
that is influenced by stress and arousal, particularly in the context of specific attach-
ment relationships (Allen et al. 2008). Moreover, mentalization is a multifaceted capac-
ity. Multiple polarities underlie mentalizing, and patients may show impairments in
some of these polarities but not necessarily in others (Fonagy and Luyten 2009; Luyten
et al., submitted 2011c).
On the basis of brain imaging studies of social cognition, Patrick Luyten and col-
leagues proposed that mentalization is underpinned by four functional polarities:
1. Automatic — Controlled
2. Internally focused — Externally focused
3. Self-oriented — Other-oriented
4. Cognitive process — Affective process
Each of these polarities is related to relatively distinct neural systems (Luyten et al.,
submitted 2011c. Taken together, they provide a comprehensive matrix not only for the
conceptualization and assessment of the various aspects of mentalization but also for
the relation between mentalization and closely related constructs such as theory of
mind, empathy, mindfulness, alexithymia, emotional intelligence, psychological mind-

edness, and insight. These polarities mostly constitute systems in which a single rep-
resentation dysfunction at one end of the pole can manifest as an excess at the other
polarity. For example, a dysfunction in cognitively focused mentalization may manifest
as excessively emotion-focused mental representations that (because they are not bal-
anced by appropriate cognitive considerations) appear as inappropriate representations
of emotional states.
Automatic (Implicit) and

Controlled (Explicit) Mentalization
The most fundamental polarity underlying mentalizing is the automatic or implicit
compared with controlled or explicit dimension (Lieberman 2007; Satpute and Lieber-
man 2006; Uddin et al. 2007). Controlled or explicit mentalizing reflects a serial and
relatively slow process, which is typically verbal and requires reflection, attention, in-
tention, awareness, and effort (Allen et al. 2008; Fonagy and Luyten 2009; Luyten et
al., submitted 2011c). Automatic or implicit mentalization, in contrast, involves parallel
and therefore much faster processing; is typically reflexive; and requires little or no at-
tention, intention, awareness, and effort (Satpute and Lieberman 2006).
In our daily interactions, mentalization is predominantly implicit and automatic
because in most interpersonal situations we rely on automatic and unreflective assump-
tions about ourselves, others, and ourselves in relation to others. When things go
smoothly, particularly within secure attachment relationships, relying on automatic
mentalization appears to be normal because more reflective processing is unnecessary
(Fonagy and Bateman 2006a). Indeed, given the speed with which most interpersonal
encounters unfold, controlled mentalization may actually hamper interactions rather
than facilitate them, and a “hypermentalizing” (unnecessarily detailed and necessarily
inaccurate mentalizing) stance is likely to be counterproductive in many social interac-
tions, particularly those with attachment figures. It could mark at-risk status for per-
sonality disorder (Sharp et al., in press). In fact, both commonsense psychology and
neuroscience have shown that individuals relax controlled mentalization and judg-
ments of social intent and social trustworthiness in secure attachment relationships
(“love is blind”; Bartels and Zeki 2004) and rely on more automatic, intuitive processes.
The mother who is playing with her child or the husband who is discussing holiday
plans with his wife over dinner will rely predominantly on fast, nonreflexive, automatic
mentalization. Yet if necessary, she or he can flexibly switch to controlled mentaliza-
tion, and this adaptive flexibility (Allen et al. 2008) may be an important marker of secure
attachment and high levels of mentalization that until recently has received surpris-
ingly little attention. For instance, when a child starts crying during play, the mother
will immediately wonder why and will actively start inquiring about the reasons for this
change in affect—whether she said or did something wrong or other reasons that might
account for her child’s tears. The husband who notices that his wife is unusually silent
in their discussion of holiday plans will ask her if something is wrong or if something is
on her mind. Hence, high levels of mentalization imply being mindful of minds and in-
volve adaptive flexibility in switching from automatic to controlled mentalization.
By contrast, mentalizing problems are likely to arise if mentalization relies exclu-
sively on automatic assumptions about the self and others that are distorted or overly
simplistic or when it is difficult to make such automatic assumptions accessible to con-
scious reflection and to challenge them. In fact, arguably psychotherapy, regardless of
theoretical orientation, involves challenging such automatic distorted and simplistic as-
sumptions about the self and others, making these assumptions conscious, and inviting
the patient to enter into a joint process of reflecting on these assumptions in the context
of a therapeutic relationship. One of the basic assumptions of the current integrative
approach to psychological treatment is that the essence of psychotherapy entails the
process of mental-izing (i.e., transforming the unmentalized or nonmental into the
mental) (Allen et al. 2008). Although this may sound simple, it is no easy task.
In line with clinical observations that automatic and controlled mentalization in-
volve two very different processes, evidence from neuroimaging studies indicates that
different neural systems underlie these two types of mentalization (Keysers and Gaz-
zola 2007). Neural systems that have been linked to automatic mentalization include
the amygdala, basal ganglia, ventromedial PFC, lateral temporal cortex, and dorsal an-
terior cingulate cortex, whereas brain circuits implicated in controlled mentalization
include the lateral PFC, medial PFC, lateral parietal cortex, medial parietal cortex, me-
dial temporal lobe, and rostral anterior cingulate cortex (Lieberman 2007; Satpute and
Lieberman 2006; Uddin et al. 2007). Automatic mentalization thus seems to be under-
pinned by somewhat phylogenetically older brain circuits that rely heavily on sensory
information, whereas controlled mentalization involves phylogenetically newer brain
circuits that rely more on linguistic and symbolic information.
As described earlier, stress or arousal facilitates automatic mentalization while in-
hibiting the neural systems associated with controlled mentalization (Lieberman 2007;
Mayes 2006). This has several important implications both for our understanding of
the therapeutic process and for the assessment of mentalization. First and foremost,
any clinical intervention that calls for reflection, such as clarification or elaboration, is
asking the patient to engage in controlled mentalizing. Although many patients may
perform relatively well under low stress or low arousal conditions (e.g., during an in-
take interview), under higher levels of stress, when automatic mentalization dominates,
they may find it much more difficult to understand and reflect on their own experiences
and those of others. For instance, BPD patients may be able to perform experimental
mentalizing tasks relatively successfully (Arntz et al. 2006), but when they become
emotionally aroused, automatic mentalization predominates, and they may show con-
siderable confusion as they are dominated by overly schematic assumptions about other
people’s internal states and find it challenging to reflect and moderate these assump-
tions. In other words, in a state of emotional arousal, they typically lose the ability for
controlled mentalizing and are likely to be handicapped in creating a probable scenario

that might explain the states of mind of others.
Moreover, mentalization that initially requires controlled efforts becomes increas-
ingly automatized and thus escapes conscious and deliberate reflection (Satpute and
Lieberman 2006), which makes it particularly difficult to change deeply ingrained dis-
positional attributes that rely on automatic and preconceived judgments of self and
others. These findings present therapists with a particular challenge. Regardless of
theoretical orientation, therapists often address and aim to provide broader under-
standings for issues that trigger intense emotional reactions such as challenging inter-
personal situations that often involve intense feelings of shame, guilt, or inadequacy
(Fonagy and Bateman 2006b). Yet therapists usually assume that patients are able to en-
gage in conscious reflection and controlled mentalization regarding these issues. How-
ever, many patients are unable to perform these tasks when experiencing relatively high
levels of arousal. This may well be the case in the context of an attachment relationship
(i.e., with the therapist) that is put under stress by such a discussion. Although each of
us is likely to revert to automatic mentalization under increasing levels of stress, the
combination of a comparatively weak explicit mentalizing capacity and proneness to in-
tense arousal may explain why patients who show this combination are less able to ben-
efit from psychotherapy and why their automatic implicit assumptions about internal
states of others can be particularly difficult to change (Arntz et al. 2005), especially if
the deficiency in mentalizing capacity is not taken into account in the therapist’s ap-
proach to the patient’s problems (Fonagy and Luyten 2009).
Mentalization Based on Internal or

External Features of Self and Others
A second important polarity underpinning mentalizing has emerged from neuroimag-
ing research (Lieberman 2007). Internally focused mentalization refers to mental pro-
cesses that focus on one’s own or another’s mental interior (e.g., thoughts, feelings,
experiences), whereas externally focused mentalizing refers to mental processes that
rely on physical and visible features and one’s own or another’s actions. This distinction
differs from the self-other polarity discussed later in this chapter because both inter-
nally and externally focused mentalization may be either self- or other-focused.
From an assessment perspective, the internal-external distinction is particularly
relevant in helping us to understand why some patients appear to be severely impaired
in their capacity to “read the mind” of others after consideration of more internal fea-
tures (e.g., desires, wishes), but are hypersensitive to emotions resulting from their ob-
servations of facial expressions or bodily posture. For instance, patients with BPD find
it very difficult to understand the intentions of others (an internally based task; e.g.,
King-Casas et al. 2008); however, they are often hypersensitive to facial expressions (an
externally based task; Domes et al. 2008, 2009; Lynch et al. 2006). By contrast, patients
with antisocial personality disorder may lack the ability to read fearful emotions from
facial expressions (an externally based task; Marsh and Blair 2008), but they are often
experts in reading the inner states of others and coercing or manipulating them based
on this ability (Bateman and Fonagy 2008a).
Similarly, clinicians are often struck by the inability of young parents to mentalize
about their infants (Slade et al. 2005). In early development, and particularly given the
nonverbal nature of infants younger than 24 months, parents have to mentalize and
thus give meaning to their infant’s internal mental states largely on the basis of external
features such as infant behavior and facial expression (Beebe et al. 2008, 2010). Al-
though some parents have considerable difficulty with this process, they are often much
better at reflecting on their children’s internal mental states once they grow older and
mentalization is much more based on internal features (Sharp and Fonagy 2008a). For
instance, Sleede and Fonagy (2009) found that some mothers who appeared highly at-
tuned to their infants when their interaction with their child was rated from external
signal-guided videotapes scored low on measures of reflective function based on a rep-
resentation of the child’s internal state as assessed by Slade and colleagues’ (2005) Par-
ent Development Interview. This also may help to explain the effects of parent-infant
intervention programs that use video feedback (Slade and Sadler 2007). Parents in
these interventions are invited to reflect together with a therapist about the possible
meanings of behavior and expressions, thus developing their skills to read the minds of
others based on external features and linking this ability to their capacity to reflect on
the minds of others based on internal features.
Somewhat different neural networks underlying the capacities for internally and
externally focused mentalization have been identified. This may explain dissociations
such as those described earlier, as well as link them to the distinction between automatic
and controlled mentalization. Relatively speaking, mentalization based on external fea-
tures of self and others reflects the functioning of a lateral frontotemporoparietal net-
work, which essentially entails less controlled and reflective processes, whereas
mentalization focused on internal features activates a medial frontoparietal network,
which involves more active and controlled reflection (Satpute and Lieberman 2006).
Distortions of mentalizing may become apparent only when the balance of internal
and external cues used to establish the mental state of the other is considered. For ex-
ample, BPD patients are often hypersensitive to emotions in others (Gunderson and
Lyons-Ruth 2008), including the therapist. They often fail to develop plausible scenar-
ios concerning the states of mind of others based on these feelings and are unable or un-
willing to consider alternative explanations. Many BPD patients believe that the
therapist is completely bored if he or she leans back and yawns just slightly. If the ther-
apist momentarily looks angry or disgusted, then he or she must be angry at or dis-
gusted with the patient. Mentalizing interventions often need to start by examining
interpretations based on external features and then generate possible plausible scenar-
ios about internal states of mind, particularly the subtleties and complexities of people’s
internal worlds.
Some patients are hypersensitive to external features, whereas others seem totally
uninterested in other people’s facial or postural expressions or seem to lack the ability
to read those expressions. Some patients (perhaps particularly those with narcissistic
traits) do not seem to be able to read from others’ faces and nonverbal indications that
they are bored or pressed for time and do not welcome the elaboration of mental con-
tent based on internal cues, however accurate. Yet these very same patients are often
preoccupied with thoughts about other people’s internal states of mind, leading to a
tendency for hypermentalization, perhaps because of the absence of a self-limiting pro-
cess introduced by accurate mental state detection.
These failures to integrate external and internal cues regarding social cognition
provide important information about the development of the awareness of internal men-
tal states. The development of this awareness is normally facilitated through the child’s
caregivers’ pedagogical communicative stance, which provides the child with an oppor-
tunity to observe, mirror, and eventually internalize the caregiver’s ability to represent
and reflect on internal mental states (Fonagy et al. 2007). The pedagogic stance places
the child into a “learning” mode (Csibra and Gergely 2006; Gergely and Unoka 2008;
Gergely et al. 2007), particularly with regard to intentional internal states of self and
others based on external cues. Ostensive cues accompanying the caregiver’s affect mir-
roring induce the referential interpretive attitude of the “pedagogical stance” in the in-
fant and activate a search for the intended referent. As a result of its “markedness”
(subtle but biologically encoded indicators that the mirrored affect is not that of the
person displaying the affect), the emotion expressed is “decoupled” from the caregiver
and is understood not to be expressing his or her own emotional state. The infant then
has to work out what the “marked” emotion display refers to (i.e., what the internal state
underlying the emotion is). In doing so, he or she relies on the external cues of referent
identification such as eye-gaze direction of the caregiver, which accompanies the com-
municative emotion display. Because the caregiver is looking at and oriented toward
the infant while producing these infant-directed marked emotion mirroring displays,
the infant’s attention will be directed toward his or her own face and body—that is, his
or her own external physical self as the referent that the caregiver’s cues indicate and to
which the marked (and decoupled) affect display should be referentially anchored
(Fonagy et al. 2007). This contingent feedback lays the foundation for the infant to de-
velop an understanding not only of the other’s emotions and intentions but also of his
or her own emotions (Fonagy et al. 2002a; Gergely and Watson 1996). These processes
are fundamentally interdependent and intertwined and involve a continuous back-and-
forth between external and internal features of self and other.
When the parent’s affective expressions are not contingent on the infant’s affect,
this is likely to undermine the appropriate labeling of internal states (i.e., the establish-
ment of introspectively accessible second-order representations for them) of both self
and others. These internal states therefore remain confusing or frightening and are ex-
perienced as unsymbolized and difficult to regulate. This problem may be characteris-
tic not only of patients with severe personality disorders but also of patients with
somatoform disorders. Such patients show a defensive avoidance of linking internal and
external features of the self or an inability to link such features. For example, some pa-
tients with somatoform disorder may feel oppressed in life and may simultaneously
have bodily feelings of oppression (e.g., the feeling of being squashed in a press) but
may not be able to link the two. The extent to which patients are able to link such feel-
ings is an important indication of their mentalizing potential.
Mentalization With Regard to Self Versus Others

With regard to the object of mentalization (i.e., the self or others), it is important to as-
sess the extent to which individuals show impairments in the following forms:
1. Impaired mentalizing about both the self and others

2. Marked imbalances in mentalizing about the self and others
3. Imbalances in different ways of mentalizing about the self and others
Concerning the first type of impairment, it is a central tenet of our theoretical approach
that the self and the capacity for mentalization develop in the context of attachment re-
lationships. The child observes, mirrors, and then internalizes his or her attachment
figures’ ability to represent and reflect on internal mental states (Fonagy et al. 2007).
Hence the self and others—and the capacity to reflect on the self and others—are
closely intertwined. In line with these assumptions, neuroimaging studies suggest that
the capacity to mentalize about others is closely related to the ability to reflect on one-
self because the two capacities rely on common neural substrates (Dimaggio et al. 2008;
Lieberman 2007; Lombardo et al. 2010; Uddin et al. 2007). Hence, it is not surprising
that disorders that are characterized by severe impairments in feelings of self-iden-
tity—most notably, psychosis and BPD (e.g., Barnow et al. 2005; Bender and Skodol
2007; Blatt and Auerbach 1988; Fuchs 2007; Kernberg et al. 2002)—are also charac-
terized by severe deficits in the ability to reflect about others’ mental states. However,
this does not mean that impairments in the capacity to reflect about the self necessarily
imply impairments in the capacity to mentalize about the mental states of others.
The second type of impairment is less global and involves imbalances between
these two capacities, which may reflect compensatory relationships. For instance, as
noted earlier, patients with antisocial personality disorder are often experts in “reading
the mind” of others but typically lack any real understanding of their own inner world
(Bateman and Fonagy 2006a, 2008a). Similarly, many patients show excessive concern
about their own internal mental states (hypermentalization with regard to the self) and
even appear to have exceptional self-reflective capacities that are sometimes difficult to
distinguish from genuine mentalization. However, they lack any interest in or capacity
to perceive other people’s mental states (Dimaggio et al. 2008).
A third set of potential impairments is related to two distinct ways of knowing oth-
ers and the self that appear to be supported by different neural networks (Lieberman
2007; Northoff et al. 2010; Uddin et al. 2007). The first and developmentally more ba-
sic and earlier neural system implicated in mentalizing with regard to self and others
consists of a more bodily based, frontoparietal mirror neuron system that is involved in
understanding the multimodal embodied self (e.g., face and body recognition) and oth-
ers through motor simulation mechanisms (Gallese et al. 2004; Rizzolatti and Craigh-
ero 2004). Hence one fundamental mechanism that allows us to understand the actions
and emotions of others involves a direct sharing of their actions (Keysers and Gazzola
2006; Rizzolatti et al. 2006), and a single mechanism underpinned by shared neural cir-
cuits applies to both witnessing the actions, sensations, and emotions of other individ-
uals and performing these same actions ourselves (Calvo-Merino et al. 2006). Likewise,
feeling the same sensations and emotions and translating the sight and sound of what
other people do and feel into our own actions and feelings provide intuitive insights for
the observer into the inner life of the person observed. This implicit, automatic system
provides physical other-to-self and self-to-other mapping, which is involved in the im-
mediate understanding (or misunderstanding) of self and others. The so-called chame-
leon effect, the unconscious imitation of a conversational partner’s gestures (Chartrand
and Bargh 1999) or the felt temptation to yawn when someone else yawns, also may be
an example of this direct other-to-self mapping system.
A second, cortical midline system, which consists of the medial PFC, anterior cin-
gulate cortex, and precuneus, is less bodily based, processes information about the self
and others in more abstract and symbolic ways (Frith 2007; Northoff et al. 2009; Uddin
et al. 2007), and appears to play a crucial role in distinguishing between one’s own ex-
periences and those of others. Importantly, this system is more experienced based,
emerges later in development, and is mainly shaped by interpersonal relationships
across development, whereas the frontoparietal system is less experience based.
Understanding the mental interior of others implies recognition that others have
minds with desires, thoughts, and feelings that can be different from one’s own. Earlier
formulations of the mentalization-based approach to psychopathology have primarily
emphasized this capacity, as operationalized in the Reflective Functioning Scale (Fon-
agy et al. 1998), which is closely related to research on theory of mind, belief-desire rea-
soning, perspective taking, and cognitive empathy (Choi-Kain and Gunderson 2008;
Decety and Moriguchi 2007). The other way of knowing others is more visceral, un-
mediated, and typically studied in research on affective empathy and the mirror neuron
system (Decety and Moriguchi 2007; Fonagy et al. 2007; Uddin et al. 2007). Both clin-
ical practice and neuroimaging research suggest that there are two different ways of
knowing oneself and others. The embodied, visceral, unmediated system (reflecting
automatic processing) perhaps responds to exteriors, whereas the more abstract system
involves symbolic reasoning about one’s inner states of mind (reflecting more con-
trolled processing). The former capacity is central in Eastern philosophy and more re-
cently in mindfulness-based approaches (Allen et al. 2008; Hayes et al. 2004; Linehan
1993a; Teasdale et al. 2000). Failures in the latter self-representational capacity are
closely linked to research on alexithymia, somatoform disorders, eating disorders, and
the translation of bodily feelings into conscious awareness, as well as studies on insight,
psychological mindedness, and the linguistic understanding of the self (Bouchard et al.
2008; Choi-Kain and Gunderson 2008; Holmes 2006; Zonnevijlle-Bender et al. 2002).
The finding that two different neural systems are involved in mentalization with
regard to self and others has important implications for conceptualizing mentalization.
More specifically, studies suggest that a subregion within the lateral PFC inhibits one’s
own reactions while thinking about the mind of someone else, and impairments in this
capacity may be related to naïve realism (Pronin et al. 2004), a tendency to ignore the
intentional states underpinning behavior and actions, which is also known as the psychic
equivalence mode (Fonagy and Bateman 2006a). Naïve realism refers to a phenomeno-
logical stance that entails the failure to perceive one’s own biases and to see others as
more susceptible to distortions of a cognitive and motivational nature. It is well estab-
lished that naïve realism is exacerbated by people’s tendency to have greater confidence
in their own introspections about potential influences on judgment and behavior than
they have in similar introspections by others. The tendency to assume the universality
of one’s own position has developmental roots because the evolutionary underpinnings
of human culture require the infant to turn to others for essential information about the
world (Csibra and Gergely 2006; Fonagy et al. 2007; Gergely and Csibra 2005). In par-
ticular, children consider the things that they are taught to be shared cultural knowl-
edge available to all others. Thus, the small child assumes that his or her knowledge is
knowledge held by all. What he or she knows is known by others, and what is taught by
others is accessible to all others. The child therefore also will assume that his or her
own thoughts or feelings are not unique (Fonagy et al. 2007). Developmentally, with
the acquisition of the realization that not all knowledge is shared by all—a key aspect of
theory of mind (Bloom 2004)—children normally learn the conditions under which
this assumption should be suspended. The overvaluation of one’s own perspective char-
acteristic of naïve realism stems from the same developmental source as the “curse of
knowledge bias” (Birch and Bloom 2004), the tendency to assume that if one knows
something about the world then everyone else must know it, too (Camerer et al. 1989),
which provides an excellent explanation of the so-called egocentrism of young chil-
dren. Three-year-old children readily assume that other children will know facts that
they themselves have just learned (Birch and Bloom 2003). They find it challenging to
appreciate another person’s perspective, not, importantly, because they assume that ev-
eryone’s perspective is the same as theirs, but because they assume that everyone knows the
same things (Birch and Bloom 2003; Keysar et al. 2003). Piaget’s concept of egocentrism
(Piaget and Inhelder 1948/1956) thus has exactly the opposite emotional valence to
what is actually taking place. Developmentally, it is not the overvaluing of private
knowledge but rather the undifferentiated experience of shared knowledge that hinders
perspective-taking prior to the development of the lateral PFC and the ability to dis-
tinguish between self and others.
Thus, a capacity to inhibit both this egocentric point of view and direct imitative
behavior is needed. Neuroimaging studies indicate that the neural regions that are
most often recruited in the inhibition of imitative behavior are the anterior frontome-
dial cortex and the temporoparietal junction area (Brass et al. 2005; Derrfuss et al.
2005), cortical areas that are also related to mentalizing, self-referential processing, and
self-agency. The temporoparietal junction is involved in perspective taking (Aichhorn
et al. 2006; Ruby and Decety 2001, 2003), sense of agency (Decety and Grezes 2006;
Farrer et al. 2003), and mentalizing (Frith and Frith 2006). The anterior frontomedial
cortex is involved in mentalizing (Amodio and Frith 2006; Frith and Frith 2006; Gil-
bert et al. 2007) and self-referential processing (Northoff et al. 2006). In fact, studies by
Brass and colleagues (2007) have suggested that a functional relation exists between the
inhibition of imitative behavior and the capacity for belief-desire reasoning.
Patients with limitations in the functioning of medial PFC and temporoparietal
junction regions may be overly affected by the regions of the brain subserving “chame-
leon” phenomena. They are excessively sensitive to the attitudes of others, and their
sense of self may be readily taken over by their experience of others as part of a process
of primary identification (Sandler 1993). Perhaps it makes sense for these individuals to
“guarantee” their separateness from others by engaging in projective identification to
what could be considered an excessive degree (as is clinically noted to be the case with
many forms of severe personality disorder) (Leiman 1994; Meissner 1980; Ogden
1982).
Hence, in normal development, by reflecting on and detecting the intention of the
other, we gradually create a distinction between our own and other people’s experience
and learn to decouple the direct activation of corresponding motor representations
when we observe others’ actions. The capacity to inhibit imitative behavior may be key
to enabling us to generate a sense of “me”-ness through achieving a “not-other”-ness
through quarantining our own perspective (Allen et al. 2008). In other words, each time
we interpret another person’s actions, there may be a sequence in which an initial im-
itative response within a motor neuron self-other system interacts with the reflective
mentalizing self-other system. This necessarily involves an inhibition of the mirror sys-
tem and reduces the extent of “primary identification” with the other. If medial pre-
frontal and temporoparietal mentalizing function fails, this might leave the individual
with difficulties in decoupling his or her representations of another person’s experience
from his or her self-representations, leaving him or her vulnerable to experiencing
emotional contagion because he or she is unable to adequately inhibit the alternative
states of mind that are imposed on him or her when he or she observes others. Conse-
quently, these individuals feel excessively vulnerable to losing their sense of separate-
ness and individuality. Reflective mentalizing maintains self-other differentiation by
enabling us to distinguish our own and others’ intentions and inhibiting the tendency
for overly concrete experience of other people as if they were physically part of the self.
One way to understand the rage and frustration of patients with serious impair-
ments in mentalization (Akiskal 2004) is therefore related to their inability to inhibit
their own reactions when they are thinking about the mind of someone else. These pa-
tients may be so prone to outbursts of rage and frustration because the shared world
and individual minds are not clearly demarcated for them and they fully expect others
to know what they are thinking and feeling and to see situations in exactly the same way
they do. Thus, thwarting their intentions seems malign or willfully obtuse rather than
the result of a different point of view and alternative priorities. This makes such frus-
trations not merely hurtful but also intolerable, a denial of what they believe to be a
shared reality. These tendencies also help us to understand the clinicians working with
these patients, who are notoriously vulnerable to overidentification with the patient’s
anxieties, causing problematic complications in the countertransference (Gabbard
2005).
It is finally interesting to note that the neurocognitive systems involved in mental-
izing about self and others are also implicated in reflecting about past experiences and
one’s own self-concept (Spreng et al. 2009), capacities that play a key role in all forms of
psychotherapy. Importantly, activation of the medial PFC as a result of self-reflection
has been shown to deactivate automatic processes such as amygdala activation (Pasley
et al. 2004).
Cognitive Versus Affective Mentalization

Full mentalization entails the integration of cognition and affect, as expressed in no-
tions such as affective empathy and mentalized affectivity (Fonagy et al. 2002a; Jurist
2005). Hence, ideally, mentalization integrates aspects of the belief-desire reasoning
and perspective-taking (reflecting more controlled processes) emphasized in theory of
mind and the affective and embodied basis of such reasoning (reflecting more auto-
matic processes) that is central in research on affective empathy. Distinct but somewhat
overlapping neurocognitive systems are involved in these two capacities (Sabbagh
2004; Shamay-Tsoory and Aharon-Peretz 2007; Shamay-Tsoory et al. 2007). Cogni-
tively oriented mentalization involves several areas in the PFC, whereas affectively ori-
ented mentalizing is particularly related to the ventromedial PFC, which seems to play
an important role in “marking” mental representations of self and others with affective
information that subsequently can be integrated with cognitive knowledge such as be-
lief-desire reasoning (Rochat and Striano 1999). Thus, once again, a cortical midline
structure that is more based on abstract and linguistic processing can be distinguished
from an embodied and lateralized system.
This distinction is also congruent with research suggesting a distinction between a
more basic “emotional contagion” system and a more advanced cognitive perspective-
taking system (Shamay-Tsoory et al. 2009). Baron-Cohen et al. (2008) differentiated in
this context a Theory of Mind Mechanism, which processes so-called M-representa-
tions, involving Agent—Attitude—Propositions (e.g., “Mother—believes Johnny—
took the cookies”), and The Empathising System, which processes E-representations,
involving Self—Affective state—Propositions (e.g., “I am sorry—you feel hurt—by
what I said”). Moreover, Baron-Cohen argued that The Empathising System will al-
ways create representations in which the emotion in the other is consistent with the
self-affective state. For instance, it will not create the representation that “I am pleased
that you are in pain”; the state has to be a state that the self can generate in relation to
the presumed state in the other. Importantly, this constraint may be notably absent in
individuals with antisocial features (Blair 2008).
It is therefore important to realize that different forms of psychopathology may be
distinguished in terms of the inhibition, deactivation, or simply dysfunction of one or
both systems involved, leading to potential dissociations between both systems or diffi-
culties in integrating cognitive and affective aspects of mentalization.
It is well known that some individuals give undue weight to cognitive or affective
aspects of mentalizing (Allen et al. 2008). Thus, somewhat schematically, two types of
individuals can be distinguished. Some individuals show considerable cognitive under-
standing of mental states but are not in touch with the affective core of these experi-
ences. This can be typically observed, for instance, in patients with narcissistic and
antisocial personality features (Blair 2008; Blatt 2008). Conversely, patients with de-
pendent, borderline, or histrionic traits are often overwhelmed by automatic, affect-
driven mentalizing and lack the ability to integrate these affective experiences with
more reflective and cognitive knowledge (Blatt 2008). In these patients, it appears that
a more basic “emotional contagion” system overcompensates for impairments in the
cognitive perspective-taking system (Shamay-Tsoory et al. 2009). Hence, these latter
patients’ susceptibility to emotional contagion and oversensitivity to certain emotional
cues could be interpreted as an overcompensation for a dysfunctional Theory of Mind
Mechanism system. Moreover, and importantly, the constraint Baron-Cohen sug-
gested for The Empathising System—namely, the requirement for consistency with
the self-affective state—means that these individuals will tend to attribute their own
self-states to others. This leads to serious limitations in their capacity for genuine em-
pathy, and they show self-oriented distress when confronted with sadness or pain in
others rather than genuine other-oriented empathy. Hence, important clues for the as-
sessment of mentalizing abilities can be gained by considering the individual’s re-
sponses to suffering or pain in others and whether this elicits real other-oriented
empathy or self-oriented distress.
Conversely, patients who show considerable cognitive understanding of mental
states, yet without being in touch with the affective core of these experiences, may be
characterized by an overactive Theory of Mind Mechanism system and the inhibition,
deactivation, or simply dysfunction of The Empathising System (Blair 2008; Blatt
2008). These individuals often show hypermentalization, a form of pseudomentaliza-
tion, which often can be difficult to distinguish from genuine mentalizing. The exces-
sive length of narratives, devoid of real affective core, or devoid of any connection to
reality, may point the way to recognizing such pseudomentalization. They seem to
function in the pretend mode, a mode of thinking antedating full mentalization, which is
characterized by representational thought but unconnected to reality, manifest as free-
wheeling fantasies about internal states rather than genuine mentalization. At first, they
may seem to have extraordinary mentalizing capacities, but they cannot resonate with
the feelings underlying their mentalizing efforts (Allen et al. 2008). In addition, because
no real feelings or emotional experiences provide the individual with constraints, he or
she may misuse his or her cognitive capacity in self-serving ways (e.g., to get others to
care for or feel compassion toward him or her, or to control or coerce others).
Finally, some individuals (e.g., patients with somatoform complaints) seem to be
characterized by high levels of alexithymia (i.e., difficulties in identifying emotions and
distinguishing between feelings and the bodily sensations of emotional arousal). In
these patients, although The Empathising System and Theory of Mind Mechanism
both may be functioning properly, they may have specific difficulties with integrating
cognitive interpretations of emotional experiences and the bodily sensations associated
with these experiences (Bermond et al. 2006) rather than showing dissociations be-
tween the two systems.
In summary, different types of psychopathology might be characterized by an
overemphasis on either cognitive or affective aspects of mentalization and impairments
in the integration of the two. Deficits may be manifest at one or more phases in men-
talizing about internal states: 1) naming internal states (e.g., emotions), 2) differentiat-
ing internal states, and 3) expressing them (Allen et al. 2008). Naming is difficult for
many patients not only because they can be clueless about their internal states or deny
the importance of internal states but also because they are not able to go beyond very
general and broad categories. For instance, when asked what they feel, many patients
cannot go beyond stating that they feel tense or angry, without being able to be more
specific (e.g., feeling frustrated because someone prevented them from reaching a goal
or feeling “really pissed off”). Moreover, differentiating between internal states is dif-
ficult for many patients because most experiences and conflicts evoke different and of-
ten conflicting emotions (such as love and hate), and this may utterly confuse many
patients or astonish them if suggested. Simple interventions such as “What else did you
feel?” may help them to articulate such conflicting or complex internal states of mind.
Finally, full mentalization involves being able to modulate and express internal states of
mind. This more controlled process involves not only downtuning some internal states
(such as anger or sadness) but also the reverse (i.e., amplifying states of mind), partic-
ularly in patients who have little vocabulary for internal states of mind or who tend to
gloss over emotions because of dismissive tendencies and actively try to minimize,
avoid, and suppress emotions (Allen et al. 2008). Further expression of internal states of
mind may lead to other states of mind that may be hidden underneath, and, ideally, such
expression and modulation subsequently lead to attitudinal and behavior changes, giv-
ing patients a sense of self-efficacy and control.
Although the pattern of limitations in mentalizing capacity may differ across indi-
viduals and diagnostic conditions, we suggest that in most severe disorders that involve
the personality, imbalanced mentalization on one of the four polarities described ear-
lier would be evident in adults with clinical mental disorder.
Consequences of Inhibited Mentalization:

Reemergence of Prementalistic
Representation of Internal States
We assume that the absence of fully functioning mentalization is most evident through
the reemergence of prementalistic modes of representing subjectivity. The clearest of
these, normal in a 20-month-old child, is the tendency to assume that mental states are
direct representations of psychic reality (Gopnik and Meltzoff 1997). Mentalization
gives way to a kind of “psychic equivalence” (Target and Fonagy 1996) that clinicians
often consider under the heading of “concreteness of thought.” What is thought is ex-
perienced as real and true. By the same token, through the omnipotence of subjectivity,
everything that is out there is also assumed to be known. The young child and at times,
for example, the individual with BPD have an overriding sense of certainty in relation
to their subjective experience. The hypothesis that a situation is dangerous (“There is a
tiger under the bed” or “these drugs are harming me”) demands extreme measures of
avoidance because it is experienced in the mode of psychic equivalence, so that even a
passing thought feels real. No alternative perspectives are possible. The experience of
doubt is suspended. Life can sometimes be terrifying because it is “for real.” This can
add drama and risk to interpersonal experience. The sometimes exaggerated reactions
of patients are justified by the seriousness with which they suddenly experience their
own and others’ thoughts and feelings. The vividness and bizarreness of subjective ex-
perience can appear as quasi-psychotic symptoms of BPD patients (Zanarini et al.
1990) and are also manifest in the physically compelling memories associated with
posttraumatic stress disorder (Morrison et al. 2003).
Disturbances of subjective experience linked to a failure of mentalization also can
take other forms. Thoughts and feelings can come to be almost dissociated to the point
of near meaninglessness. The young child creates mental models and pretend worlds
but can maintain these only so long as they achieve complete separateness from the
world of physical reality (Gopnik 1993). In an analogous manner, patients can discuss
experiences without contextualizing these in any kind of physical or material reality as
if they were creating a pretend world. Attempting psychotherapy with patients who are
in this pretend mode can lead the therapist to lengthy but inconsequential discussions
of internal experience that have no link to genuine experience.
Developmentally early modes of conceptualizing action solely in terms of that
which is apparent can come to dominate motivation. Within this “teleological,” out-
comes-oriented mode, the physical and observable dominate. Experience is thought to
be valid only when its consequences are apparent to all. Affection, for example, is true
only when accompanied by a physical expression (e.g., a touch or caress).
The most socially disruptive consequence of the failure of mentalization is the ten-
dency to create unacceptable experience within the other. We speculate that a child
who cannot develop a representation of her own experience through mirroring (the
self) internalizes the image of the caregiver as part of her self-representation (Winni-
cott 1956). We have called this discontinuity within the self the alien self. We under-
stand the controlling behavior of children with a history of disorganized attachment
(Kochanska et al. 2001; Solomon et al. 1995) as persistence of a pattern analogous to
projective identification, in which the experience of incoherence within the self is re-
duced through externalization. The intense need for the caregiver, which is character-
istic of separation anxiety in middle childhood that is associated with disorganized
attachment (e.g., Moss et al. 2004), might reflect the intense need for the caregiver as a
vehicle for externalization of the alien part of the self rather than simply indicating an
insecure attachment relationship. Externalization of the split-off parts of a disorga-
nized self is desirable for the child with a disorganized attachment, but it is a matter of
life and death for a traumatized individual who experiences the abuser as an internal-
ized part of the self, creating a sense of intolerable badness within. The externalization
of these internal states is widely recognized in the common countertransferential reac-
tions of therapists working with borderline patients—anger and hatred, helplessness
and worthlessness, fear and worry, resentment, and urges to save and rescue the patient
(Gabbard and Wilkinson 1994).
The alternative to using projective identification is obtaining relief from experi-
ences of overwhelming and intolerable emotion through the destruction of the self in a
teleological mode (i.e., physically, by self-harm and suicide) (Kullgren 1988; Yen et al.
2002). These and other actions also can serve to create a terrified alien self in the
other—therapist, friend, or parent—who thus becomes the vehicle for what is emotion-
ally unbearable. Not surprisingly, the need for this other who “uniquely understands”
(and thereby suffers) the patient’s dysregulated affect can become overwhelming, and an
adhesive, addictive pseudoattachment to this individual may develop.
We see the capacity to mentalize as particularly helpful when people have been
traumatized. Mentalization of adversity is capable of moderating its negative sequelae
(Fonagy et al. 1994; Stein et al. 2000). The capacity to mentalize gives those who are
subjected to traumatic experiences the power to hold back modes of primitive mental
functioning whose reemergence may have adverse effects. It makes conceptual sense,
then, that mentalizing should be a focus for therapeutic intervention if we are to help
such patients bring disrupted modes of mental functioning under better regulation and
control.
“Changing Your Mind”: Psychotherapy,

Improved Mentalization, and the Brain
Psychotherapeutic techniques are effective because they change both minds and brains.
We believe that the talking therapies exercise their therapeutic effects via their benign
effect on mentalization (Allen et al. 2008). Psychotherapy across a range of modalities

attempts to enhance mentalization, in part by activating an attachment context, which
in humans (as we have seen) provides the relational basis for finding out about minds
(our own minds and those of benign others). Numerous features, which are present to
a degree in all forms of therapy, are likely to elicit the universal dynamic described by
Bowlby (1977) for creating affectional bonds. Bowlby (1969) attributed the strength of
this need to the extended period of immaturity in human development when the urgent
subjective need for interpersonal proximity, triggered by fear, serves the evolutionary
function of ensuring the child’s safety. According to Bowlby (1988b), attachment to a
particular individual is created even in adulthood, when the activation of the behavioral
system for attachment is reciprocated by adult caregiving behaviors.
Attachment is likely to be powerfully activated when an individual in distress re-
quires assistance with self-regulation from a trusted other. The attachment system is
further activated by extensive discussions of current and past attachment relationships,
which intensify the prominence of current internal working models of attachment re-
lationships. The therapist offers assistance with the patient’s regulation of affect in
many ways, but often by contingent marked responding to the patient’s affect and by
creation of a safe and sensitive interpersonal environment (Gergely 2007). More ex-
plicitly, regardless of orientation, in the context of the therapeutic encounter, the ther-
apist creates alternative perspectives on mental experience, whether by interpreting the
transference or by working with the patient to recover from misunderstandings or rup-
tures of the therapeutic alliance. In general, the therapist has the overarching goal of
generating a safe and sensitive interpersonal environment that assists with the patient’s
regulation of affect while enhancing his or her focus on mentalizing. In some treat-
ments, the therapist explicitly encourages the patient to develop an attachment bond to
the therapist (an invitation hardly necessary for many patients). Most of the time, at-
tachment to the therapist is achieved through verbal and nonverbal strategies, which
inevitably, even if implicitly, activate attachment (“therapese” is used in much the same
way that most mothers quickly learn to speak “motherese” to their infants). In the con-
text of group therapy, the therapist may attempt to engender attachment bonds be-
tween members of the group.
Thus, it is almost inevitable that the therapeutic relationship will activate the at-
tachment system. However, is this inevitably a contributor to healing, as Bowlby
(1988a) suggested? In their earliest encounters with the psychotherapeutic process,
Freud and Breuer (1895) found that at least in some individuals, the intensity of the
bond stimulated may be nothing short of overwhelming for the patient. Can we under-
stand such overreaction via an attachment theory perspective? A psychotherapeutic hy-
peractivation of the attachment system can occur in such treatments. The emotional
challenge of the therapeutic situation gives rise to mild anxiety or even distress in the
patient, which is biologically designed to activate the attachment system and generate
proximity-seeking behavior with the aim of eliciting caregiving behavior from an adult.
A sensitive therapist responding humanely to interpersonal distress and exploring its
causes will trigger the psychological system selected over millennia to generate a pow-
erful affectional bond in the patient. The activation of the attachment system may be
benign for the most part, but the reactivation of attachment relationship schemas in in-
dividuals with highly insecure or disorganized attachment histories will inevitably cre-
ate emotionally challenging experiences for the patient in the therapeutic setting.
For example, consider a woman who as a child occasionally felt rejected by her
mother, particularly at times of great emotional need. To make matters worse, she be-
lieved that her sister received more unconditional care. Given the activation of these
relationship models, while remembering her past the patient will be hypersensitive
when the therapist fails to be immediately attentive. She will be especially sensitive to
the comings and goings of the other patients for whom the therapist has professional
responsibility. The activation of childhood relationship schemas thus has created re-
peated emotional challenges in the therapeutic experience of this individual with an in-
secure attachment history. Of course, the distress and anxiety generated by these
challenging experiences of therapeutic sibling rivalry will trigger the patient’s attach-
ment system further, generating even more proximity seeking. This triggers caregiving
behavior in the therapist, thus strengthening the affectional bond. The intensity of the
attachment increases the potential for emotionally challenging encounters in relation
to other patients or slight rejections by the therapist. Thus, for those in whom high-
conflict internal working models have been activated, the therapeutic situation often
generates distress that intensifies the attachment relationship, leaving the patient even
more open to experiencing future distress associated with the treatment.
Depending on the model of psychotherapy, we could look at this type of scenario in
at least two different ways. The psychotherapeutic hyperactivation of the attachment
system could be thought of as creating an opportunity for the patient to work through
high-conflict relationship models that are triggered in numerous other relational con-
texts that cause the patient significant difficulties. It is better to experience, express, re-
flect on, and resolve problematic high-conflict models of interpersonal relationships,
and psychotherapy offers an opportunity to do so. This clearly would be the preferred
perspective of most psychodynamic psychotherapists (e.g., Davies 2004). Even from a
cognitive-behavioral therapy (CBT) perspective, we may see clear justification for ex-
ploring emergent schemas, testing their validity and robustness (Young 1999).
However, from the perspective of the mentalizing model of psychotherapeutic
process, the hyperactivation of the attachment system calls for caution. Good evidence
indicates that intense activation of the neurobehavioral system underpinning attach-
ment is associated with deactivation of affect regulation systems (Luyten et al., submit-
ted 2011a), as well as the deactivation of neurocognitive systems likely to generate
interpersonal suspicion (i.e., those involved in social cognition or mentalization, in-
cluding the lateral PFC, medial PFC, lateral parietal cortex, medial parietal cortex, me-
dial temporal lobe, and rostral anterior cingulate cortex) (Bartels and Zeki 2000, 2004;
Lieberman 2007; Mayes 2000, 2006; Satpute and Lieberman 2006). The saying “Love
is blind” exists in most human languages and expresses the incompatibility of powerful
activation of the attachment system with meaningful (as opposed to ruminative) con-
templation of mental states. Put simply, as attachment intensifies and arousal increases,
mentalization switches from a primarily controlled, reflective, internally focused, cog-
nitively complex, prefrontally guided process to an automatic, externally focused, emo-
tionally intense, posterior-cortically and subcortically driven process.
How might this attachment perspective affect psychotherapy, given its overarching
aim of enhancing the capacity for mentalization? The intensification of attachment as-
pects of the therapist-patient relationship will initially play an important role in
strengthening the patient’s focus on mental states, probably increasing curiosity and ac-
curacy. To benefit from this focus on mental states, the therapist has to retain a capacity
for “marked” mirroring. Just as the securely attached mother appears to be able to
markedly mirror her infant’s sadness rather than being overwhelmed by it (Strathearn
et al. 2009b), therapists must be able to indicate attunement and compassion while
communicating self-other differentiation through “marking” their mirroring with in-
dications of coping in their affect displays (e.g., exaggerated, slowed-down, schematic,
or only partial motor execution of their primary canonical motor pattern; Fonagy et al.
2002a; Gergely 2004, 2007; Gergely and Unoka 2008; Gergely and Watson 1996).
Work on videotaped short-term therapy has shown that more experienced and more
effective therapists show less obvious facial affect in response to patients than do inex-
perienced ones (Anstadt et al. 1997). Perhaps experienced therapists are more aware
that showing too much empathy could overstimulate the patient. To be optimally ef-
fective, therapists must be able to stop short of creating attachment system hyper-
arousal by “stoking” the system. They must avoid intensifying the attachment
relationship to the point that risks hyperstimulation and disorganization. Overactivat-
ing attachment undermines the patient’s mentalizing capacity, leaving him or her un-
able to benefit from the treatment despite the intense attachment it offers. At that
point, because mentalizing is reduced, memories of insecure relationship patterns
come to dominate the patient’s mind and color his or her experience of the therapeutic
relationship. The resulting (mis)perceptions are experienced “as if real” in the non-
mentalizing transferential heat of the disorganization of therapeutic attachment. Tele-
ologically motivated behaviors (“enactments”) may occur with great frequency. If
mentalizing is replaced by pretend mode, much may be said, but little will mean any-
thing.
When working with patients with disorganized self-structures, it is particularly im-
portant for therapists to be aware of moment-to-moment changes in the patient’s men-
tal state and to be ready to step back from the heat of the encounter (Bateman and
Fonagy 2006a). Tragically, as we have noted elsewhere (Fonagy and Bateman 2006b),
interpretations demanding considerable reflective capacity are often given when the
patient is least able to grasp and implement the implications of the therapist’s comment.
We contend that psychological therapy works by simultaneously activating what
may be two mutually inhibitory sets of brain systems. The therapist attempts to en-
hance mentalizing by using specific techniques (e.g., interpreting actions, calling for
reflection) and generically encouraging and taking an interest in the patient’s mental
world. At the same time, the therapist also deliberately and purposefully activates the
attachment system. Thus, therapy generates a paradoxical state by maintaining the re-
quirement for a mental state focus while at the same time directly activating attach-
ment. We hypothesize that this complex mental state (which we have previously labeled
mentalized affectivity; Fonagy et al. 2002a) generates the insight into emotional experi-
ence that psychotherapy provides.
For both parties to the therapeutic encounter, it can be quite a challenge to main-
tain a mental state focus while keeping the attachment system active. This is perhaps
where the science of psychotherapy enters the realm of a performance art (Allen 2006).
The paradoxical pattern of activation is maintained in two ways: 1) by titrated activa-
tion of negative emotions, as the therapist encourages the patient to confront current
adversities and traumatic experiences, and 2) by encouragement to retrieve affect-laden
episodic memories, including traumatic memories.
If psychotherapy demands the paradoxical activation of two normally mutually in-
hibitory systems within the brain, what does this achieve? Why is it essential for ther-
apy to activate the attachment system? Why is the therapeutic alliance a necessary
condition for change? Why does a stronger alliance predict greater change, with early
alliance predicting improvement in symptoms at end of treatment (e.g., Horvath and
Bedi 2002; Orlinksy et al. 2004)?
Therapeutic technique activates systems associated with negative emotions at the
same time that social and moral judgments and mentalizing are partially inhibited by
the attachment system. The patient is asked to look at memories and thoughts while
making use of the wired-in connections of the attachment system that serve in a sense
to anesthetize the patient from the full reality of the experience. Unless the attachment
system is overaroused, the patient looks at himself or herself through the rose-colored
spectacles that positive attachment experiences provide. Psychotherapy entails more
(and more accurate and intense) thinking about feelings, thoughts, and beliefs than is
normally available, delivered by moderate activation of attachment. We speculate that
the activation of attachment feelings creates a brain state that reduces the dominance of
constraints on understanding the present by way of the past and thus creates the pos-
sibility of rethinking and reconfiguring intersubjective relationship networks. In psy-
choanalytic discourse, authors may have used Winnicott’s concept of “transitional
space” (Winnicott 1953) to denote this particular therapy-specific mental state (e.g.,
Adler 1989; Auerbach and Blatt 2001; Elmhirst 1980; Gaddini and Gaddini 1970).
In Freud’s (1900) considerations of the origins of dynamic psychotherapy, he came
upon Schiller’s 1788 comments, which to his mind described the phenomenon of de-
activated constraints on cognition that we are also attempting to describe here: “[O]n
the other hand, where there is a creative mind, Reason—so it seems to me—relaxes its
watch upon the gates, and the ideas rush in pell-mell, and only then does it look them
through and examine them in a mass” (Schiller 1788, as cited in Freud 1900, p. 103).
Freud goes on to recognize explicitly the same phenomenon but misses the crucial role
that attachment (the therapeutic relationship) has in making the process possible: “[A]n
attitude of uncritical self-observation...is by no means difficult. Most of my patients
achieve it after their first instructions. I myself can do so very completely, by the help of
writing down my ideas as they occur to me” (Freud 1900, p. 103). We can bring no ev-
idence to bear on the extent to which Freud’s statement about his ability to achieve this
state of mind by himself can be considered veridical. Let the record state, however, that
since Freud, few have found self-understanding and insight readily on their own with-
out the presence of another mind skillfully working to create and maintain a setting
within which acute self-perception is possible because overwhelming moral scrutiny is
reined in as a result of the activation of the attachment system, which is associated with
the inhibition of brain systems mediating aspects of critical thinking about the present.
We suggest that the psychological therapies affect the brain by providing an envi-
ronment in which the patient is repeatedly exposed to new perceptual stimuli, making
new learning possible. New stimuli include new approaches to monitoring one’s own
thoughts and feelings, new verbal formulations of experience, new behavioral re-
sponses to fear, or new appraisals of experience encoded in memory. All psychothera-
peutic techniques enhance mentalization processes to some degree, although some
techniques may be more effective than others, depending on which aspect of mental-
izing is in need of reinforcement. All patients in mental distress can benefit from psy-
chological therapy, but it is important to use the right technique for the presenting
complaint and to review each patient’s treatment needs regularly.
Although all psychotherapies present novel stimuli, by way of fresh reflections on
the patient’s mind (fresh metacognitive content), this is rarely done outside the thera-
peutic relationship. We propose that a brain-level explanation exists for this constraint,
too. Mild activation of the attachment system appears to facilitate mentalizing and thus
helps the therapist encourage the patient to adopt a controlled, internally focused, self-
other differentiated stance toward his or her mental state. However, for reasons that
may carry selective advantage from an evolutionary perspective, the intense activation
of the networks underpinning attachment feelings and experiences also appears to in-
hibit the intensity of cognitive and emotional scrutiny over mental contents. This state
of affairs creates a unique opportunity for the psychotherapist. By balancing the acti-
vation of attachment against the presentation of negative mental contents, the psycho-
therapist is able to present new mental contents to the patient without evoking mental
resistance against the incorporation of new ways of experiencing the world into existing
cognitive-emotional schemas.
This process can be compromised by the hyperactivation of the attachment sys-
tem. This is predictable given what we know about the attachment system and psycho-
therapy. When the therapy itself gives rise to distress and fear, perhaps because material
emerges that frightens the patient and the therapist is unable or unwilling to offer re-
assurance, the patient’s attachment system inevitably will be activated. Proximity seek-
ing to a therapist who lacks the capacity to soothe or whose interventions are designed
to create additional anxiety at these moments will risk causing disorganization to the
therapeutic attachment system. This state of affairs is of course most likely to occur
with individuals who have had exceptionally adverse attachment experiences. When
such experiences are reactivated by the process of the therapy, this can lead to experi-
ences of distress in the context of the therapeutic relationship. In these instances, the
balance of mentalizing and attachment needs to be redressed before meaningful ther-
apeutic work can begin. If this is not achieved, the treatment might become one of
those 5%–10% of cases in which therapy not only fails to lead to improvement but also
causes unintended harm to the patient. We hope that appropriate consideration of the
factors that can serve to impair mentalization might serve to reduce the frequency with
which these regrettable events occur.
Treatment Implications
The therapeutic implications of the model outlined in this chapter are extensive and are
elaborated in detail in subsequent chapters. Our formulation implies the need to aban-
don the overvaluation of specific techniques in favor of a generic therapeutic stance
that cuts across theoretical modalities. Here we touch on some salient points about
mentalization-based treatments summarized in greater detail elsewhere in this book
and in other monographs (Allen et al. 2008; Bateman and Fonagy 2004, 2006a).
From the perspective developed in this chapter, the overall aim of treatment
should be simultaneously to stimulate a patient’s attachment and involvement with
treatment and to help him or her maintain mentalization. A titrated but more or less
exclusive focus on the patient’s current mental state while activating the attachment re-
lationship is expected to enhance the patient’s mentalizing capacities without generat-
ing iatrogenic effects as it inevitably activates the attachment system. Hence, treatment
should avoid situations in which patients are expected to talk of mental states that they
cannot link to subjectively felt reality. Thus, with regard to dynamic therapies, this con-
cern implies that there should be:
1. A deemphasis of deep unconscious interpretations in favor of conscious or near-

conscious content
2. A modification of therapeutic aim, especially with severely disturbed patients, from
insight to recovery of mentalization (i.e., achieving representational coherence and
integration)
3. A careful eschewing of descriptions of complex mental states (conflict, ambiva-
lence, unconscious) that are incomprehensible to a person whose mentalizing is
vulnerable
4. Avoidance of extensive discussion of past trauma, except in the context of reflecting
on current perceptions of the mental states of maltreating figures and on changes in
mental state from one’s past as a victim to one’s experiences now
Our theoretical model also implies that to maximize effect on the patient’s ability
to consider thoughts and feelings in relationship contexts, especially in the early phases
of treatment, the therapist is probably most helpful when interventions:
1. Are simple and easy to understand

2. Are affect focused
3. Actively engage the patient
4. Focus on the patient’s mind rather than on behavior
5. Relate to current events or activities (the patient’s currently felt mental reality) in
working memory
6. Make use of the therapist’s mind as a model (i.e., by talking to the patient about how
the therapist anticipates that he or she might react in the situation being discussed)
In addition, the therapist must be able to adjust the complexity and emotional intensity
of interventions flexibly in response to the intensity of the patient’s emotional arousal
(withdrawing when arousal and attachment are strongly activated).
The key task of therapy is to promote curiosity about the way mental states moti-
vate and explain the actions of self and others. Therapists achieve this through judicious
use of the “inquisitive stance,” highlighting their own interest in the mental states un-
derpinning behavior, qualifying their own understanding and inferences (showing re-
spect for the opaqueness in mental states), and showing how such information can help
the patient to make sense of his or her experiences. Pseudomentalization and other fill-
ers to replace genuine mentalization must be explicitly identified by therapists, and the
lack of practical success associated with them should be clearly highlighted. In this way,
therapists can help their patients to learn about how they think and feel about them-
selves and others, how that shapes their responses to others, and how errors in under-
standing self and others may lead to inappropriate actions.
Put simply, the therapist should not tell patients how they feel; what they think;
how they should behave; or what may be the underlying reasons, conscious or uncon-
scious, for their difficulties. Any therapy approach that moves toward claiming to know
how patients are, how they should behave and think, and why they are the way they are
is likely to be harmful to patients whose capacity to mentalize is vulnerable. This prin-
ciple applies to CBT as much as to psychodynamic psychotherapy. For example, David-
son and colleagues (2007) reported that high levels of therapists’ integrative complexity
(an indication of the number of ideas being combined in a single statement) were as-
sociated with poor outcome in CBT, whereas patients’ increases in integrative com-
plexity marked improvement in social functioning.
From a practical standpoint, an effective mentalization-based intervention may
unfold along the following lines:
1. The therapist identifies a break in mentalizing (described earlier as psychic equiv-

alence, pretend, or teleological modes of thought)
2. Patient and therapist rewind to the moment before the break in subjective conti-
nuity
3. The current emotional context for the break in the session is explored by identify-
ing the momentary affective state between patient and therapist
4. The therapist explicitly identifies and owns up to his or her own contribution to the
break in mentalizing
5. The therapist seeks to help the patient understand the mental states implicit in the
current state of the patient-therapist relationship (mentalize the transference)
The therapist’s mentalizing therapeutic stance should include the following:
1. Maintaining humility derived from a sense of not knowing

2. Taking time to identify differences in perspectives whenever possible
3. Legitimizing and accepting different perspectives
4. Actively questioning the patient about his or her experience, asking for detailed de-
scriptions (“what” questions) rather than explanations (“why” questions)
5. Eschewing the need to understand what makes no sense (i.e., saying explicitly that
something is unclear)
An important component of this stance is monitoring and acknowledging one’s own

mistakes as a therapist. This not only models honesty and courage and tends to lower
arousal through the therapist taking responsibility but also offers invaluable opportu-
nities to explore how mistakes can arise out of incorrect assumptions about opaque
mental states and how misunderstanding can lead to massively aversive experiences. In
this context, it is important to be aware that the therapist is constantly at risk of losing
his or her capacity to mentalize in the face of a nonmentalizing patient. Consequently,
we consider therapists’ occasional enactments as an acceptable concomitant of the
therapeutic alliance, something that simply has to be owned up to. As with other in-
stances of breaks in mentalizing, such incidents require that the process be rewound
and the incident explored. Hence, in this collaborative patient-therapist relationship,
the two partners involved have a joint responsibility to understand enactments.
Conclusion
In this introductory chapter, we hope that we have set the scene for the application of the
principles of a mentalization-based clinical approach to a range of patient groups seen by
psychiatrists and other mental health professionals in various contexts. We hope we have
made the all-important point about the fundamental nature of the capacity to mentalize,
which invariably will play a part in any mental health intervention. It is at the core of psy-
chological treatment that we take into consideration the patient’s experience of his or
her own mental states, and with this, we also take on board the patient’s experience of the
thoughts and feelings of others. We have noted that these ideas can condition the sense
of self and that turning to a trusted other in moments when one’s confidence in the
strength of one’s own subjectivity is weakened is a universal human predisposition that
antedates the “talking cure.” Patients hope to recover a more robust experience of their
self-representation through understanding others’ views of them. It is vital to maintain
a sense of this process, regardless of orientation or treatment approach. If we do not pay
attention to the patient’s need to see himself or herself through our eyes as mental health
professionals, we risk harming the individuals whom we have committed ourselves to
protect.
Suggested Readings
Allen J, Fonagy P, Bateman A: Mentalizing in Clinical Practice. Washington, DC, American
Psychiatric Publishing, 2008
Allen J, Fonagy P (eds): Handbook of Mentalization Based Treatment. Chichester, UK, Wiley,
2006
Bateman A, Fonagy P: Mentalization based treatment for borderline personality disorder. World
Psychiatry 9:11–15, 2010
Fonagy P, Bateman A: The development of borderline personality disorder: a mentalizing mod-
el. J Pers Disord 22:4–21, 2008
Fonagy P, Bateman A: Mentalizing and borderline personality disorder. J Ment Health 16:83–
101, 2007
CHAPTER 2
Assessment of
Mentalization
As we saw in Chapter 1, many different kinds of impairments in mentalization exist

that necessitate a partially different treatment approach and focus. It is therefore es-
sential to assess and monitor a patient’s mentalizing abilities in detail with respect to
the polarities underlying mentalization, both before and during treatment. A detailed
knowledge of the specific types of impairments in mentalization—particularly the spe-
cific attachment contexts in which these impairments are manifested—may not only
inform the focus of treatment but also alert the assessor and future therapist to the type
of relationship and the associated mentalizing deficits that are likely to develop, and
thus may serve as an important “transference tracer” later in treatment (Bateman and
Fonagy 2006a). Therefore, an evaluation of an individual’s mentalizing depends on de-
tailing his or her mentalizing profile, that is, the individual’s functioning with respect to
each of the polarities underlying mentalizing, particularly because there may be disso-
43
ciations between these polarities (e.g., impairments within one polarity but not within
other polarities) (Luyten et al., submitted 2011c).
In this chapter, we provide specific guidelines for the assessment of mentalization
based on the assumption that mentalization is a multifaceted construct and that both
contextual factors and individual differences in attachment affect mentalizing. Evalua-
tion of individuals’ mentalizing depends on their functioning with respect to each of
the four polarities entailed in mentalization. It also depends on individual differences in
attachment strategies that influence the dynamic relationship between arousal or stress
and mentalization. When assessing an individual’s mentalizing, it is important to real-
ize that mentalizing is not restricted to thoughts or feelings but extends to the whole
gamut of mental states imaginable. This is particularly important in assessing an indi-
vidual’s ability to explore both his or her own inner world and that of others. We discuss
the relationship-specific and interpersonal nature of mentalizing and summarize both
structured and unstructured assessment methods for mentalizing.
Individual Differences in
Attachment, Mentalization, and Stress
As discussed in Chapter 1, mentalization is not a static, unitary capacity but a dynamic,
multifaceted ability. In this section, we consider the relation between mentalizing and
stress or arousal, particularly in the context of attachment relationships. Individuals dif-
fer in their use of attachment deactivation or hyperactivation strategies (Mikulincer
and Shaver 2007) and introjective or anaclitic cognitive-affective styles (Blatt and
Luyten 2009) for mentalization (Fonagy and Luyten 2009; Luyten et al., submitted
2011c). A consideration of the relation between mentalization stress and arousal also al-
lows us to specify further the nature of genuine mentalizing as opposed to modes of
thinking that antedate full mentalization, including hypermentalizing and pseudomen-
talizing.
Our starting point is the paradoxical relationships among attachment, stress, and
mentalization. Studies have shown that activation of the attachment system is associ-
ated with activation of the mesocorticolimbic dopaminergic system, which plays a vital
role in the brain’s reward circuitry (Insel and Young 2001; Strathearn et al. 2008) and is
associated with increased sensitivity to social cues, decreased stress levels, and de-
creased social avoidance (Fonagy and Luyten 2009; Luyten et al., submitted 2011c). Yet
at the same time, activation of this system has been associated with a relative deactiva-
tion of arousal and affect regulation systems, as well as of neurocognitive systems in-
volved in mentalization, including the lateral prefrontal cortex (PFC), medial PFC,
lateral parietal cortex, medial parietal cortex, medial temporal lobe, and rostral anterior
cingulate cortex (Bartels and Zeki 2000, 2004; Bull et al. 2008; Hurlemann et al. 2007;
Lieberman 2007; Mayes 2000, 2006; Satpute and Lieberman 2006). This complex set
Assessment of Mentalization 45
Prefrontal/ Posterior cortex and

controlled subcortical/automatic
Mentalization
Switch point
Arousal/stress
FIGURE 2–1. Biobehavioral switch model of the relation between stress and controlled
or automatic mentalization.
of associations with social behavior and stress responses may help us to account for the
puzzling combination of facilitative and inhibitory associations between attachment
history and mentalization.
More specifically, there is now good evidence to suggest that the relative activation
and deactivation of these systems is closely related to arousal and stress regulation
(Heinrichs and Domes 2008; Lieberman 2007; Mayes 2006). In this context, on the ba-
sis of Arnsten’s (1998) dual-process model, Mayes (2000, 2006) proposed that with in-
creasing stress, a switch from more prefrontal, controlled, and executive modes of
functioning to more automatic modes of functioning occurs (see Figure 2–1). The
biobehavioral switch model depicted in Figure 2–1 proposes that individual differences
in the use and strength of attachment hyperactivation and deactivation strategies in re-
sponse to stress determine three key parameters in the switch from controlled to auto-
matic mentalization: 1) the intercept (threshold) at which this switch happens; 2) the
strength of the relationship between stress and activation of controlled versus auto-
matic mentalization (slope); and 3) the time to recovery from stress with return to con-
trolled mentalization (see Figure 2–1 and Table 2–1).
Evidence from behavioral, physiological, neurobiological, and neuroimaging
studies indeed suggests that this neurobiological switch from cortical to subcortical
systems, and hence from controlled to automatic mentalizing and subsequently
nonmentalizing modes as a result of stress or arousal, is related to the relative use of at-
tachment hyperactivation and deactivation strategies (see Figure 2–1 and Table 2–1)
(Fonagy and Luyten 2009; Luyten et al., submitted 2011c). Attachment hyperactiva-
tion strategies, which are typically used by anxious attached individuals (i.e., those with
a preoccupied attachment style), usually lead to frantic efforts to find support and relief,
often expressed in demanding, clinging, and claiming behavior. Attachment deactiva-
tion strategies, typically observed in avoidant individuals (i.e., those with fearful-
avoidant and particularly dismissive attachment), involve denying attachment needs
and asserting their own autonomy, independence, and strength in an attempt to down-
regulate stress.
Therefore, somewhat schematically, the following four prototypical interactions
among attachment strategies, stress, and mentalization can be distinguished.
Attachment Hyperactivation Strategies

Attachment hyperactivation strategies in response to stress (Mikulincer and Shaver
2007) are associated with a low threshold for deactivation of brain areas involved in
controlled mentalization, and thus, more automatic, subcortical systems, including the
amygdala, have a low threshold for responding to stress (see Table 2–1). This combi-
nation of features explains anxiously attached individuals’ tendency to attach easily and
quickly to others, often resulting in many disappointments, not only because of the low
threshold for activation of the attachment system but also because of their low thresh-
old for deactivation of neural systems associated with controlled mentalization, includ-
ing neural systems involved in judging the trustworthiness of others (Allen et al. 2008;
Fonagy and Bateman 2008). Moreover, given the evidence for excitatory feedback
loops leading to increased vigilance for stress-related cues in individuals who use hy-
peractivating strategies (Mikulincer and Shaver 2007), these individuals may also show
an increased time to recovery of mentalization. Hence, they may require considerable
time to be able to recover the capacity for controlled mentalization, and such instances
during assessment (e.g., as a result of actively probing or challenging automatic as-
sumptions) should be interpreted by clinicians as a clear warning against referring such
patients to an overly interpretive approach.
Attachment Deactivation Strategies

By contrast, individuals who primarily use attachment deactivation strategies are able
to keep “online” for longer periods the neural systems involved in controlled mental-
ization, including those involved in judging the trustworthiness of other individuals
(Vrticka et al. 2008; see Table 2–1). Hence, as noted earlier, this may make it particu-
larly difficult to distinguish pseudomentalization driven by deactivation strategies from
genuine mentalization. Aside from the often excessive, overly cognitive, and pretend
TABLE 2–1. Attachment strategies, arousal, and mentalizing
Attachment Threshold for Strength of automatic Recovery of controlled

strategy switch response mentalization
Secure High Moderate Fast
Hyperactivating Low (hyperresponsive) Strong Slow
Deactivating Relatively high Weak (but moderate Relatively fast
(hyporesponsive, to strong under
but with failure under increasing stress)
increasing stress)
Disorganized Incoherent Strong Slow
(hyperresponsive,
but often with
frantic attempts
to downregulate)
mode quality of such mentalizing, it has been shown that under increasing levels of
stress, these deactivating strategies tend to fail, leading to a strong reactivation of feel-
ings of insecurity, heightened reactivation of negative self-representations, and in-
creased levels of stress (Mikulincer et al. 2004). Hence, mentalization deficits in
dismissive and avoidant individuals are more likely to be observed in the context of set-
tings that provide a strong challenge and thus strong activation of the attachment sys-
tem, such as in studies collecting Adult Attachment Interview (AAI; George et al. 1985)
narratives (e.g., Fonagy et al. 1996; Levinson and Fonagy 2004), which typically in-
clude many demand questions about affectively charged issues such as one’s own at-
tachment history. Yet deactivating strategies are also associated with a relatively brief
time to recovery of the capacity of mentalization (Mikulincer and Shaver 2007), making
it even more difficult to distinguish pseudomentalization from genuinely high levels of
mentalization. Furthermore, research has found that individuals who use deactivating
strategies may show considerable biological stress indications (such as increases in
blood pressure) but at the same time not only appear to be calm but also report that
subjectively they feel nondistressed (Dozier and Kobak 1992; Luyten et al., submitted
2011a). Potential indicators of such dissociation between subjective and biological dis-
tress, however, include the observation that individuals either appear as too calm for the
situation (e.g., talking about a history of emotional neglect without showing any signs
of discomfort), cannot provide examples illustrating general statements (e.g., cannot
provide specific attachment experiences supporting general statements), or first appear
to be calm but then suddenly become extremely uncomfortable (e.g., start sweating or
suddenly start feeling dizzy). In addition, these individuals then often attribute these
sudden changes not to the topic under discussion but to external circumstances (e.g.,
that they have not eaten enough that day and therefore feel dizzy).
Disorganized Attachment Strategies

Individuals with disorganized attachment may show both marked deficits in mentaliza-
tion and a tendency for hypermentalization (Bateman and Fonagy 2004) related to
their use of deactivating strategies when hyperactivating strategies fail or vice versa, of-
ten resulting in marked oscillations (see Table 2–1). On the one hand, the use of hy-
peractivating strategies is associated with a decoupling of controlled mentalization,
which leads to failures in understanding mental states of self and others as a result of an
overreliance on models of social cognition that antedate full mentalizing (Bateman and
Fonagy 2006a). On the other hand, attachment deactivating strategies are typically as-
sociated with minimizing and avoiding affective content, and thus individuals who use
these strategies also have a tendency for hypermentalization (i.e., continuing but un-
successful attempts to mentalize).
Secure Attachment Strategies

Secure attachment is related to the capacity to retain high levels of mentalizing, even
when in stressful situations, and to the relatively fast recovery of mentalizing capacities
(see Table 2–1). As noted, temporary lapses in mentalization are part of normal func-
tioning, but the abilities to adaptively switch from automatic to controlled mentaliza-
tion, to continue to mentalize even under stressful circumstances, and to recover
relatively quickly from lapses of mentalization are the hallmarks of genuine mentaliza-
tion. Moreover, the ability to continue to mentalize even under considerable stress is
associated with so-called broaden and build (Fredrickson 2001) cycles of attachment se-
curity, which reinforce feelings of secure attachment, personal agency, and affect reg-
ulation (“build”) and lead one into different and more adaptive environments
(“broaden”) (Mikulincer and Shaver 2007). Hence, individuals with high levels of men-
talization typically show considerable resilience in the face of stressful conditions and
are often able to gain a different and often surprising perspective on their lives as a re-
sult of adversity. Moreover, they show a good capacity for relationship recruiting (i.e.,
the capacity to become attached to caring and helping others) (Hauser et al. 2006) and
effective coregulation of stress and adversity (Luyten et al., submitted 2011a). In addi-
tion, these individuals typically have a good capacity not only to explore the external
world but also to explore their own internal world, as, for instance, expressed in marked
creativity; ability for symbolization; ability to shift perspective on their lives and those
of others; and attention to and interest in dreams and fantasies, art or music, and the in-
ternal world of people in general. This genuine and often generous mind-mindedness
is perhaps one of the best indicators for high levels of mentalization and is associated
with a sense of internal freedom to explore thoughts, feelings, desires, and experiences.
Individuals with this ability have the inner security to explore and verbalize even diffi-
cult memories or experiences and a clear desire and curiosity to explore these memo-
ries. As noted, this security of mental exploration (Allen et al. 2008), which may be
driven by either positive or negative experiences, also entails the freedom to call for
help and accept help (Grossman et al. 1999).
Hyperactivation and Deactivation

Attachment hyperactivation and deactivation strategies, in contrast, have been shown
to limit the ability to “broaden and build” in the face of stress and to inhibit other be-
havioral systems that are involved in resilience, such as exploration, affiliation, and car-
egiving (Insel and Young 2001; Mikulincer and Shaver 2007; Neumann 2008). Hence
individuals using these strategies typically have difficulty entering lasting relationships,
including relationships with mental health care professionals; show limited interest in
or genuine ability to explore their own internal world and that of others; and often seem
to have stagnated in major life tasks, such as intimacy or generativity. Briefly, individ-
uals who use predominantly hyperactivating strategies often show a centralized pattern
of relationships, with considerable vulnerability for self-other confusion (Fonagy and
Luyten 2009). They either show overly “claiming” behavior when confronted with
stress or show a pattern of idealization and subsequent denigration. By contrast, indi-
viduals who primarily rely on attachment deactivating strategies typically show a more
distributed relationship pattern, characterized by distancing of others or strong ap-
proach-avoidance conflicts and often frantic attempts to assert their own autonomy in
the face of stress (see Bateman and Fonagy 2006a and Luyten and colleagues, “Depres-
sion,” Chapter 15 in this volume). As noted, these individuals may come across as hav-
ing high levels of mentalization but lack genuine capacity to reflect on the self and
others. Although individuals with a centralized or distributed pattern may be interested
in their own internal world and their dreams and fantasies, with some important ex-
ceptions they often seem to lack true creativity. As a result, dreams and fantasies are of-
ten barren or may seem creative but on closer consideration reflect rather poor and
cliché-like images and ideas (“pseudosymbolization”).
Importantly, the switch from controlled to automatic mentalization involves the
reemergence of more automatic and often prementalistic modes of thinking about in-
ternal states such as the psychic equivalence, the pretend, and the teleological modes of
representing the internal world of oneself and others (Allen et al. 2008). Psychic equiv-
alence makes subjective experience too real, and the pretend mode severs its connec-
tion with reality and may even lead to dissociative experiences. The teleological mode
refers to a mode of thinking that equates thinking about others’ desires and feelings
with observable behavior. For example, for many patients with borderline personality
disorder, one can be loved only if one is also physically touched. For many individuals
with somatoform disorders, one can be sick only if there is “objective proof” (e.g., med-
ical tests) of one’s complaints, and sometimes, as in the case of bariatric surgery for
obesity in individuals with sexual abuse, professionals respond to such demands teleo-
logically (Morgan 2008; Wildes et al. 2008).
These modes are particularly likely to emerge in individuals with a history of

trauma. Typically, these individuals show a self-protective shutting off of mentalization
to avoid thinking about traumatic experiences (often in combination with self-mutila-
tion or substance abuse) and have a tendency to re-create frightful states of mind in oth-
ers (e.g., by starting to shout or by humiliating or threatening others). Individuals with
antisocial features may use this latter strategy deliberately to control others or to un-
dermine others’ capacities for thinking and mentalization.
Even in individuals without mental disorders, considerable evidence exists for the
persistence of developmentally earlier modes of thought in studies of “reasoning er-
rors,” including phenomena such as “hindsight bias,” “the curse of knowledge,” and
“actions speak louder than words” (Birch and Bloom 2007; Blank et al. 2008; Wertz and
German 2007).
An important implication of these considerations, as noted earlier, is that assess-
ment of mentalization should first and foremost take into account different arousal lev-
els involved in mentalizing instances. This necessarily involves the exploration of
mentalizing in different arousal contexts and necessitates the use of active probing and
challenging, which, of course, need to be tailored to the individual’s capacities. Indi-
viduals with a history of trauma, for instance, are easily overwhelmed, whereas it often
takes considerable effort to gauge the mentalizing abilities of individuals with narcis-
sistic features. Moreover, the fact that the assessment of mentalization takes place in the
context of a new attachment relationship with the assessor is important, and the re-
sponses of individuals to this new attachment relationship, and its influence on men-
talizing, should be closely monitored. Do individuals show any interest in what the
assessor thinks or feels? Or are they, in contrast, hypervigilant with respect to the as-
sessor’s responses? In addition, the extent to which the individual is able to use the as-
sessor to regulate arousal levels during the assessment, and thus is able to coregulate
stress in the context of the exploration of his or her internal world, provides important
clues about an individual’s mentalizing abilities “when the going gets tough.”
A second important implication is that individual differences in the use of second-
ary attachment strategies should be closely monitored. This could start with a rating of
the extent to which a patient’s pattern of mentalizing matches the prototypes described.
It is highly likely, however, that no patient will match completely any of these proto-
types, the more so because mentalizing abilities may differ considerably depending on
the type of attachment relationship, as we discuss in the next section.
Finally, therapists should tailor their interventions to the specific impairments in
mentalization associated with these attachment strategies. More specifically, evidence
suggests that in individuals who primarily use hyperactivating strategies (i.e., those
with a centralized pattern), the emphasis in treatment should be on the supportive as-
pects of the treatment setting, and therapists should strive to scaffold patients’ mental-
izing abilities as much as possible, particularly in the early phases of treatment (Blatt
2008). Moreover, the therapist should closely monitor the balance between closeness
and distance because coming too close may easily lead to self-other confusion and un-
dermine the patient’s mentalizing abilities, whereas being too distant may lead to feel-
ings of rejection and early dropout (Fonagy and Luyten 2009). Similarly, in patients
who primarily use deactivating strategies, the integration of cognitive and affective
mentalization will take center stage and will particularly involve bringing these patients
into contact with their emotions, specifically as they emerge in the therapeutic rela-
tionship. The danger here is that patients drop out when they start to realize that treat-
ment involves a new attachment relationship that endangers their deactivating
strategies. Another important pitfall is that the therapist assumes too readily that the
patient has sufficient capacity for insight and gets lost in intellectualized accounts of the
nature of the patient’s problems (Bateman and Fonagy 2006a).
Relationship-Specific Mentalization and

the Interpersonal Nature of Mentalization
It follows from the preceding discussion that although current assessment methods of
mentalization, such as the Reflective Functioning Scale (Fonagy et al. 1998), the Child
Attachment Interview (Ensink 2003), and the Parent Development Interview (Slade et
al. unpublished protocol, 2004a), involve the aggregation of mentalization across dif-
ferent attachment relationships and contexts, it is more appropriate to conceptualize
mentalization first and foremost as a relationship-specific ability. Mentalization is al-
ways embedded within specific attachment relationships and thus may differ consider-
ably from one attachment relationship to another.
Congruent with this assumption, studies have found that mentalization may show
considerable fluctuations over time and across relationship contexts (Luyten et al., sub-
mitted 2011c). O’Connor and Hirsch (1999), for example, found that young adoles-
cents had lower levels of mentalization and more distorted mentalization with regard to
least-liked teachers as compared with most-liked teachers. Also, increasing evidence in-
dicates that large individual differences exist with regard to mentalization about one’s
own infant, and correlations with mentalization as scored on the AAI are modest (for a
review, see Sharp and Fonagy 2008a). Finally, levels of mentalization have been shown
to fluctuate considerably within and between psychotherapy sessions and in relation to
the therapist (Diamond and Yeomans 2008; Diamond et al. 2003; Prunetti et al. 2008;
Vermote et al. 2009).
Moreover, mentalization may not only differ between relationship contexts but
also fluctuate within relationships. In terms of the switch model discussed earlier, be-
tween and within different attachment relationships, varying levels of stress may be in-
volved, leading to different activation gradients of the attachment system and different
switch points.
Furthermore, these switch points also depend on the mentalizing abilities of the
relationship partner, once again emphasizing the dyadic and reciprocal nature of men-
talization. Relationship partners may provide corrective experiences, and individuals,

in turn, may show marked differences in their ability to use such corrective experiences.
Conversely, relationship partners may further exacerbate mentalizing lapses, leading to
a downward spiral. Hence, from this perspective, mentalization is as much an interper-
sonal capacity as it is an intrapersonal one. Mentalizing develops in attachment rela-
tionships and continues to be intimately tied to relationships. Even when individuals
are mentalizing their own internal states, the extent to which they can find secure in-
ternalized attachment representations, or allow themselves to be assisted by external
secure attachment figures (such as a therapist), ultimately determines their capacity to
explore their inner world and that of others. For instance, patients with somatoform
disorders are often unable to mentalize their bodily feelings, but they can be either re-
inforced or corrected by their partners, depending on the mentalizing abilities of their
partners. Likewise, Diamond et al. (2003) found that the quality of mentalization in pa-
tient-therapist dyads was bidirectional in that the level of mentalization of the therapist
determined, in part, the level of mentalization observed in the patient and vice versa.
Similarly, Prunetti et al. (2008) reported that patients with borderline personality dis-
order showed temporary failures in mentalization in response to validation interven-
tions in dialectical behavior therapy, which activate the patients’ attachment system,
more frequently than in response to neutral interventions. With regard to the devel-
opment of mentalization, it is highly likely that biological features such as childhood
temperament and environmental characteristics such as poverty may influence mental-
ization in the parent-infant dyad and beyond.
Hence assessment of mentalization without regard to context, or based on a single
relationship, may be somewhat misleading (see also Choi-Kain and Gunderson 2008).
Clinicians should be particularly attentive to gross imbalances in mentalizing in differ-
ent contexts or relationships. For example, some patients seem to have considerable
abilities for mentalizing across many relationships but fall short in mentalizing about
their relationship with their mother, father, or partner. Hence in assessing mentaliza-
tion, assessors should strive to broaden the context and routinely probe for different re-
lationships, specifically those that patients do not spontaneously or only briefly discuss.
Finally, one should assess the extent to which they can coregulate stress in relation to
the assessor and are able to recover mentalizing during the assessment. In the following
two sections, we summarize these and other implications for the assessment of mental-
ization and provide a set of guidelines for the structured and unstructured assessment
of mentalization.
Structured Assessment of Mentalization

A good deal of the original formulations and research concerning mentalization has
been inspired by work with the Reflective Functioning Scale (Fonagy et al. 1998), a
broad measure of mentalization that can be scored on interviews such as the AAI (Hesse
2008), the more recently developed Child Attachment Interview (Shmueli-Goetz et al.
2008; Target et al. 2003), and the Object Relations Inventory (Diamond et al., unpub-
lished research manual, 1991). More recently, the Reflective Functioning Scale also has
been scored on psychotherapy transcripts (Karlsson and Kermott 2006; Szecsody 2008)
and responses to the Thematic Apperception Test (Luyten et al., submitted 2011b). Al-
though the Reflective Functioning Scale originally was developed to score general
mentalization aggregated across different contexts and attachment experiences (as is
the case with the AAI), the Reflective Functioning Scale also can be used to score men-
talization with regard to specific issues or symptoms (e.g., anxiety attacks) (Rudden et
al. 2006, 2009) and specific attachment figures and relationships (Diamond et al. 2003).
Currently, the validation of a self-report questionnaire, the Reflective Function Ques-
tionnaire, is under way (Fonagy and Ghinai, unpublished manuscript, 2008; Perkins
2009). Moreover, Levy and colleagues have developed a clinician-rated multidimen-
sional Reflective Functioning Scale (Levy et al., unpublished manuscript, 2005),
whereas Vrouva and Fonagy (2009) recently reported preliminary data concerning the
validity of a Mentalization Stories Test for Adolescents.
Relationship-specific measures of mentalization include measures of parental
mentalization, such as a modified Reflective Functioning Scale, which can be scored on
the Parent Development Interview (Slade et al., unpublished protocol 2004a; Slade et
al. unpublished manuscript, 2004b) or on an adapted version of the Working Model of
the Child Interview (Schechter et al. 2005). The Maternal Mind Mindedness Scale de-
veloped by Elisabeth Meins and colleagues, which can be scored on different types of
narrative material (Meins and Fernyhough, unpublished manuscript, 2006), also taps
into aspects of parental mentalization. Moreover, the validation of a self-report paren-
tal reflective functioning questionnaire is under way (Luyten et al. 2009), and in addi-
tion, several experimental paradigms have been developed to assess (relationship-
specific) mentalization in children and adolescents (Sharp and Fonagy 2008a).
However, the assessment of mentalization is by no means limited to these instru-
ments and scales; a wide variety of measures of social cognition tap into different as-
pects or dimensions of mentalization, as outlined in this chapter, in children,
adolescents, and adults. Thus, these measures also can serve as proxies for the polarities
underlying mentalization. Without attempting to be exhaustive, Table 2–2 provides an
illustrative overview of measures that assess aspects of the polarities underlying men-
talization (see also Sharp and Fonagy 2008a). A selection of these measures can be part
of a standard assessment battery or a battery that can be adapted for specific patients or
populations. For instance, clinicians working primarily with patients who have antiso-
cial personality disorder might want to include measures that assess cognitive and af-
fective aspects of mentalizing (Bateman and Fonagy 2008a), whereas those working
with borderline patients might want to assess primarily the extent of mentalizing im-
pairments with regard to self and others (Fonagy and Luyten 2009). Hence measures
listed in Table 2–2 may help both clinicians and researchers in developing a mentalizing
profile. Moreover, the overview of measures in Table 2–2 also might assist in selecting
instruments when researchers and clinicians want to test hypotheses about mentaliza-
tion impairments in specific patients or patient groups.
With few exceptions, most of the measures listed in Table 2–2 primarily assess con-
trolled mentalization, although some of these measures (e.g., the AAI Reflective Func-
tioning Scale) include an assessment of more automatic mentalization or can be
adapted to assess less controlled mentalization (e.g., using stress and affective priming
procedures or using eye tracking or electroencephalograms, which tap into less con-
trolled aspects of mentalization). Moreover, some of these measures assess mentaliza-
tion retrospectively (“offline”), whereas others assess mentalizing as social interactions
evolve (“online”). Yet these latter methods are currently relatively cumbersome. How-
ever, as noted in the following section (Unstructured Assessment of Mentalization), the
assessment of the extent of loss of mentalization under stress, particularly in social in-
teractions, may be clinically most relevant. Hence, brief, easy-to-use measures must be
developed and validated to assess this key feature of mentalization. Most of the mea-
sures listed in Table 2–2 require that individuals integrate cognition and affect in per-
forming the tasks or completing the measures. For instance, the Reading the Mind in
the Eyes Test (Baron-Cohen et al. 2001) clearly involves both cognitive and affective
knowledge and the integration of the two. However, procedures have been developed
to assess aspects of cognitive and affective mentalizing separately. These include
Baron-Cohen’s self-report measure of cognitive versus affective empathy (Baron-
Cohen and Wheelwright 2004), measures of cognitive versus affective alexithymia
(Bermond and Vorst, unpublished manual, 1998), and experimental procedures devel-
oped by Shamay-Tsoory et al. (2009), but future work is needed to devise assessment
methods that are able to capture more subtle impairments in the integration of cogni-
tive and affective aspects (Bouchard et al. 2008). Finally, measures of nonmentalizing
modes include experimental paradigms used to assess reasoning errors and egocen-
trism, such as “hindsight bias,” “the curse of knowledge,” and “actions speak louder
than words” (Birch and Bloom 2007; Blank et al. 2008; Wertz and German 2007), but
more work in this area is also needed.
Clearly, although many measures tap into the different dimensions underlying
mentalization, many issues concerning the assessment of mentalization have not yet
been solved. Large-scale psychometric studies are needed in this context, which also in-
cludes the investigation of the interrelation among the various dimensions of mental-
ization, before we can make more definitive recommendations about the assessment of
mentalizing capacities. However, such studies are currently under way, and we hope
that this chapter may guide research efforts in this context.
Unstructured Assessment of Mentalization

In our opinion, a comprehensive assessment of mentalization is based on at least one,
and preferably two to three, detailed clinical interviews. Such interviews need to review
Assessment of Mentalization
TABLE 2–2. Illustrative list of measures assessing dimensions of mentalization
Self - Other Cognitive - Affective Internal - External Automatic - Controlled

Questionnaires
Beliefs About Emotions Scale (Rimes and Chalder 2010) x (x) x x x x
Toronto Alexithymia Scale (Bagby et al. 1994) x x x x x
Kentucky Inventory of Mindfulness Skills—Describe and x x x x (x) x
Act With Awareness subscales (Baer et al. 2004)
Mindful Attention Awareness Scale (Brown and Ryan 2003) x x x x (x) x
Levels of Emotional Awareness Scale (Lane et al. 1990) x x x x x x
Psychological Mindedness Scale (Shill and Lumley 2002) x x x x x x
Interpersonal Reactivity Index—Perspective Taking x x x x x
subscale (Davis 1983)
Empathy Quotient (Lawrence et al. 2004) x x x x x (x) x
Mayer-Salovey-Caruso Emotional Intelligence Test x x x x x x (x) x
(Salovey and Grewal 2005)
Reflective Function Questionnaire (Fonagy and Ghinai, x x x x x (x) x
unpublished manuscript, 2008)
Parental Reflective Functioning Questionnaire (Luyten et x x x x x (x) x
al. 2009)
Mentalization Stories Test for Adolescents (Vrouva and x x x x (x) x
Fonagy 2009)
55
56
TABLE 2–2. Illustrative list of measures assessing dimensions of mentalization (continued)

Interviews/narrative coding systems
Adult Attachment Interview–Reflective Functioning Scale x x x x x (x) (x) x
(Fonagy et al. 1998)
Parent Development Interview–Reflective Functioning x x x x x (x) (x) x
Scale (Slade et al. 2002)
Working Model of the Child Interview–Reflective x x x x x (x) (x) x
Functioning Scale (Grienenberger et al. 2005)
Toronto Structured Interview for Alexithymia (Bagby et al. x x x x (x) x
Handbook of Mentalizing in Mental Health Practice

2006)
Mental States Measure and Grille de l’Élaboration Verbale x x x x x (x) (x) x
de l’Affect (Bouchard et al. 2008)
Metacognition Assessment Scale (Carcione et al. 2007) x x x x x (x) x
Intentionality Scale (Hill et al. 2007) x x x x (x) (x) x
Internal State Lexicon (Beeghly and Cicchetti 1994) x x x x x (x) x
Experimental/observational tasks
Reading the Mind in the Eyes Test (Baron-Cohen et al. 2001) x x x x x
Reading the Mind in the Voice Test (Golan et al. 2007) x x x x x
Reading the Mind in Films Task (Golan et al. 2008) x x x x x x
International Affective Picture System (Lang et al. 2008) x x x x x
NimStim set of facial expressions (Tottenham et al. 2009) x x x x x
Face morphs (Bailey et al. 2008) x x x x x (x) x
Assessment of Mentalization
TABLE 2–2. Illustrative list of measures assessing dimensions of mentalization (continued)

Experimental/observational tasks (continued)
Dynamic body expressions (Pichon et al. 2009) x x x x (x) x
Electromyography of facial mimicry (Sonnby-Borgström (x) x (x) x x x
and Jönsson 2004)
Affect labeling (Lieberman et al. 2007) x x x x x
Movie for the Assessment of Social Cognition (Dziobek et x x x x x (x) x
al. 2006)
Trust task (King-Casas et al. 2008) (x) x x x x x
Interoceptive sensitivity (Barrett et al. 2004) x x x x x
Empathy for pain in others (Hein and Singer 2008) (x) x x x x x x
Manipulating body consciousness (Brass et al. 2007; x x x x x x x x
Lenggenhager et al. 2007)
Animated Theory of Mind Inventory for Children x x x x x (x) x
(Beaumont and Sofronoff 2008)
Maternal Mind Mindedness (Meins and Fernyhough, x x x x x (x) (x) x
unpublished manuscript, 2006)
Maternal accuracy paradigm (Sharp et al. 2006) x x x x (x) (x) x
Strange Stories Task (Happé 1994) x x x x x
Projective measures
Thematic Apperception Test (Luyten et al. 2010) (x) x x x x x (x) x
Projective Imagination Test (Blackshaw et al. 2001) (x) x x x x x (x) x
Note. x=applicable; (x)=partially applicable.
57
TABLE 2–3. What does good mentalization look like?
Security of mental exploration and openness to discovery, and internal freedom to explore even
painful memories and experiences
Acknowledgment of opaqueness and tentativeness of mental states
Genuine interest in the mental states of self and others and their relation
Adaptive flexibility in switching from automatic to controlled mentalization
Acknowledgment of changeability of mental states, including awareness of developmental
perspective (i.e., that one’s own attachment history influences one’s current ways of relating
to self and others)
Integration of cognitive and affective features of self and others (“embodied mentalization”)
Sense of realistic predictability and controllability of mental states
Ability to regulate distress in relation to others
Capacity to be relaxed and flexible, not “stuck” in one point of view
Capacity to be playful, with humor that is engaging rather than hurtful or distancing
Ability to solve problems by give-and-take between one’s own and others’ perspectives
Ability to describe one’s own experience rather than defining other people’s experience or
intentions
Willingness to convey “ownership” of one’s own behavior rather than believing that it
“happens to” one
Curiosity about other people’s perspectives and expectations that one’s own views will be
extended by others
Relational strengths
Curiosity
Safe uncertainty
Contemplation and reflection
Perspective taking
Forgiveness
Impact awareness
Nonparanoid attitude
Perception of one’s own mental functioning
Developmental perspective
Realistic skepticism
Internal conflict awareness
Self-inquisitive stance
Awareness of the effect of affect
Acknowledgment of unconscious or preconscious functioning
Belief in changeability
TABLE 2–3. What does good mentalization look like? (continued)
Self-representation
Rich internal life
Autobiographical continuity
Advanced explanatory and listening skills
General values and attitudes
Tentativeness
Humility (moderation)
Playfulness and humor
Flexibility
Give-and-take
Responsibility and accountability
TABLE 2–4. What does bad mentalization look like?
Dominance of unreflective, naive, distorted automatic assumptions

Unjustified certainty about internal states of mind of self and/or others
Rigid adherence to one’s own perspective or excessively flexible in changing perspectives
Overly focused on external or internal features of self and others, or complete neglect of one
or both (“mindblindedness”)
Inability to consider both one’s own and other perspectives
Emphasis on cognitive or affective aspects of mentalization (i.e., overly analytical versus being
overwhelmed by states of mind of self and/or others)
Engagement in excessively sparse or overdetailed mentalizing
Focus on external factors (e.g., government, school, colleagues, neighbors)
Focus on “empty,” purely behavioral personality descriptors (“tired,” “lazy”) or diagnoses
Lack of interest in mental states, or defensive attempts to avoid mentalizing by becoming
aggressive or manipulative, being in denial, changing the subject, or acting otherwise
noncooperatively (“I don’t know”)
the patient’s attachment history, with particular attention to past and current relation-
ships. Moreover, these interviews need to include clear demand questions, explicitly
probing for mentalization in the context of past and current attachment relationships as
well as with regard to the context and the way patients experience their symptoms and
complaints. Without such explicit probing, initial assessment of patients may leave as-
sessors (and therapists) with the incorrect impression that they are working with an in-
dividual with relatively high psychological-mindedness and someone highly suitable
for insight-oriented psychotherapy. Relevant questions containing demand character-

istics with regard to attachment history include the following: “Do you know why your
parent or partner acted as he or she did?” “Do you think what happened to you as a
child explains the way you are as an adult?” “How has your relationship with your par-
ents changed since childhood?” “In what ways have you changed since childhood?”
With regard to experiences of loss, abuse, and neglect, the clinician should ask, “How
did you feel at the time?” (Bateman and Fonagy 2006a).
The account that patients give of their symptoms and complaints provides an im-
portant additional opportunity for gauging the potential for either temporary or more
global failures of mentalization, as well as a patient’s ability to recover from such lapses
of mentalization. For instance, most patients show partial failures of mentalization in
their responses about self-harm or suicide, from which they can subsequently recover
in the remainder of the interview. Some patients, however, are totally unable to give an
account of such experiences and become totally overwhelmed (e.g., in patients with a
history of severe trauma) or become constricted in excessively lengthy accounts of their
symptoms (e.g., in patients with obsessive-compulsive or somatoform disorders). Im-
portantly, the assessor should discount “canned” or “borrowed” accounts of symptoms,
complaints, or the nature of problems more generally. These have often been learned
from other professionals, patients, family and friends, or the Internet.
During these assessment interviews, assessors should map an individual’s mental-
izing profile, starting from a general assessment, and should work toward a more de-
tailed picture of the individual’s mentalizing profile, as explained more specifically
below.
In a first phase, the assessor should try to obtain a good impression of the patient’s
general mentalization abilities. Similarly to the scoring of the AAI Reflective Function-
ing Scale, this entails a global assessment across contexts and relationships of mental-
izing (see Tables 2–3, 2–4, and 2–5).
Second, the assessor should detail an individual’s mentalizing profile, as depicted in
Figure 2–2. Here, one should first plot the position of the individual on the different di-
mensions separately and subsequently consider the compensatory or reinforcing rela-
tionships between the various polarities, with special attention to marked discrepancies
between mentalizing abilities both within and between polarities (see Tables 2–6 through
2–10). This process also includes an assessment of the various parameters of the switch
model—that is, the activation gradient of mentalization (e.g., how fast individuals start
mentalizing), the switch between controlled and automatic mentalization, and the time
to recovery of controlled mentalization (see Table 2–9). This determination necessarily
entails a detailed assessment of the relational context of individuals, with special attention
to attachment history and the use of secure versus hyperactivating and deactivating at-
tachment strategies. Assessors should particularly attend to the extent to which these pa-
rameters differ across specific attachment relationships and the degree to which the
individual is able to self-correct mentalizing lapses and to allow responses from the as-
sessor (and attachment figures more generally) to correct these lapses.
TABLE 2–5. Reflective Functioning Scale
Score Description Level

9 Full or exceptional: Interviewee’s answers show
exceptional sophistication; are surprising, quite
complex, or elaborate; and consistently
manifest reasoning in a causal way using mental
states.
Moderate to high reflective
7 Marked: Numerous statements indicate full functioning
reflective functioning, which shows awareness
of the nature of mental states and explicit
attempts at teasing out mental states underlying
behavior.
5 Definite or ordinary: Interviewee shows several

instances of reflective functioning, even if
prompted by the interviewer rather than
emerging spontaneously from the interviewee.
3 Questionable or low: Some evidence shows

consideration of mental states throughout the
interview, albeit at a fairly rudimentary level. Negative to limited reflective
functioning
1 Absent but not repudiated: Reflective functioning
is totally or almost totally absent.
−1 Negative: Interviewee systematically resists

taking a reflective stance throughout the
interview.
Importantly, the polarities provide a meaningful guide and structure for assess-
ment because they clarify that a full assessment of mentalization includes actively prob-
ing for the patient’s attention to internal and external features of the self and others, for
his or her own internal states as well as those of others, and for the integration of cog-
nitive and affective features involved. For instance, one may ask questions such as:
“Why did you think he looked at you so angrily?” “You’ve been telling me how you felt
toward her, but how do you think she feels?” or “You’ve been telling me now what you
thought in this situation, but how did you feel?” Such switching of perspectives, or
challenging of a patient’s mentalizing by counterfactual responses (e.g., suggesting an
explanation that is the opposite of the patient’s explanations), may identify important
discrepancies between mentalizing abilities. For example, a patient may be totally un-
able to switch from his or her own perspective to that of the other, or vice versa, or a pa-
tient may be totally surprised when asked how he or she felt as opposed to thought or
“was supposed to feel” in a particular situation. Finally, challenging patients’ perspec-
tives may lead to uncovering of pseudomentalization when patients readily agree with
this change in perspective or rigidly adhere to their views (Bateman and Fonagy 2006a).
Very High
● ●
High
● ●
Ordinary/
Average
●
Low
●
●
Very Low
●
● ● ● ●
Internal External Self Other Cognitive Affective
Typical mentalizing profile for borderline personality disorder
Typical mentalizing profile for narcissistic personality disorder
FIGURE 2–2. Prototypical mentalizing profiles.
TABLE 2–6. Internally and externally focused mentalization
• Awareness of internal and external features of self and others and the relation
between the two
• Sensitivity to internal and external features of self and others
• Ability to perceive and to self-correct initial impressions on the basis of external
features and to let others correct these impressions (e.g., “I immediately saw on
his face that he couldn’t be trusted”; “I didn’t like the way he talked, and there-
fore I can never like him”)
Third, the prevalence and nature of prementalizing modes should be assessed.

This includes assessment of pseudomentalization. Table 2–10 provides some criteria
that can be used in this context (see Bateman and Fonagy 2006a). Note that these dif-
ferent categories are not mutually exclusive. For instance, hypermentalizing involves,
by definition, pretend mode functioning and often includes statements reflecting psy-
chic equivalence. Most of these nonmentalizing modes are self-serving, either implic-
itly or explicitly. In fact, patients with the most severe impairments in mentalization
TABLE 2–7. Mentalization with regard to self and others
• Presence of egocentrism (i.e., to see others in terms of self) versus degree of

control or inhibition of one’s own perspective
• Liability to emotional contagion (self-other diffusion with regard to mental
states) versus defensive separation from mental states of others
• Response to contrary moves, particularly flexibility to move between self and
other perspectives
• Ability to integrate embodied knowledge with more reflective knowledge of self
and others
TABLE 2–8. Cognitive and affective mentalizing
• Tendency to see mind reading as an intellectual, rational game

• Tendency to use either cognitive or affective hypermentalizing or
pseudomentalizing
• Tendency to be overwhelmed by affect in thinking about states of mind
• Ability to use “mentalized affectivity” and “embodied mentalization” (i.e., to
integrate cognitive knowledge and affective knowledge of the self and others)
TABLE 2–9. Assessment of automatic and controlled mentalizing in specific

contexts and relationships
• Are there global impairments in mentalizing (e.g., marked automatic mentalizing

based on distorted assumptions about the self and others) or more partial
difficulties?
• Are there marked discrepancies for mentalizing in nonstressful and stressful
conditions, or are mentalizing levels approximately equally high or low in both
conditions?
• What is the optimal stress level for adequate mentalizing?
• Are there differences related to self-other and context (particularly attachment
relationships) (e.g., gross imbalances with regard to mentalizing about self and
others or between attachment figures)?
• How extensive is failure of mentalization under stress?
• How long is the time to recovery (e.g., relatively quick or slow)?
• Does the patient have the ability to self-correct and be corrected by others under
high stress levels?
• Is there a sense of sufficient and realistic security in relation to the assessor or
therapist (e.g., patients may feel very stressed, may be constantly on their guard,
or may have an unrealistic sense of security as if they have known their therapist
for years)?
• Are there specific attachment relationships that lead to impairments in
mentalizing?
TABLE 2–10. Nonmentalizing and pseudomentalizing modes
• Pretend mode (i.e., reasoning about mental states but without any real connection with
reality)
• Psychic equivalence mode (i.e., concrete understanding; e.g., “You do not love me because
you didn’t call me”; “I know you are in love with me because you smiled at me”)
• Teleological mode (i.e., internal states of mind reduced to observable behavior; e.g., “The
only time I feel loved is when you are near me”)
• Pseudomentalizing (i.e., mostly self-serving, improbable, and inaccurate state of mind)
• Intrusive: “knowing what others think”
• Overactive (“hypermentalizing”): excessively detailed, decoupled from (affective) reality
• Destructively inaccurate: denying others’ internal states and replacing them with one’s
own construction (e.g., “You want to destroy me, I’m sure; don’t deny it; there’s no way
you can ever deny this”)
often seem to be the ones who make use of the most distorted mentalization to deny
painful feelings or realities and to seduce, manipulate, or control others. For instance,
borderline patients’ hypersensitivity to emotional states in others, combined with their
high proclivity for emotional contagion, often leads to vicious interpersonal cycles,
marked by attributions of hostile intent, induction of guilt and shame, impulsive out-
bursts of aggression, and subsequent rejection by others (Fonagy and Luyten 2009). In-
dividuals with antisocial personality disorder often use their sensitivity to others’
internal states to engender trust in others, to detect their sensitivities and induce them
to buy or sell goods, or to feel compassion, but they also may use these capacities to de-
liberately undermine others’ mentalizing capacities.
Conclusion
A comprehensive assessment of mentalization that has the ability to inform subsequent
treatment must evaluate different facets of mentalization under varying stress condi-
tions, and thus in various relationships, including the relationship with the assessor.
This necessitates probing and testing the limits, disregarding “canned” mentalization.
Hence, it follows that the assessment of mentalization implies a multidimensional
perspective that takes context into account, with particular attention to the capacity for
mentalization in high- and low-stress contexts, which are typically related to specific
attachment relationships.
Suggested Readings
Choi-Kain LW, Gunderson JG: Mentalization: ontogeny, assessment, and application in the
treatment of borderline personality disorder. Am J Psychiatry 165:1127–1135, 2008
Diamond D, Stovall-McClough C, Clarkin JF, et al: Patient-therapist attachment in the treat-
ment of borderline personality disorder. Bull Menninger Clin 67:227–259, 2003
Fonagy P, Luyten P, Bateman A, et al: Attachment and personality pathology, in Psychodynamic
Psychotherapy for Personality Disorders: A Clinical Handbook. Edited by Clarkin JF, Fon-
agy P, Gabbard GO. Washington, DC, American Psychiatric Publishing, 2010, pp 37–87
Mayes LC: Arousal regulation, emotional flexibility, medial amygdala function, and the impact
of early experience: comments on the paper of Lewis et al. Ann N Y Acad Sci 1094:178–
192, 2006
CHAPTER 3
Individual Techniques
of the Basic Model
I n this chapter, we clarify some of the psychotherapeutic techniques used in individ-

ual sessions of mentalization-based treatment (MBT). Our experience of providing
training courses has taught us that some topics have previously caused confusion. Ini-
tially, we built our treatment manual for borderline personality disorder (BPD) (Bate-
man and Fonagy 2006a) on a foundation of generic therapeutic processes, in the hope
that MBT could be learned by relative novices. This has proved to be possible up to a
certain point, but it has become apparent to us that translating a coherent theoretical
stance that guides and orients treatment into an articulate therapeutic interaction is
more difficult. Readers will benefit from reading this chapter in conjunction with
Chapter 11 (Bateman and Fonagy) on BPD, in which the basic principles of developing
a mentalizing stance are outlined. The ability to adopt this stance is crucial to the ef-
fective use of the specific techniques of individual therapy described here.
67
Don’t Worry and Don’t Know

We have often said that therapists do not need to be overly worried about the primary
task of MBT—stimulating mentalizing when it is lost—because they are probably al-
ready doing this without being aware of it. Any technique that promotes mentalizing is
valid. Rather than beginning afresh, our model requires the therapist to reexamine his
or her current practice from the perspective of whether the interventions stimulate
mentalizing or actually inhibit it. In addition, the therapist needs to be aware of his or
her own state of mentalizing. As we have put it before, “Ironically, when you become
aware of your nonmentalizing interventions, you are mentalizing. A further irony:
when you start obsessing about mentalizing in the middle of a session, you have lost
mentalizing, because you are no longer paying attention to your patient” (Allen et al.
2008, p. 164). Paying attention to the patient’s mind is at the heart of mentalizing. Par-
adoxically, it is the clever or highly trained therapist who is more likely to turn off a pa-
tient’s mentalizing by taking an expert role. Once the therapist knows why something is
wrong with the patient and how it can be corrected, the therapist is not mentalizing. A
general reluctance to admit to oneself that one does not know what is happening in
therapy sessions compounds the problem.
Knowing takes many forms—therapists profess a deep understanding of uncon-
scious process, are sure about good and bad thought processes, and empathically tell
patients what they are feeling, all of which are nonmentalizing stances. The MBT ther-
apist needs to stimulate a joint consideration of underlying processes rather than claim-
ing to understand them; to explore different components of thought processes rather
than socratically showing their inaccuracy; and to help the patient attend to his or her
own feelings instead of methodically naming these for the patient. The therapist fo-
cuses on the process rather than the content of the patient’s thoughts and feelings and,
in doing so, asks the patient to attend consciously to the processes within both the pa-
tient’s own and other people’s minds and to maintain this attention as his or her feelings
fluctuate. To develop this process, the therapist uses a range of interventions that share
the primary aims of maintaining mentalizing and reinstating it when it is lost.
Emotional Closeness in Therapy Sessions

Once the therapist has adopted the mentalizing stance and stimulated a mentalizing
process, the task is to maintain mentalizing within himself or herself and the patient
while recognizing that therapy will potentially destabilize mentalizing by stimulating
the attachment system (see Fonagy et al., Chapter 1, for a discussion of this phenom-
enon). Mentalizing will be threatened simply because the therapist probes, stimulates
feelings, and asks questions, all of which are likely to make the patient anxious. Alert to
this, the therapist moves emotionally closer to the patient during a session only to the
point at which he or she judges that the patient is on the verge of losing mentalizing. At
Individual Techniques of the Basic Model 69
this moment, the therapist moves back, distancing from the patient, to reduce the level
of emotional arousal. This process is a clinically significant paradox—just when the
therapist would naturally move emotionally closer to the patient, we ask that he or she
move away. Any person talking with someone who is becoming increasingly disturbed
or upset will naturally become more sympathetic and caring. At such times, one is likely
to become gentler in demeanor, speak more quietly, and try to show an ever more pro-
found understanding of the patient’s emotional state. Yet this will stimulate the patient’s
attachment system, leading to further impairment of mentalizing capacity; this occurs
particularly in patients with BPD because of the hypersensitivity of their attachment
system.
For this reason, we ask the therapist to curb his or her natural tendency to become
increasingly sympathetic when the patient becomes emotional and to distance himself
or herself emotionally by becoming less expressive, even if only momentarily. Once
mentalizing is regained, the therapist can regain emotional involvement, begin to
probe again, empathize, and focus on the patient-therapist relationship. However, the
therapist should not be surprised to find that this rekindles the attachment system. He
or she needs to continue to monitor sensitively for further losses of mentalizing and to
step back rapidly when necessary. This does not amount to a recommendation that a
caring therapist become uncaring. However, caring that manifests itself as sweetness,
concern, and sympathy at this moment will only add fuel to the fire, inflaming attach-
ment needs and stimulating further mental deterioration in the patient just at the mo-
ment when it is crucial to find a way to stimulate more robust mental processes.
Ms. A became distressed while talking about her boyfriend being sexually unfaithful. She
talked about leaving him but said that she could not because she loved him. The therapist
made many sympathetic noises during this story and made increasingly supportive state-
ments about the problem for Ms. A in coping with her conflicting experience. Ms. A be-
came increasingly distressed and was inconsolable for most of the rest of the session. The
therapist then felt that she should offer an additional session. This immediately intensi-
fied the patient’s needs; Ms. A then asked if the current session could continue because
she felt unable to leave the room.
Inadvertently, the therapist had aroused Ms. A’s dependency and made her even
more vulnerable by becoming more sympathetic and offering additional sessions when
instead she needed to step back from the patient.
Stepping back in the face of distress requires conscious effort on the therapist’s part
if it is to be done sensitively. This approach not only goes against his or her instincts and
natural tendencies but also defies all that was learned in training. Therapists tend to
lower their voices, speak softly, and show apprehension in their facial expressions as
they become increasingly concerned and sympathetic. To reduce the power of the emo-
tional interaction, the therapist initially must respond in a somewhat matter-of-fact
manner or move the patient away from the current focus rather than continuing to fo-
cus on either affect or the interaction between patient and therapist, both of which will
continue to stimulate the patient’s attachment needs. In the preceding case example,
the therapist would have done better to move Ms. A away from an internal focus on her
affect and to deemphasize the patient-therapist relationship. One way of doing this
might have been to push Ms. A to consider the motivations of her boyfriend, a move-
ment out of the session itself to consider someone “out there.” The therapist should
aim to help the patient maintain some elements of mentalizing (in this case, consider-
ation of others’ minds) when other aspects are overwhelmed (in this case, the capacity
for reflection about the self). Insistence on further exploration of internal states at times
of emotional arousal will only overburden the patient; we suggest contrary moves at
these times.
Contrary Moves
Therapists should consider moving patients outward when they are self-focused and in-
ward when they are other-focused, and moving themselves toward the patients when
the patient moves away and away from the patient when the patient moves toward them
(Table 3–1). We envision a balancing act as the therapist and the patient seesaw up and
down, advancing the scope for reflection and dialogue. We anticipate that the therapist
and patient will oscillate back and forth as the therapist titrates the intensity of the at-
tachment relationship. At some moments, the patient will become self-focused, and this
often should be commended; yet this self-reflection may begin to take on a ruminative
quality, or the patient may get stuck in a rigidly negative, shameful, self-condemning
mode. At such times the therapist should try to move the patient out of his or her own
mind and into another person’s mind: “How do you think that affects her?” “What was
going on for her that led him to do that?” The therapist should not be deflected from
this task once having decided that it is an appropriate move in treatment. Many patients
respond by saying that they “don’t know” and quickly return to their ruminative con-
cern with their own state of mind. Therapists may need to be more insistent: “Bear with
me a bit—I was wondering what you made of what was happening to him that made him
respond like that?”
At times, therapists will need to make the opposite move. Patients who are preoc-
cupied with understanding others and what they are like may need pushing to reflect on
their own state of mind: “What did you feel about that?” or “How do you understand
your reaction?”
Such moves reflect the balance between self and others inherent in the concept of
mentalizing. This balance must be mirrored in the movement between the patient and
the therapist within a session; a reciprocal flow of attention moves back and forth from
patient to therapist and vice versa. Therapists must demonstrate their own capacity to
reflect on the process at any given moment, once again modeling the active stance.
TABLE 3–1. Contrary moves
Patient/Therapist Therapist/Patient
Knowing Unknowing
Self-reflection Other reflection
Emotional distance Emotional closeness
Certainty Doubt
TABLE 3–2. Intervention process in mentalization-based treatment
• Supportive, empathic, clarification
• Challenge
• Affect focus
• Mentalizing the transference
Intervention Process
From a practical standpoint and for clarity when training people in mentalizing inter-
ventions, we suggest that effective mentalization-based interventions be developed
gradually along a specific line, although inevitably this line is often not followed in an
orderly way in sessions. Nevertheless, we exhort MBT therapists to follow it as best
they can. The steps undertaken by the therapist are outlined in Table 3–2.
First, the therapist identifies a break in mentalizing, which may be indicated by
psychic equivalence, pretend mode, or teleological understanding. The emergence of
these modes of thinking indicates that mentalizing is vulnerable and should alert the
therapist to the need to try to restimulate mentalizing by initially being empathic and
exploring the trigger to the loss of mentalizing. Second, the therapist asks the patient to
“rewind” to the moment before the break in subjective continuity occurred. If neces-
sary, the therapist pinpoints the moment when he or she thought a change occurred.
Third, the therapist explores the current emotional context contributing to the break
in the session by identifying the momentary affective state between patient and thera-
pist. Fourth, the therapist explicitly identifies and owns up to his or her contribution to
the break in mentalizing. Only after this work has been done does the therapist seek to
help the patient understand the mental states implicit in the current state of the patient-
therapist relationship (see the later subsection Mentalizing the Transference).
Inevitably, our recommendation of this stepwise procedure has met with some crit-
icism for being too prescriptive, reifying an interactive and dynamic process, and being
reductionistic about a complex process. This censure has some merit. Nevertheless, we
hope that the specificity of the procedure will help the therapist to think carefully about
what he or she is doing, enabling him or her to avoid attempting to work with a patient
at a level that is beyond the patient’s current mental capacity.
Clinical Example of Stepwise Intervention

PATIENT: As far as I can see, your receptionists have been trained to ignore patients.
THERAPIST: What makes you say that?
PATIENT: I rang the bell, and no one answered. I could see through the window that peo-
ple were in the office talking. So, obviously, they did not want to let me in.
THERAPIST: I don’t quite follow. Why on earth would they not want to let you in?
Here, the patient’s statement about the reception staff and the conclusions he
draws suggest that his mind is operating teleologically—he understands others’ mo-
tives by the actual outcome, which in this case was that they did not let him in. The
therapist begins by trying to draw the patient’s attention to the fact that what may seem
obvious to him is not so obvious to the therapist:
PATIENT: Because I am six feet tall and big, and they were frightened of me.
THERAPIST: Well, you are over six feet and very large, but I was unaware that they hadn’t
let you in before, so what was different this time?
PATIENT: You don’t believe me, do you? They would not let me in. I eventually got in by
attracting their attention by leaving my finger on the bell until they answered.
THERAPIST: I’m glad that you got in, but can we go back to your sense that they didn’t
want to let you in? It occurs to me that it is more complex than the fact that you are
over six feet and large, because the staff know who you are.
PATIENT: Well, most people take one look at me and move away.
Here, the therapist is trying to rewind to the point at which the patient appears to
have little doubt about his conclusions. This does not have much effect, so the therapist
correctly rewinds to an earlier point:
THERAPIST: Well, it is awful to feel that you are not wanted. I can understand that, so can
we go back further? How were you feeling about yourself before the session?
PATIENT: Fucked off. I think that the housing department is trying to trick me.
The therapist was then able to explore the patient’s experience of the housing de-
partment and his suspicion that they were trying to deceive him and absolve themselves
of responsibility for his accommodation—in short, that they did not want him. The
therapist then explored what the patient’s experience and state of mind had been after
leaving the housing department and inquired about how this might have affected the
patient’s experience with the reception staff. In doing so, he also identified the affect fo-
cus within the session (see the later subsection Affect Focus):
THERAPIST: Earlier in the session, you reacted quite strongly when I asked why you
thought the staff didn’t let you in, by saying that I didn’t believe you. Are we still
sitting here with me thinking the situation is more complicated, and you feeling
that I don’t really believe your explanation?
PATIENT [reacts immediately]: Well, you don’t, do you?
THERAPIST: I can see that when I pointed out that you’ve always been over six feet and
large, it might make you think I didn’t believe you. In some ways, I suppose that I
don’t think that was the primary reason that they didn’t answer the bell.
Here, the therapist is indicating that he has had a role in stimulating the sense of
disbelief in the patient:
PATIENT: So, I was right that you didn’t believe me.

THERAPIST: Yes, to some extent. I didn’t fully believe your explanation. It occurs to me
that you listen very carefully to how I say things to see if I believe you or not much
of the time.
PATIENT: I suppose that I don’t really trust you to be on my side.
At this point, the therapist has identified the affect focus relevant to the current
session. He can now move toward mentalizing the transference as long as the patient
shows some flexibility and ability to reflect on his own state of mind and that of the
therapist. We discuss this in more detail later.
Challenge
Sometimes the therapist may need to challenge the patient’s nonmentalizing. We rec-
ommend challenge as an intervention when other potentially harmful techniques have
failed to restimulate mentalizing. Challenge is a high-risk intervention, but the risk can
pay off; at times, challenge may prevent unchecked nonmentalizing from reaching its
inevitably disastrous outcome, whether that be self- or other-directed destructive be-
havior or a sudden uncontrollable emotional storm.
The purpose of challenge is to stimulate mentalizing by inserting something un-
expected into the dialogue. The aim is not to confront the patient and get into an ar-
gument. Many patients become adept at anticipating what their therapists are likely to
say. They are aware of therapists’ usual responses in the same way that therapists are
aware of patients’ personal themes and perspectives. In challenge, it is important that
the therapist’s statement or comment is unexpected and not anticipated within the nor-
mal dialogue between patient and therapist. Initially, the therapist can simply challenge
mildly by making a counterfactual comment. For example, if a patient is railing about
how his girlfriend does not love him, the therapist could simply ask him what it would
be like for him if she did love him and how he would know if she did. In effect, the ther-
apist asks the patient to consider the converse and turns the direction of flow of the di-
alogue in the opposite direction, with the aim of restimulating the patient’s mind to
begin reflecting on itself.
More striking challenges need considerable care, and yet they may be necessary at
a moment of emotional turmoil within the session, so the therapist first must be certain
of a well-established therapeutic alliance. These challenges are far removed from any
expectation the patient has from the therapist, but they must remain within the bound-
aries of therapy. They often include an element of humor and self-deprecation and are
offered alongside or in parallel to rather than as an alternative to the current flow of di-
alogue. The aim is to derail the patient’s mental processes and establish a window
within which the mentalizing process can be restarted. If the challenge is effective in
derailing the patient’s flow, the therapist needs to pause the session immediately at that
point and begin focusing the patient on what has been happening.
Ms. B was talking about how the nurses at the local hospital were against her and how she
was determined to oppose the hospital authorities, whom she believed had not taken se-
riously her complaints about her admission to an acute inpatient ward. The therapist
tried to intervene to ask her to consider her complaints in more detail and define them
better, but he was continually dismissed as only trying to stop her from registering her
complaints: “You don’t want me to complain because you are part of them, and it might
get you into trouble as well.” Ms. B did not elaborate on this statement either, despite the
therapist’s attempt to have her do so. Ms. B became increasingly emotional about her de-
termination to obtain redress for her ill-treatment.
At this moment, while the therapist was trying to think how else he might intervene
to reduce the patient’s arousal, he glanced out of the window. Ms. B immediately said,
“Don’t you look out of the window. You listen to me.”
The therapist responded, “I am a man, and I can multitask. I can look and listen.”
This response so surprised Ms. B that she stopped and laughed for a moment. At this
point the therapist quickly jumped in, saying, “Phew, at least I got your attention for a
moment! Can we just rest for a moment and consider where we have gotten to with all
this? For me, I am lost, yet you seem very certain, so we have a problem.”
In this example, the therapist has managed to insert himself and his state of mind
back into the patient’s mind. He then begins the task of focusing the session.
Affect Focus
In the past, there has been some confusion over our use of the term affect focus. This has
arisen because affect focus is more generally considered to be a process of focusing on
the patient’s current affective state, identifying what he or she is feeling, and labeling
the emotion. Although important, this process is not sufficient to characterize the af-
fect focus within a session, and it is only part of the focus on affect that is central to the
practice of MBT. In the context of MBT, the affect focus is the current affect shared be-
tween patient and therapist at any given point in a session. It fluctuates and tends to op-
erate just beneath the level of awareness of both the patient and the therapist. It is the
therapist’s task to try to identify and express it so that it becomes available as part of the
joint work.
Identification of the affect focus is subjective and requires the therapist to monitor
his or her own mental states extremely carefully. The therapist might begin to worry
about the patient, notice something about how the patient behaves toward him, find
himself unable to think clearly, and yet not understand what is contributing to this ex-
perience. All of these examples of information can be used to identify the affect focus.
In the following example, eschewing the need to have a fully formed understanding, the
MBT therapist expresses his experience to the patient for joint consideration, ensuring
that in doing so, he describes his experience as arising from within himself:
Ms. C had been talking about how suicidal she had felt, but she said that she thought she
had now managed it quite well and was able to cope better.
THERAPIST: That’s great. Tell me a bit more about how you have managed it and
what it is that makes you feel able to cope better.
In asking this question, the therapist is attempting to persuade Ms. C to explain her
current experience in more detail, but before doing so, he gives judicious praise about her
sense that she has managed to work something out well.
PATIENT: I contacted my friend and started to talk to her about what was hap-
pening, and she was really nice about it. She offered to come to my flat and
to stay there for the night.
Ms. C talked further, and the therapist started to worry that she remained vulnerable
and that she was not quite as safe from a suicide attempt as she had stated. Limited evi-
dence for this was seen in the content of what Ms. C talked about, but certainly Ms. C ap-
peared nervous while talking.
THERAPIST: You know, as you are talking, you seem nervous, and I am a bit ner-
vous, too. It occurs to me that we have only 15 minutes left of the session
and that we both might be worrying that we haven’t consolidated the good
work you did last night.
PATIENT: I suppose that I’m not so sure, and I don’t know what to do tonight.
THERAPIST: Maybe that is what we have to think about together rather than ei-
ther you or me feeling that one of us has to come up with a solution.
In this dialogue, the therapist is trying to capture the affect focus. On this occasion,
the affect focus is related to both patient and therapist pretending that Ms. C is safe
when actually both of them are feeling nervous and uncertain. The therapist expresses
this shared affect to try to focus the session.
Identifying the affect focus is an important step in MBT because it links general ex-
ploratory work, rewinding with clarification, and challenge to the important process of
mentalizing the transference. Here, detailed work is done between patient and thera-
pist, with the attachment relationship at its most intense level of stimulation.
Mentalizing the Transference

Some practitioners have argued that the use of the term mentalizing the transference con-
fuses a process that could more simply be called mentalizing the relationship. We agree
with this criticism and would have little problem in accepting substitution of the word
relationship for transference in our exposition below. We will try to make clear our rea-
sons for this. In developing MBT, we used the term transference partly because of its dy-
namic therapy origins, but we were aware that the term transference has a long and
complicated history. Thus, we attempted to define exactly what we meant by the term
and also to identify some steps necessary to mentalize the transference fully. The steps
of mentalizing the transference are outlined in Table 3–3. These steps are not specifi-
cally dependent on a view that transference represents a window into the past but are
reliant on an acceptance of the relationship between the therapist and the patient as an
important vehicle for rehearsing mentalizing within increasingly intimate interactions.
Our first step is the validation of the transference feeling through the second step,
exploration. The danger of the genetic approach to the transference is that it might im-
plicitly invalidate the patient’s experience. The MBT therapist spends considerable
time within the not-knowing stance, verifying how the patient is experiencing what he
states he is experiencing. As a result of this exploration, the third step will be generated.
As the events that generated the transference feelings are identified and the behaviors
to which the thoughts or feelings are tied are made explicit, sometimes in painful detail,
the contribution of the therapist to these thoughts and feelings will become apparent.
In the third step, the therapist must accept her own enactment and her contribution to-
ward the patient’s experience. The patient’s experience of his interaction with the ther-
apist is likely to be based on a partially accurate perception of the interaction, even if it
is based on a small component of it. Often, the therapist has been drawn into the trans-
ference and acted in some way that is consistent with the patient’s perception of her. It
may be easy to attribute this to the patient, but this would be completely unhelpful.
Rather, the therapist should initially explicitly acknowledge even partial enactments of
the transference as inexplicable voluntary actions for which she accepts agency rather
than identifying them as a distortion by the patient. Authenticity is required to do this
well. Drawing attention to the therapist’s contribution may be particularly significant
in that it shows the patient that it is possible to accept agency for involuntary acts and
that such acts do not invalidate the general attitude that the therapist is trying to con-
vey. Only after this consideration of the therapist’s contribution can distortions be ex-
plored.
TABLE 3–3. Mentalizing the transference
1. Validation of experience
2. Exploration in the current relationship
3. Acceptance and exploration of enactment (therapist’s contribution, therapist’s own distortions)
4. Collaboration in arriving at an understanding
5. Presentation of an alternative perspective
6. Monitoring of the patient’s reaction
7. Exploration of the patient’s reaction to the new understanding
The fourth step is collaboration in arriving at an alternative perspective. Mental-

izing alternative perspectives about the patient-therapist relationship must be arrived
at in the same spirit of collaboration as for any other form of mentalizing. The meta-
phor we use in training is that the therapist must imagine sitting side by side with the
patient rather than opposite him or her. They sit side by side and discuss the patient’s
thoughts and feelings; when possible, both adopt an inquisitive stance about them. In
the fifth step, the therapist presents an alternative perspective. The sixth step is to mon-
itor carefully both the patient’s and the therapist’s reactions, and the seventh and final
step is to explore the patient’s understanding of the new understanding.
We suggest that these steps be taken in sequence, and we talk about mentalizing
the transference to distinguish the process from transference interpretation, which is
commonly viewed as a technique to provide insight. Mentalizing the transference is a
shorthand term for encouraging patients to think about the relationship they are in at
the current moment (the therapist relationship) with the aim of focusing their attention
on another mind—the mind of a therapist—and assisting them in the task of contrast-
ing their own perception of themselves with how they are perceived by another, such as
the therapist or members of a therapeutic group. We might point to similarities in pat-
terns of relationships in the therapy and in childhood or currently outside of the ther-
apy, but the aim of this is not to provide patients with an explanation (insight) that they
might be able to use to control their behavior but far more simply to identify one more
puzzling phenomenon that requires thought and contemplation, part of our general in-
quisitive stance aimed to facilitate the recovery of mentalization within affective states,
which we see as the overall aim of treatment.
Countertransference
A discussion about transference is not complete without consideration of countertrans-
ference. Our technical use of countertransference in MBT borrows heavily from the
work of Racker (1957), who distinguished between complementary and concordant
countertransference, but we combine this with our understanding of “marking” emo-
tional experience (see Affect Regulation subsection under Development of Social Cog-
nition in Chapter 1).
Complementary countertransferences are defined as emotions that arise out of the pa-
tient’s treatment of the therapist as an object of one of the patient’s earlier relationships.
They are closely linked to the notion of projective identification. Taking this viewpoint
leads therapists to consider their countertransference as representing part of the pa-
tient’s internal state. This leads many therapists to adopt the technique of placing the
experience they themselves are having back with the patient. In effect, the feelings ex-
perienced by the therapist are understood as projections of the patient’s internal state,
and the most common technique in dynamic therapy to manage this situation is for the
therapist to use his or her experience to say more about the patient’s state of mind. This
technical maneuver is avoided in MBT at the point at which the therapist experiences
some feelings strongly in relation to the patient. Why? Countertransference experi-
ences are most commonly associated with turbulence in patients’ mental state; asking
patients to consider the possibility that they might be misattributing their own feelings
to the therapist will overwhelm their precarious state of mentalizing just at the moment
when they are in need of mental support. For example, a therapist may feel under per-
sistent attack even though the patient is not overtly being aggressive. In addition, the
patient might say that she feels attacked by the therapist, although the therapist does
not experience herself as attacking. From the perspective of MBT, this situation indi-
cates a difficulty of mentalizing for both patient and therapist, so the most important
task is not to attribute the source of loss of mentalizing to the patient, for example, but
to highlight the current precarious nature of the mentalizing and to consider the ori-
gins of the difficulty. Therefore, the therapist would not say, “Perhaps you are feeling
somewhat under attack at the moment,” because this asks the patient to scrutinize her
own mental state in detail while struggling to maintain stability, but might say, “It is re-
ally difficult for us at the moment to work out what is going on.” This does not require
too much self-scrutiny by the patient.
In contrast, concordant countertransferences are defined as empathic concordant re-
sponses based on the therapist’s emotional resonance with the patient. Concordant
countertransferences therefore link with affective attunement, empathy, mirroring,
and a sense that certain aspects of all relationships are based on emotional identifica-
tions that are not solely projections. Stern’s (1985) “affective attunement” between
mother and infant and, by extension, between therapist and patient is a different way of
explaining such interaction, which involves the ability of the mother (therapist) to
“read” the child’s (patient’s) behavior and respond in a complementary manner that is
“read” by the child (patient). Technically, in MBT countertransference experience is
used with this understanding in mind. Countertransference is stated as the therapist’s
experience; that is, it is “marked.” It is not considered initially as a result of projective
identification, and the therapist must identify the experience clearly as his or her own.
The simplest way to do this is to state “I” at the beginning of an intervention. Intrigu-
ingly, this seems to be difficult for therapists, who understandably worry about violat-
TABLE 3–4. Psychological function and common countertransference experiences
Psychological function Countertransference experience

Pretend mode Feeling bored
Perceiving patient’s statements as trivial
Seeming to “operate on autopilot”
Lacking appropriate affect modulation (feeling flat, rigid,
out of contact)
Teleological process Wishing to do something
Making lists
Offering coping strategies
Giving practical advice
Psychic equivalence Feeling puzzled
Feeling confused
Nodding excessively
Not being sure what to say
Feeling angry with the patient
ing therapeutic boundaries. Yet we are not suggesting that therapists start expressing
their personal problems or start talking about just any feeling that they happen to have
in a session, whether relevant to the process or not. Rather, we are maintaining that the
therapist’s current experience of the process of therapy with the patient is to be shared
openly to ensure that the complexity of the interactional process can be considered. Pa-
tients need to be aware that their mental processes have an effect on others’ mental
states and that these, in turn, will influence the direction of the interaction.
Therapists have several common countertransference experiences when treating
patients with BPD, which is associated with particular modes of psychological func-
tioning. These are summarized in Table 3–4. Gradually, therapists need to become
comfortable with managing these states of mind and be able to express them construc-
tively in the service of extending the patient-therapist collaboration. We recommend
that all therapists regularly role-play situations in which they have experienced some
aspects of these feelings, simply because the feelings are so common.
Many nonmentalizing states of mind are indicated by the therapist’s actual behav-
ior; for a considerable time, the therapist may be unaware that his or her actions are
changing. Therapists who only grunt as the patient talks and clearly lose concentration
are often being affected by pretend mode functioning in the patient; therapists who
start to give suggestions about how to solve problems or who tell the patient what to do
without exploration are likely to be involved in teleological process; and the confused
therapist who nods wisely is more often than not struggling with understanding what is
being said and is trying too hard to understand psychic equivalent modes of thought. In
all circumstances, once alerted by a change in his or her own behavior, the therapist
should focus more carefully on his or her feeling and identify it.
To reiterate our point: the expression of the therapist’s underlying feeling can be a
useful tool in therapy if it is done openly and carefully marked. It is “owned” by the
therapist to ensure that the patient is not overburdened with emotional responsibility.
Implicitly telling the patient that he or she has created the feelings in the therapist in-
creases the mental work required from the patient just at the time when mentalizing is
already in danger of being lost, thereby inadvertently increasing the likelihood of this
outcome.
Conclusion
In this chapter, we have discussed some of the techniques used in MBT that present
problems for therapists as they try to refine their practice. We hope that we have clar-
ified some of the confusion that was of our own making in regard to individual tech-
niques. In the true spirit of mentalizing, we continue to listen and to reflect and to
modify our stance according to what we find, which perhaps creates additional uncer-
tainty. But a key characteristic of a good MBT therapist is the ability to tolerate uncer-
tainty, and of this there can be no greater example than the need for this personal
quality when running MBT groups. In the next chapter, we will discuss the techniques
used in group psychotherapy.
Suggested Readings
Allen JG, Fonagy P, Bateman A: Mentalizing in Clinical Practice. Washington, DC, American
Bateman A, Fonagy P: Mentalization Based Treatment: A Practical Guide. Oxford, UK, Oxford
University Press, 2006
Racker H: The meanings and uses of countertransference. Psychoanal Q 26:303–357, 1957
Stern DN: The Interpersonal World of the Infant: A View From Psychoanalysis and Develop-
mental Psychology. New York, Basic Books, 1985
CHAPTER 4
Group Therapy
Techniques
I n Chapter 3, Bateman and Fonagy discussed some of the individual techniques that
characterize mentalization-based treatment (MBT). In many respects, individual tech-
niques have been better specified than have mentalizing techniques used in the context
of group therapy. In this chapter, we try to redress this imbalance. The lack of speci-
ficity about mentalizing in groups is not surprising. Interactions in groups are complex
to grasp, and identifying specific interventions amidst an almost infinite range of inter-
personal and affective communication is such a daunting task as to appear nearly im-
possible. Perhaps this complexity explains the singular lack of manuals for group-based
dynamic therapies. In short, there is a pressing need to refine our understanding of
mentalizing in groups.
MBT was developed in the dynamic matrix of long-term day hospital treatment for
patients with personality disorder, involving multiple therapists and multiple treatment
formats (Bateman and Fonagy 2001), in which groups played a prominent part. Struc-
turally, a key aspect of MBT has been its nature as a conjoint psychotherapy, integrating
individual and group psychotherapy. This conjoint structure has been preserved in the
intensive outpatient format (Bateman and Fonagy 2008b). Most of this chapter is
81
devoted to a consideration of group psychotherapy as an integral part of this conjoint

structure. We hope that this will help MBT therapists to become increasingly aware of
how to stimulate mentalizing in groups and how to integrate this with the individual
therapy. Over time, practitioners have started to use mentalizing theory, and some of
the associated interventions, in group therapy offered as a single-modality treatment.
We call this mentalization-informed group psychotherapy in contrast to MBT group ther-
apy, which is part of a combined treatment involving individual plus group therapy. We
hope that those readers who are more interested in adapting their practice of group
psychotherapy as a stand-alone treatment will find this chapter as relevant as those
readers who are practicing a more formal program of MBT.
Concurrent Psychotherapy
Concurrent group and individual psychotherapy can be undertaken as either combined
or conjoint treatments. In combined group and individual psychotherapy, the same
therapist conducts both the group and the individual sessions. In conjoint treatment,
the individual therapist is different from the group therapist, so potentially all patients
in a group might have different individual therapists.
Concurrent group and individual psychotherapy dates back to 1949 (Wender and
Stein 1949). Prominent contributors to the literature have been Ormont and Strean
(1978), Caligor et al. (1984), and Porter (1993). The history has been summarized by
Karterud et al. (2007). Concurrent psychotherapy has been regarded as a useful ap-
proach for a variety of mental disorders, with an emphasis on severe personality disor-
ders in general (Ormont 2001) and borderline personality disorder (BPD) in particular
(Schachter 1988; Scheidlinger 1982; Stein 1964). There is a widespread belief that the
two therapies have a synergistic effect and provide a complementary approach to the
patient’s needs, with group therapy emphasizing the exploration of interpersonal rela-
tionships and individual therapy emphasizing intrapsychic exploration. However, nei-
ther the efficacy of concurrent psychotherapy nor the supposed therapeutic
mechanisms have been properly tested by research. Nevertheless, both the American
and the English guidelines for treatment of BPD advocate concurrent psychotherapy
(American Psychiatric Association 2001; National Institute for Health and Clinical Ex-
cellence 2009b). The National Institute for Health and Clinical Excellence (NICE)
guidelines clearly state that when psychological treatment is offered, therapy should be
provided in at least two modalities (e.g., individual and group), should have a well-
structured program and a coherent theory of practice, and should include therapist su-
pervision within the framework of the service. These recommendations were based on
the positive results of randomized controlled trials (RCTs) of dialectical behavior ther-
apy (DBT) and MBT, both of which have a concurrent format and professional con-
sensus. However, no studies have compared concurrent DBT (or MBT) with DBT (or
MBT) as a stand-alone individual or group therapy.
Group Therapy Techniques 83
To our knowledge, only one study has compared a conjoint treatment with a sin-
gle-modality approach for the same kind of therapy. The Italian group of Ivaldi et al.
(2007) compared combined (same therapist) individual and group cognitive-evolution-
ary therapy for outpatients with personality disorders (mostly BPD) (n=85) with indi-
vidual cognitive-evolutionary therapy as a single modality (n=24). The results seemed
to favor the combined treatment on a range of outcome measures (dropout rates, Glo-
bal Assessment of Functioning Scale, symptom reduction, quality of life, and self-
harm). However, the design was not an RCT, and the patient allocation to the different
conditions was not balanced. The study was in no way conclusive, but it was the first
empirical indication that combined psychotherapy for patients with personality disor-
ders may be superior to individual therapy alone.
Strictly speaking, then, we suppose that the two formats have a synergistic effect on each
other when implemented properly. However, it is important to underscore that the two for-
mats, when operating together, are not exactly equivalent to the two formats when operat-
ing alone. Individual psychotherapy, when conducted in concert with group psychotherapy,
differs in certain ways from individual psychotherapy conducted as a single modality. The
same is true for group psychotherapy. When the two formats are combined, the therapists
in each modality will of course explore the patients’ experiences in the other modality. But
more important, each therapist will have representations of the patient-in-the-other-mo-
dality in his or her mind as an ongoing and changing process. These representations are dif-
ferent from representations of the patient-in-relation-to-other-attachment-figures because
they are informed not only by stories told by the patient but also by information and reflections
provided by the other therapist(s). This point was highlighted in a study by Kegerreis (2007),
who described a conjoint individual and group psychotherapy program with borderline pa-
tients from a British National Health Service outpatient psychotherapy department. Keg-
erreis emphasized the therapist couple and how the sharing of information is crucial for
identifying and containing parts of the self that are being kept apart by being located in one
or other of the modalities. This type of splitting makes it difficult to work toward an inte-
gration in the here and now in either of the modalities alone. However, the close coopera-
tion between the therapist couple may make them more aware of these dynamics and
facilitate containment, reflection, and change processes.
MBT has been a combined treatment within a conjoint framework, which is in part
a result of its origins in a day hospital treatment program. Historically, in day hospitals,
group and individual psychotherapy were conducted by different professionals, including
milieu therapists, psychologists, psychiatrists, and occupational therapists, and conjoint
therapies were considered a “natural” way of cooperation. Furthermore, day hospital
groups were traditionally conducted by two therapists, so half of the patients could be as-
signed to one of the group therapists for individual sessions and the rest to the other. But
this has been considered counterproductive because of the risk of stimulating splitting, ri-
valry, and envy.
MBT takes a team approach, acknowledging that difficult-to-treat borderline pa-
tients will commonly engage several therapists in different aspects of treatment. The
advantages of the team approach are that heavy responsibilities and countertransfer-
ences are shared by several people and that different perspectives on intricate problems
supplement and enrich one another. The risk is that different and competing perspec-
tives among different therapists may increase the possibility of destructive enactments
of the patient’s internal drama. The MBT format thus presupposes that therapists share
the same theoretical position and that procedures exist for frequent exchange of infor-
mation between the therapists.
Clinical Vignette
Mr. A, a 33-year-old patient, experienced a major depression when his mother died, and
in the aftermath, he deliberately tried to kill himself through heavy drinking. He suc-
ceeded only in inducing recurrent acute pancreatitis. Mr. A continued to lead a desper-
ate, self-destructive life for years, until he was referred for day hospital treatment. His
Axis II diagnoses were borderline and narcissistic personality disorders. Mr. A was absent
from the day hospital at least every second day, maintaining tight control of his degree of
involvement and attachment. Despite this detachment and poor therapeutic alliance, Mr.
A was offered conjoint follow-up treatment once a week.
In the individual therapy, Mr. A was very dismissive of the group, primarily remark-
ing on the inferiority of his fellow patients but also on the inadequacies of the group ther-
apists. He said that the other group members were “sick” and “stupid” and that he could
not care less about their misery and helplessness. Mr. A believed that he had developed
far beyond their level of maturity years ago by his own intellectual achievement. Mr. A
saw the group therapy as a regrettable adjunct to the individual therapy, which he could
accept more easily. However, he also believed that individual therapy was unlikely to
make any great difference because he saw his destructive tendencies as a reflection of the
general corruption and evil within civilization.
Overall, Mr. A showed a pseudomentalizing style, which apparently gave him some
credibility in the underground artistic scene of which he was a part. He had “hundreds of
friends and acquaintances” whom he preferred to talk to and give his advice to rather
than discussing things with the “creepy group.” When the individual therapist asked
about his group experiences, Mr. A would respond with single words such as “boring”
and “uninteresting.” He could not define any particular episode or group member that
was “boring”; everything was just boring. Mr. A also could not provide any coherent nar-
rative of group events or describe how he perceived the individual members so that the
individual therapist could get an impression of what was going on in the group. More-
over, he was absent from more than half of the group sessions; one can understand the
despairing feelings of the group therapists.
Several meetings took place between the therapists and Mr. A on the topic of his
poor attendance, but the effect was only temporary. Soon he was back to his dismissive
pattern. It was encouragement from the individual therapist that enabled the group ther-
apists to keep going. The individual therapist found it meaningful to have this close ex-
perience of Mr. A’s destructive attitude and reported that Mr. A’s tendency to engage in
pseudomentalization, which was his main strategy for keeping other people at a distance,
and his destructiveness (psychic equivalence functioning) were lessening slightly. His de-
valuation of the group brought these themes closer to the here and now and helped the
individual therapist to avoid the trap of colluding with his defensive idealization of the in-
dividual therapy. The group therapists were convinced by these arguments, although
they found Mr. A’s seemingly chronic devaluation of their work intensely irritating and
provocative.
The first year passed in this way. After another few months, the individual therapist
asked, as usual, “How was the group yesterday?” Mr. A calmly answered, “Oh, it was
okay.” The therapist wondered if he had heard correctly. “Was it okay?” “Yes, it was.” “So
tell me a bit more about it.” Nothing dramatic had happened. However, it seemed that
Mr. A had been able to talk about a current relationship in a more intimate way that elic-
ited responses that he could accept; there was a dialogue, and he felt that “it was okay.”
This was a turning point. He continued to improve over the next year with containment
and steady work on his pseudomentalization, psychic equivalent thinking, dismissing at-
tachment style, and indecisiveness, which came more to the fore when he was trying to
approach a girl whom he had met in the meantime. From that point onward, Mr. A pro-
gressed rapidly. His attendance and his capacity for intimacy improved alongside an en-
hanced ability to provide and explore more coherent narratives of intersubjective
exchanges.
This vignette illustrates a major problem and challenge in working with patients
with severe personality disorders. Although group psychotherapy might provide a
multitude of fruitful therapeutic opportunities, most patients with severe personality
disorders tend to experience strong fears and anxieties about the group, and they fre-
quently respond by regression with respect to their mentalizing capacities. Mr. A was so
provoked by the therapeutic group situation that he experienced his fellow group mem-
bers, who bored him immensely, as being sick and stupid. Left alone with the group, he
surely would have dropped out. However, in the one-to-one relationship, he managed
to regain, develop, and consolidate his mentalizing capacities with the help of a sensi-
tive therapist, and this eventually enabled him to benefit from the more complex and
challenging group situation. So, why are groups so frightening, and how can this be ex-
ploited for therapeutic purposes?
Group Anxieties and Mentalizing

The human potential for regressive behavior in group situations has been a major con-
cern for Western philosophy for centuries (Trotter 1915). The psychological explora-
tion of the phenomenon was pioneered by McDougall (1920) and Freud (1921) and
became the main topic for Bion (1961) in his celebrated volume Experiences in Groups.
Bion observed that regression in groups did not occur randomly and chaotically, but
seemed to happen in some sort of “organized” way as if everybody were affected by sim-
ilar collective forces. The end point (i.e., groups in a regressed state) typically appeared
as either fight-or-flight groups, dependency groups, or pairing groups, each of them
being defined by a common basic assumption: 1) the reason for the group’s existence is
to fight or flee from a common enemy; 2) the reason for its existence is for the members
to support one another in mutual help and concern as helpless beings while waiting to
be nurtured by an Almighty; or 3) the reason for its existence is to indulge in pleasure,
enjoyment, and sex while waiting hopefully for a great future.
In Bion’s view, acting on any of these basic assumptions was a regressive turning
aside from the primary self-reflective task of the psychotherapeutic group. According
to Bion, self-reflection, some aspects of which we would now consider as mentalizing,
was profoundly frightening. The very process provoked regression toward acting on
those primitive (and false) basic assumptions. Bion (1961) invoked Kleinian theory,
claiming that self-reflection in a group situation approximated too closely an extremely
early Oedipal scene in which destructive aggression was mobilized, which in turn acti-
vated early psychotic anxieties of annihilation and primitive defenses against these anx-
ieties. The group’s basic assumptions represented the primitive defenses.
Leaving aside the question of the validity of this Kleinian theory, the important
point here is that in the very act of reflecting on one’s own and other minds in concert,
one might encounter confusing self-states (and affects) that are extremely difficult to
think about and represent (mentalize), and the concreteness of psychic equivalent
thinking—actually being physically together and feeling united against a concrete en-
emy—provides welcome relief. This conceptualization is closer to the theory of men-
talizing than the original Freudian view that the reason for regressive propensities in
groups was that the individuals had deprived themselves of some mental capacities by
projecting parts of their ego ideal onto the leader in order to become a cohesive group.
The self psychology view has been that the individual regresses simply through being
deprived of customary selfobject control strategies and responses, which are para-
mount to a sense of self-cohesion. Faced with the uncertainty of strange others, the in-
dividual will fall back on archaic internal configurations, such as an archaic grandiose
self, or will submit to the longing for an archaic idealized selfobject (Karterud 1990).
Group Analysis and

Mentalization-Based Treatment
Theories of small group development typically define some of the anxieties and con-
cerns likely to be experienced among new group members. The therapist’s response is
considered decisive in determining what kind of group will evolve. In cognitive, cog-
nitive-behavioral, and, to a lesser extent, short-term dynamic groups, the therapist
takes a firm lead by offering explanations, instructions, and structuring of the group.
Patients usually find it a relief to realize that the group has manageable tasks, that the
therapist will take a firm lead in these tasks, and that the group is a time-limited enter-
prise.
The psychodynamic perspective has been that although such strategies provide an
immediate relief, they do not address the deeper yearning for a restoration of the self.
Psychodynamic authors claim that this aim requires longer-term treatment with a less
directive group therapist who allows the group to develop more slowly according to its
internal dynamics and using its own resources. The central idea of group analysis is that
the individual develops through the very process of becoming a responsible group
member (e.g., through negotiations with the other group members on issues such as
rules and regulations, confidentiality, norms of behavior, needs for sharing and toler-
ance, and participation in creating the group mentality that encourages exploration of
shameful affects and thoughts). The group analytical slogan is “leave it to the group.”
But how can “sick” people develop a functional group almost by themselves? Foulkes
(1975) responded by claiming that although each individual diverges from the social
norm in certain respects, each will do so in different realms. As a group, they will com-
pensate for one another’s deficits. The difficulties of each individual group member will
eventually emerge as deviations from the group norms. Therefore, the main task of the
group analyst is to help the group to work with and resolve its own problems with be-
coming and being a group.
This group-oriented and collectivistic approach has gained more of a foothold in
Europe than in the United States, where, in psychodynamic group psychotherapy, the
dynamics of the individual are monitored more carefully (Rutan et al. 2007), and prag-
matic considerations have allowed for outpatient concurrent group and individual
treatment when the group modality has been considered ineffective alone (Alonso and
Rutan 1990). From a European group analytical perspective, the pragmatics of adding
individual therapy are basically suspect, akin to an export of problems that the group
does not dare to deal with. The differences between the two approaches are summa-
rized in Table 4–1.
TABLE 4–1. Comparison of dynamic and mentalizing groups
Dynamic group therapist Mentalizing group therapist

Passive>active Active>passive
Negotiates rules, regulations, norms of States rules, regulations, norms of behavior
behavior
Observer>participant Participant>observer
Group>individual-oriented focus Individual>group focus
Group-as-a-whole interventions—some Group-as-a-whole interventions—rare
Stop, slow, or “rewind” the group—rare Stop, slow, or “rewind” the group—common
Leave it to the group Intervene
Change through finding self in the group Change through stimulating mentalizing in
complex interpersonal context
What is the MBT position with respect to these issues? Concerning pragmatics, it is
closer to (American) psychodynamic group psychotherapy than to group analysis. It is also
more individually oriented. In most instances, therapists do not wait to see how “the group
deals with it” but intervene when the opportunity, or need, exists for mentalizing work. As
far as we are aware, no research evidence supports the Foulkesian claim that even groups
with severe personality disorders can develop a sound and productive group culture with
the help of a minimally engaged group analyst. On the contrary, the literature is full of an-
ecdotes of chaotic group situations involving borderline and narcissistic patients. Further-
more, the dropout rates of such groups are high, and patients frequently explain their
decision to drop out as the result of painful negative affect states that were activated, but not
resolved, by the group (Hummelen et al. 2007). In our opinion, there is a tendency to un-
derestimate the mentalizing deficits of borderline patients and to expose such patients to
group situations that are far beyond their capacity. We share the views of Dalal (1998) that
Foulkes held an idealized concept of the nature of humans and group dynamics and that he
underestimated the power of destructiveness.
Mentalization-Based Group Therapy

The MBT response to the high risk for individual and collective regression in patients with
BPD is to address both structural and dynamic issues. The structural elements are summa-
rized in Table 4–2. This structure has to be kept in mind when we proceed to the dynamic
issues.
Ideally, patients should be well prepared before joining an MBT group. A clinical
and standardized diagnosis will have been made, their personality and relational dy-
namics will have been formulated and explored, and they will have undertaken intro-
ductory MBT sessions (see the section Educating Patients About Mentalizing, this
volume, Chapter 7). In the spirit of mentalizing, this process will have been open and
collaborative and discussed with them. Within the assessment and introductory pro-
cess, they will have learned that the primary task of the group is to provide a training
ground for mentalization and that their group experiences can be further explored in the
individual sessions. Mentalization is explained as the central mechanism of self-cohesion.
Successful mentalization (i.e., a “true” understanding of one’s own feelings, motives,
and thoughts in relation to other minds in specific situations) provides a sense of self-
hood, identity, and trust in the capacities of one’s own mind. Its opposite, failures of
mentalization, might induce confusion, misunderstandings, painful and inexplicable
affects, a sense of disorganization and fluctuating self-states, and a feeling of detach-
ment from others. Patients are told that everybody will now and then experience loss of
their mentalizing capacities in the group and that this might even include the thera-
pists. The common responsibility is to try to identify these instances, to explore them,
to understand them, and to restore the ability to think and feel. The very process of
working with these problems is the supposedly curative mechanism of the group. This
TABLE 4–2. Structural elements of group mentalization-based treatment
• Crisis plan for each patient

• Schedules of group and individual sessions
• Regular meetings for the conjoint therapists
• Weekly supervision
• Meetings every third month to monitor treatment progress
• Consultations with a psychiatrist to discuss medication
• Offering of a pretreatment (or beginning of treatment) psychoeducational group for
8–12 sessions that addresses issues such as mentalization, affects, attachment, borderline
and other personality disorder dynamics, and the rationale behind the treatment program.
In concert, these elements function as a solid holding environment.
view resonates with Foulkes’ concept of “ego training in action” and the more modern
version, “self development through subjective interaction” (Brown 1994). Change does
not occur through revelation of some hidden secrets, or through deep insights or pro-
found interpretations by the therapists, or by receiving good advice from fellow pa-
tients.
Of course, such intellectual understanding is of little use when patients lose men-
talizing and become victims of psychic equivalent thinking during the group process. In
this mode, they will forget all the psychoeducational preparation. However, fellow pa-
tients may not lose mentalizing simultaneously and, preserving their capacities, may act
as responsible group members in concert with the therapist to alleviate the pain and re-
store the mentalizing abilities of the protagonist. On a group level, the therapist thus
strives for a “good interactive mentalizing group.” When the group does its job, most
of the patients are active in exploration, are inquisitive, provide alternative perspec-
tives, challenge stereotypes and false beliefs, share their own experiences, and reflect on
what is happening in novel ways. In such instances, the therapist can refrain from active
verbal behavior. However, the therapist is more active than most group analysts and
psychodynamic group therapists in efforts to prevent collective regression (i.e., to avoid
fight-or-flight and dependency group functioning). We return to the techniques avail-
able for the therapist later. First, we comment briefly on therapist activity and depen-
dency.
Therapist Activity and Dependency

In line with our approach in individual therapy, the MBT approach advocates an active
and engaged group therapeutic style. Profound group-as-a-whole interventions are
rare. The therapist openly and repeatedly explains the primary task of the group and
may praise the group when its members have done their work properly or point out
when the group seems to have gone astray. The therapist is further advised to structure
the group work by 1) not allowing aggressive outbursts to escalate, 2) stopping the
group process when it is unproductive or is missing important opportunities for men-
talizing exploration in the here and now, 3) initiating careful step-by-step explorations
of crucial intersubjective transactions, and 4) demonstrating and explaining the pri-
macy of the here and now.
Relative to group analysis, the MBT approach involves more frequent and longer
sequences of explorations of individual patients’ perceptions and interpretations of
interactions with others. However, “individual therapy in group,” or deliberate turn
taking, is not the objective. The therapists strive to establish a process with active and
engaged group members but not for a “psychotherapy through the group process,”
which is an ideal for several other psychodynamic group therapies. For this to be a
meaningful objective, the therapist has to be more patient and wait for enactments of
complex scenarios in the group. The MBT group therapist is advised to intervene more
frequently. But how can such an active group therapist avoid creating a group depen-
dency?
In our experience, patients seem to be enlivened by the mentalizing stance in
groups, in a way that counteracts passivity and submission. The therapist balances his
or her leadership on structural issues with a genuine “not knowing” and “let’s try to find
out” attitude concerning the content of others’ minds and how this influences their in-
teractions. We suggest that it is not passivity or activity of the therapist per se that pro-
motes dependency groups but rather explicit and implicit signals that convey a sense
that the therapist has some sort of privileged access to the unconscious of the individual
and the group. Interpretations that tell the individual and the group what is “really” go-
ing on are proscribed in MBT.
The “not knowing but curious to find out” mentalizing stance (see also the section
Don’t Worry and Don’t Know, in Chapter 3) is more than a technique. It is a general at-
titude that permeates the whole range of more specific types of interventions. A simple
example is the attitude toward expressions from patients such as “I know exactly what
you are talking about” or “I had exactly the same experience.” Such statements usually
initiate a verbal exchange between patients, leading to some sort of supposed agree-
ment on a matter of interest. In psychodynamic group psychotherapy, such statements
are believed to contribute to a (positive) experience of communality and universality:
“I’m not alone in the world”; “I have fellow travelers and sufferers”; and “My ailment is
not unique but shared by others.” The MBT approach does not assume this and thus is
gently challenging: “It is possible, but are you sure?” or adds: “For my part, I find it a bit
difficult to grasp what Linda is talking about” or “Shall we try to find out a bit more
about what happened in the situation that Linda describes?” or “I’m curious about what
kind of feelings Linda experienced when....” In general, group members have a ten-
dency to jump to conclusions. They often act on broad and stereotyped generaliza-
tions. A major task of the MBT therapist is to slow down this process.
Illustrative Group Session

To illustrate the MBT approach, we describe a group session with comments on the in-
dividual and the group dynamics as well as the interventions provided by the therapist.
Our comments and citations are based on a study of a video recording of the session,
which was made for research purposes. The patients have agreed to this (slightly dis-
guised) report and analysis:
The group included eight patients, all of whom were seriously affected by their person-
ality pathology. Before this treatment, most of them had been hospitalized. Everybody
except Mr. G had been out of work for several years. Their relationships with their fam-
ilies of origin were very poor or nonexistent, and their ability to establish a family of their
own was equally compromised. Mr. L had no contact with his two daughters, and the
child welfare authorities had removed Mr. G’s three children because of his chaotic re-
lationships, breakdowns, and suicide attempts. This particular group is a continuation of
group therapy after an initial short-term (18-week) day hospital treatment. At the time of
this session, most of the group members have improved considerably.
Mr. J is the most recent member of the group (4 months), and he has not stabilized
yet. He was in bad shape when he started: hospitalized (acute ward) because of a mental
breakdown and self-harm, he attended the group with bandages on both arms, heavily
medicated, and very shabbily dressed. The other members have attended the group for
between 1 and 3 years. Several have terminated their concomitant time-limited (2 years)
individual psychotherapy. The group therapist has frequent contacts with Mr. J’s thera-
pist because of his irregular attendance and with Mr. O’s therapist because of his ongoing
drug dependency.
• Mr. L, a 45-year-old immigrant from the Middle East, has never managed to get
integrated into the local community. His diagnoses are paranoid personality dis-
order, generalized anxiety disorder, and recurrent major depression. His
chronic rage and ideas of revenge have made him isolated and lonely, he has no
family or friends, and he has made numerous serious suicide attempts.
• Ms. I, a 32-year-old patient, has BPD with schizoid features. She describes a
profound lack of an inner sense of self, confusing self-states, and feelings that
she cannot describe, and she frequently becomes trapped in abusive relation-
ships that she does not understand.
• Ms. R, a 42-year-old patient, has a depressive personality disorder. She is the
most reflective member in the group but has a tendency to get lost in long se-
quences of pseudomentalization, becoming alienated from herself and others
and starting to cry.
• Ms. F, a 35-year-old patient, joined the group while taking multiple medications
for her BPD, bipolar II disorder, attention-deficit/hyperactivity disorder, and
obsessive-compulsive disorder.
• Mr. G, a 38-year-old patient, has an avoidant personality disorder and alexi-
thymia. He does not know how to react because he does not feel anything but
bodily discomfort.
• Mr. J, a 26-year-old member of an ethnic gang, has been convicted for violence,
and he has BPD, antisocial personality disorder, and substance dependence (am-
phetamine and cannabis).
• Mr. O, a 30-year-old patient, has an avoidant personality disorder with depen-
dent features and cannabis and diazepam dependency.
• Ms. N, a 35-year-old patient, has BPD with schizotypal features (periodic
delusions of being poisoned), eating disorder, and panic disorder with agora-
phobia.
At this particular session, Ms. I is absent because of flu, and Ms. N is away because
she is visiting a terminally ill family member in another city. The group contains several
sequences with somewhat different, but related, themes. In the first short sequence,
Ms. F announces that this month she will be working full-time as a nurse. The message
is received and acclaimed by the members, and there is a sharing of contentment and
pride. Ms. F and others comment on the contrast with the way she was when she started
treatment. At that time, Ms. F was regularly hospitalized, was extremely compulsive, had
panic attacks, was unable to go outdoors without company, was heavily medicated, and
felt hopeless for the future. She could not even dream of her current existence of being
independent and managing to live alone, taking care of her sons, and even enjoying work.
The therapist gently supports this authentic sharing of good news and general sense of
pride. Since Ms. F is going to terminate therapy in a couple of months, the therapist
brings up that theme. The response is that Ms. F is so busy with working these days that
it has been difficult to find time for the group (1:30 P.M. to 3:00 P.M.), and she looks for-
ward to terminating. The therapist thinks there is an element of emotional denial here
but turns to Mr. L (which initiates the next sequence) and asks how he is doing because he
is also terminating, and that was a difficult topic for him during the last session.
In that session, Mr. L had been angry and unforgiving in a way that provoked the
other members, who confronted him, but the session ended with someone commenting
that other emotions also seemed to plague him, and he became very sad. Now Mr. L
talked with tears in his eyes about his sadness, which had persisted the whole week, in a
way that seemed to move the other members. For the first time, he talked about different
and opposite feelings and thoughts inside himself. The theme also related to the group;
something in him wanted to attend and join in with the group, but he also had felt like
staying away.
Ms. R asked if that was related to the last session; Mr. L nodded, and Ms. R said:
“Yes, we did not let you get stuck with your unforgiveness.”
Mr. J, who previously had been so angry with Mr. L that he had nearly left the group
in rage, now seemed to support him by saying: “Yes, we all have a sad and negative side
and a positive side. We have to go for the positive one. We have to find our way, but I
don’t know what is yours. But it seems that you often identify yourself with the negative
side.”
MR. L: Yes, I look at myself in a very negative way.

MS. R: You are perhaps not your own best friend.
MR. L: No, I’m not, but that’s a realistic view.
MS. R [challenging the psychic equivalence]: I don’t agree at all that you are in sync
with reality when you downgrade yourself.
MR. L [now being more modest]: It’s very difficult to talk about these things.
I don’t share thoughts like this with others; I keep them hidden.
The therapist thought that this piece of work with Mr. L was quite helpful for ev-
erybody (Mr. L owning his sadness; staying with it and displaying it; and at the same time
acknowledging other aggressive and revengeful feelings that were related to the forth-
coming rupture of his attachment, the connection to the last session, and the caring
shown by the other patients but also their challenge of his psychic equivalent thinking).
However, because Mr. L had occupied such a large part of the last session, the therapist
turned to Mr. J and said that he was pleased to notice that Mr. J was an active and engaged
member this session; that he looked much better than previously, which possibly indi-
cated that he was feeling better about himself; and that he also noticed that Mr. J had now
attended two sessions in a row and wondered if that was an indicator of some kind of
change in relation to the group. Mr. J confirmed that he felt better and attributed it to de-
veloping a more normal structure to his existence after finding a new job. Concerning the
group, he talked about his difficulties with getting to know the others and engaging him-
self in their problems because so much seemed so different from his own life experiences.
Then Mr. J added: “But I’m here for myself, and I cannot promise to be a regular
member. When I become frustrated, I have to withdraw.”
Ms. R challenged Mr. J: “So you expect us to be stable and make up the group while
you yourself have the freedom to come and go?” Because anger was a difficult emotion for
Ms. R, the therapist commented: “It sounds as if you were a bit irritated now. Is that so?”
MS. R: Yes, I am, but I’m also sad. What Mr. J says brings up something stern
in me.
MR. L: You can be very harsh on yourself and others, and you can become very
irritated. Do you think you do enough work on that problem here, like last
time with Ms. I?
A discussion about Ms. R’s anger followed; she corrected Mr. L’s impression by say-
ing that his observation was an accurate description of how she used to be, but her own
perception was that she had now changed. Ms. R clarified this by explaining how she had
perceived and thought about the incident with Ms. I and how she had felt more com-
posed and independent afterward, and that was the reason that she went straight home
afterward, without chatting with the others. The therapist commented that her explana-
tion of the incident and how she had reacted fit in with his own observations in that par-
ticular session (validation).
Ms. R then proceeded with a story about a telephone conversation with her mother
about some tickets for an event 2 months later. Her mother had supposedly said that Ms.
R should have known that she would be out of town at the time of the event, so she should
not be asking her if she wanted a ticket. Ms. R had answered that she did not keep track
of all her mother’s movements. The conversation had escalated into an argument, and
the mother had supposedly told Ms. R to stop because the conversation was becoming
very unpleasant for her.
The therapist thought that the way Ms. R presented this event showed the progress
she had made. Often, she got lost in long and confusing narratives and failed to capture
the attention of the others (pseudomentalization). Now the narrative was short, to the
point, and free from excessive and irrelevant details. He wondered if he should comment
on this but chose to ask the other members about their thoughts and feelings on this
story.
Either course of action is consistent with the MBT approach. If the therapist had
chosen to comment on it, he would have presented his own thoughts and feelings about
the story, becoming an active participant of the group rather than an observer. He might
have said, “Listening to you makes me realize how differently you tell us about things
now. To me, you seem clear and able to stick to the point, which I find so much better.
What do other people think?”
In this way, the therapist provides some judicious praise by stating his experience
and then tries to get other perspectives from the rest of the group.
Through the questions and comments of the other group members and the thera-
pist, the account of the interaction between Ms. R and her mother became more detailed:
“How did you respond to what she was saying?” “Why do you think she said that—wasn’t
that curious?” In addition to such exploratory questions that favor mentalization, several
eager comments from other group members compared Ms. R’s mother with their own
mothers (“It sounds exactly like my own mother”) and described how they had reacted in
similar circumstances. Throughout this lively interaction, Ms. R kept to her main theme,
which was allowing herself to be more self-assertive toward her mother. She spoke of
how her father had imposed a role on her from childhood. Ms. R had the special task of
comforting her mother and her sensitive nerves and never disturbing her. The therapist
asked how she felt about the way she had handled the telephone call with her mother
now, here in the group. “I’m mostly confident, but I’m also ashamed. Something in me
says that I should not have done it.”
About half of the session had now passed. The therapist, becoming increasingly
concerned that Mr. O had not yet spoken, asked: “What about you, Mr. O, any thoughts
about Ms. R and her mother?”
Mr. O responded by saying that with his own mother, it was both different and sim-
ilar. “I keep a lot of things concealed from her; I believe I try to protect her. I can also yell
at her, but afterward I say ‘sorry.’”
Ms. R exclaimed: “It is important for me to know when I should not say ‘sorry.’”
The word sorry seemed to trigger the whole group. In the following sequence, they
discussed how often and how rarely they said “sorry” and why.
MR. G: I also often say “sorry.”

MR. J: I never used to say “sorry.”
THERAPIST: Have you said “sorry” too seldom?
MR. J: Yes, all too seldom. For 23 years, nothing was my fault.
MR. G: I have always been the guilty one.
MS. R: Me, too. Even if there was no reason for it, I could feel guilty just for ex-
isting, for being in the world, for being me, for not being clever enough.
MR. J: I’m quite different. If someone happens to bump into me on the street, or
disturbs me on a bus, I say, “Oh, thank you! Have a good recovery!” Fuck-
ing bitches. For cars that come too close, I can kick the front and show
them my finger. Sometimes when I come home, I think, “Oh, that was on
the edge.”
THERAPIST: So, you have some thoughts afterward, but they don’t sound like
guilt feelings.
MR. J: No, I don’t think so; it’s more that I was close to a fight or something like
that. It’s hard to say.
MR. G: But good to hear that you have some second thoughts. They come a bit
late, though, but better late than never.
MS. G: I’m curious about this “thank you.” I also say that, but perhaps in a dif-
ferent way; I don’t know. I can say that to my sons, and today when I left
the rehabilitation center where I work, I said to one of the clients, “Thank
you, Chris, good work.”
MR. J: That is different, isn’t it? I’m aggressive, and it is irony. It seems that you
reward other people.
MS. G: Yes, I think so. It’s different, it’s more positive. Curious.
MS. R: It’s exhausting to ask for forgiveness all the time.
MR. L: Your father pushed you into it; it’s not fair.
MS. R: My mother was perceived as so weak.
MS. G: Oh, hello! How much I have gone tiptoeing like that! Not to disturb
anyone. I can’t take it any longer. It makes me sick.
[Ms. F illustrates this by putting her hand on her upper chest.]
THERAPIST: What is that, Ms. F?
MS. G: I don’t know exactly. I get filled up. Nausea? Disgust, perhaps?
Ms. R continues, describing another event with her mother. It concerned an invita-
tion to Sunday dinner. Her mother had called her on Saturday. Ms. R felt a bit trapped
because she had not decided yet on some other options for the weekend, and her mother
wanted an immediate response because she was going to buy the food. Several members
commented that her mother seemed rigid and demanding.
MS. G: Just like my mother. Why can’t they be a bit flexible, eh? I used to be like
that myself, but now, thank God, I’ve changed. I can improvise with my
kids.
THERAPIST: Seems like this topic engages everybody, but could we also look at it
from the mother’s side?
There was some attempt to consider the perspective of Ms. R’s mother—it was Sat-
urday, already a bit late—but in general, there was skepticism.
THERAPIST: What are we thinking now? That Ms. R’s mother exploited the sit-
uation and used some kind of pressure?
MR. L: Ms. R, your mother is terrible, ugly, and hysterical, and she gives you
nothing for free.
THERAPIST: From what you have heard here, it seems that you, Mr. L, have
formed a very bad image of Ms. R’s mother, and others too seem to have
made up their minds in some way.

MS. G: I think that what we hear activates much from our experiences with our
own parents.
THERAPIST: Yes, I believe so, too; so it is perhaps important to try to find out how
far our internal images correspond with the reality.
MR. L: I believe you have been brought up under a heavy dictatorship.
MR. G: Mr. L, do you really mean that? I cannot see how you can arrive at such
a harsh view of Ms. R’s mother with such certainty from the scarce infor-
mation we have here.
Some of the participants nod, and Mr. J says: “Yes, should we give her a chance? Ev-
erybody has some good sides.”
Ms. R then gives a lengthy and complicated account of how she views her upbring-
ing and says that she freely chooses to spend time with her mother.
THERAPIST: As I hear it, you say in a somewhat complicated manner that you
find several good sides to your mother, too.
MS. R: Yes.
MS. G: Even my mother, who I believe is worse, has some good sides.
Mr. J then starts to talk about his relationship with his parents. The group has pre-
viously learned that he was adopted from another continent and that he had been a dif-
ficult child who failed to become integrated in the new country and chose to identify
himself with a gang of young immigrants from the same region. Now he talks about visits
to his adoptive parents, how they used to treat him when he was a child (everybody in the
group nodding), how rigid they were, and how a long time ago he stopped trying to
change his parents. Then he recalls a good memory from a tour of Rome with his father.
His parents’ marriage was bad at that time, but he and his father had a rather good time.
Mr. J had talked a bit about his cannabis smoking. Later, when he came back, Mr. J heard
from his mother that she was very concerned about what his father had told her. He felt
disappointed and betrayed, and for this he received some support from the group mem-
bers, who seemed to be suggesting that parents should not behave as united couples.
Mr. J wanted to have a separate relationship with each of his parents. The group mem-
bers listened to his story and commented as he was telling it, supporting his feelings of
betrayal while not making a devil out of his father.
Mr. J closed this sequence by saying: “Yes, previously I thought they were hopeless,
then I withdrew, but okay, nevertheless, they are not that bad; perhaps I should change
a bit.”
MR. G: I thought I should talk today. Is it okay? Well, you know that I have a
problem with aggression. I almost never get angry. Something new has
happened. I got furious, and it felt good.
MR. J [exclaims]: Great!
Mr. G described a telephone conversation with one of his former wives about the
visit day for one of his sons. His relationships with his former wives, his sons, and the
child welfare authorities had been a major topic during his treatment. These complex
matters now seemed to function better for all involved parties, but this time, Mr. G’s ex-
wife wanted to change their appointment and accused him of being a bad father when he
hesitated to comply. He described the exchange between them to the group and how he
got increasingly annoyed and eventually said that because he experienced her as unrea-
sonable and not willing to listen to his arguments, he chose to hang up.
The therapist asked how angry Mr. G was on a scale from 1 to 10. “Nine,” he re-
plied, and the other members praised him that he still managed to behave with some con-
trol. “Yes, I was on the edge of throwing the phone at the wall and screaming at her, but
I didn’t, and I believe she got the message that I was a bit irritated but not that I was fu-
rious.”
MR. J: Great! Rational aggression!
The group members discussed anger, level of anger, and how to control it yet ex-
press it in a way that conveys the feeling but does not ruin the interaction and relation-
ship.
The therapist asked Mr. G how he viewed his way of dealing with this complicated
matter now, in retrospect. Mr. G said that he was content, especially in light of the cur-
rent group discussion. He added that he had spoken to his ex-wife again the following
day, despite being very nervous, and that this time, he felt sorry for her and understood
her arguments. Nevertheless, he still felt that it was her problem, and he did not feel that
he was being unreasonable, so he kept to his original position, which she eventually ac-
cepted. The therapist ended the group by saying that it seemed that Mr. G had handled
this situation quite well and that he was pleased to hear that Mr. G also was able to think
of his ex-wife as having good sides that he could respect.
Discussion of the Group Material

If we were to supervise this session, the first and overarching question would be “Is this
a reasonably good MBT group in the sense that most of the members get engaged in
mentalizing activities in the here and now?” For example, are psychic equivalence and
pseudomentalization challenged? Is there an affect focus that links affects to current in-
terpersonal events and to the here and now? Is the process of finding out privileged
over gaining insight or receiving advice? We first discuss these questions on a group
level and then proceed to the therapist interventions.
Group Level
This group was definitely not a dependency group. The group was rather lively, and the
members oscillated between listening to Ms. R’s often lengthy elaborations and periods of
intense engagement when they interrupted one another, sometimes with humor and laugh-
ter. It was closer to a fight-or-flight group, sometimes a bit intense and favoring psychic
equivalence thinking, such as when Ms. F perceived Ms. R’s mother as “exactly like my own
mother” and Mr. L perceived her as “terrible...and hysterical” and as having Ms. R under
“a heavy dictatorship.” However, the group never engaged in excessive and malign collec-
tive projective identification. On the contrary, Mr. G confronted Mr. L about his “harsh
view” of Ms. R’s mother, and from then on, the central theme was how to deal with good
and bad sides of attachment figures, related emotions, and responsibilities. Mr. J, Mr. G,
Ms. R, and Ms. F were the active members of this “working subgroup.” Mr. L was probably
silenced by Mr. G’s confrontation and resorted to an outsider position, whereas Mr. O
seemed to participate as a kind of interested onlooker. Optimally, the therapist should have
sorted out these positions, but it seemed inappropriate in the light of Mr. G’s intense en-
gagement in the last 15 minutes.
The “working subgroup” in this session conveys a sense of group cohesion to the ob-
server or reader. However, over time, the group self, defined as the collective investment in
and loyalty to the purpose of the group (Karterud and Stone 2003), was highly vulnerable,
as is typical for these kinds of groups. This was not a group that was encouraged to meet on
their own when the therapist was absent. Without the therapist’s continuous effort in main-
taining a mentalizing dialogue, the group would deteriorate. We return to this in a later
subsection, Countertransference.
Therapist Level
The activity of the group therapist was clear. Early on in the session, he brought up the fact
that Ms. F was finishing; he asked Mr. O questions because he had been silent; he became
part of the group, actively using his own impressions to stimulate alternative ideas; and he
insisted that the group consider different perspectives about others’ motives—for example,
asking the group to consider Ms. R’s mother’s perspective. He gave judicious praise to Mr.
G, pointing out that he could understand things from his wife’s point of view while main-
taining his own view; he expressed relief that he could understand Ms. R more easily be-
cause she spoke more to the point, and her narrative was free from excessive detail; and he
shared an observation that Mr. J seemed more attentive and appeared to feel better. These
aspects of the activity of the therapist underscore an important principle followed by MBT
therapists—the mental processes of the therapist are open to the group and become an im-
portant element in stimulating the mentalizing process.
Lack of open mental activity in a group from the MBT therapist suggests that the
group therapist has become lost in the group and does not understand what is happening or
what is being talked about, or that he or she has become defensive. In effect, lack of activity
suggests that the therapist is no longer able to mentalize. Of course, this is not necessarily
the case. The therapist may be quiet simply because robust mentalizing is taking place be-
tween group members, but even under these circumstances, the therapist might be ex-
pected to join in. At times when mentalizing gets lost, either in the therapist or within the
group process, the therapist is advised to “rewind” the group.
Rewind and Explore

Rewinding takes three forms. The first of these is rewinding within the current group
process. Active rewinding of the group within the current process is a common proce-
dure in MBT groups simply because it can be extremely difficult to follow the interac-
tional processes of a group composed of people with BPD. Groups need to slow down!
Otherwise, assumptions are made, opinions remain unquestioned, events are not used
as opportunities to learn, and the group becomes unfocused.
In this particular group session, there was no need to do this because the group was
able to focus, and the therapist remained actively involved. However, if necessary, the
therapist rewinds the group to a point at which he or she could understand what the
group was focusing on: “I’m sorry, but I am lost here. Can we go back to when...?” The
therapist can then take the group forward moment by moment, exploring the interac-
tion as it happened and interjecting with his or her own understanding or questions.
The mental processes of the group members are rewound so that the members can re-
flect on them and consider their nuances in more detail.
The second form of rewinding is to ask the patients to reflect on themselves in a sit-
uation they are describing outside the group: “Looking back now at what happened,
what do you make of what was happening for you at the time?”
In this group, the therapist asked Mr. G to consider in retrospect how he managed
the conversation with his former wife. In doing so, the therapist encouraged Mr. G to
reflect once more on his ability to manage his impulses and emotions under circum-
stances that normally would provoke loss of control and to consider the positive ben-
efits that ensued. This also ensures that the other members of the group become
involved in what has happened and can describe their own reactions, thereby continu-
ing the mentalizing process. If the group members make no response, the therapist ac-
tively takes it forward by asking other group participants to contribute: “What do
others think about how Mr. G managed things?” In this group, such an intervention
was unnecessary.
The third component of rewinding involves asking the group to consider them-
selves in the context of something that has occurred in an earlier group. Here, the ther-
apist asked Mr. L to consider what happened in the previous group session and actively
encouraged Mr. L to reflect on the complexity of his earlier reactions and why the
group might have felt provoked. Mr. L responded by talking about what he had thought
about over the week and how it left him feeling. This theme was taken up by the group
partly because the therapist identified an affect focus.
Affect Focus
Recognizing the affect focus for a group is a key task for the MBT therapist, and Bate-
man and Fonagy have already discussed some aspects of this in Chapter 3. In the con-
text of a group, the affect focus is defined as the predominant affect that currently
determines the interactions either between group members or between them and the
therapist. The affects are commonly covert or preconscious. Identifying the affect is
important because it concentrates the emotional interactions and in so doing creates
the conditions that tend to induce loss of mentalizing in patients with BPD—namely,
stimulation of the attachment system within interpersonal contexts. This might sound
perverse, but it is more akin to in vivo practice in which the patients and therapist grad-
ually increase their capacity to manage their emotional states within complex interper-
sonal interactions by maintaining mentalizing. The therapist’s task is to help them to do
this.
At the beginning of this group, the therapist was aware that the group had been in
difficulty at the end of the previous session and that memories of this were likely to in-
fluence the current group. First, he allowed the expression of the good news about Ms.
F starting to work full-time. This in itself encouraged interaction, with some expres-
sions of pleasure from the members of the group about her achievements. This should
not be confused with an affect focus. In this context, affect focus relates to the covert af-
fect influencing the mentalizing process. Once the pleasure of Ms. F’s success had re-
ceded, the therapist might have said something like “I was wondering, though, about
how you are getting on, Mr. L, because you are leaving as well, and it occurred to me
that I am feeling a bit anxious about what I say now after what happened last week when
I ended with a rather uncomfortable feeling.” In this case, the therapist did not have to
make such an extensive statement of his own impression and simply could have asked
how Mr. L was feeling, but for the purposes of discussion, we have added more detail
here. In making such a statement, the MBT therapist was trying to identify the affect
that might be influencing some members of the group, but he stated his own under-
standing—in other words, he made it clear that this was his current state of mind, which
might or might not be relevant to other members of the group. It was not a statement
about the group as a functioning organism in its own right. Mr. L immediately took up
the theme, suggesting that the therapist understood the prevailing feeling, and this was
further confirmed when Ms. R continued the discussion. If Mr. L or the group had ig-
nored the suggestion, the MBT therapist would likely do no more than ask the group to
consider in what way he was wrong in the hope of rekindling a mentalizing process be-
fore allowing the group to progress.
Recruiting, Joining, and Validating

Patients need to participate in a group if they are to benefit. This is made clear to pa-
tients in their preparation for an MBT group. In keeping with this directive, the MBT
therapist persists in recruiting members to participate actively in the group. In this
group, the therapist recruited some of the patients by asking them direct questions, of-
ten bringing the topic that was being discussed into sharper focus. The therapist
brought in Mr. L, Mr. J, and eventually Mr. O, who had been silent, asking him to give
his thoughts about Ms. R and her mother. Sometimes, the therapist may ask a patient
something specific if he or she knows it is relevant to the patient: “Peter, this is impor-
tant to you, I think. Can you say a bit about it from your point of view?”
At times, it is advisable for the MBT therapist to take a particular patient’s side. In-
dicators of the need for this shift in therapist role include the scapegoating of a patient,
isolation of a patient within the group, and a concerted attack on a patient. First, the
therapist must assess how vulnerable a patient is and how likely he or she is to have a
negative response. The more vulnerable a patient is and the more likely he or she is to
react behaviorally (e.g., by walking out of the group, harming himself or herself, or
leaving the group altogether), the more quickly the therapist should side with the pa-
tient.
Clinical Vignette: The Hopeless Patient

Ms. B continually complained that no one really understood how she felt. All the other
patients spent considerable time listening to her and responding to what she described,
even sometimes giving her advice. Ms. B always responded by saying that she had already
tried what they were suggesting, and it was of no use. This dynamic of the patient reject-
ing the help of her peers and leaving them feeling helpless was suddenly openly expressed
in the group when Ms. B was talking about ending her relationship with her boyfriend.
One patient said: “Every time we suggest something, you always say that you have
already tried it. We might as well not bother because you don’t find anything helpful.
Why don’t you just stay at home and be hopeless?”
Another patient concurred, saying: “You are so negative all the time. Maybe you will
have to accept that you are just a negative person and you can’t get anything out of life.”
At this point, the therapist recognized the risk to Ms. B, who had taken overdoses in
the past when she was feeling rejected and hopeless. He therefore joined the group on
the side of the patient: “I don’t think that is very fair. As I see it, Ms. B has been trying
quite hard to think about what has been said to her, and I was quite impressed with how
she had considered things last week.”
The other patients reacted by saying that it was not their impression. The therapist
had momentarily drawn the fire away from Ms. B, but it was now important to restart a
mentalizing process as soon as possible.
THERAPIST: As far as I can see, Ms. B has been trying harder recently, and the
problem for me is how I deal with being unsure about what to do or say
when things seem to be unhelpful.
PATIENT: She doesn’t listen to us.
THERAPIST: I don’t agree, and I wonder if we are somehow saying things in the
wrong way. That is what I am trying to work out, so it would help if we
could go back to the suggestion that you might contact your boyfriend,
which you thought was no good. Was there something about that sugges-
tion that missed how you feel?
MS. B: They just don’t like me.
THERAPIST: I can understand how you get to that [validation], but it occurs to me
that the others are more frustrated. What do you feel [directing it to the pa-
tient who initially verbalized the problem] about whether we missed some-
thing in suggesting that Ms. B contact her boyfriend?
The session continued with the therapist trying to move from a position of protecting
the patient to one of standing alongside her to one of ensuring that the affects of help-
lessness and frustration were identified and considered without alienating Ms. B. In fact,
she felt that no one understood how humiliating it was for her to seem to be “crawling”
back to her boyfriend, who would probably ill-treat her, which would lead to everyone
saying she was a fool.
In this clinical vignette and in the report of the group session earlier in the chapter,
validation of a patient’s experience by the therapist is apparent. But validation is not
simply agreeing with the patient’s experience; it is more about promoting consideration
and understanding of how mental states can be evoked. In the example of the hopeless
patient, although the therapist stated that he could understand Ms. B’s feeling of being
disliked, he still needs to promote greater evaluation of the experience in the current
context of the group so that the initial validation becomes a step to further mentalizing
and is not an end in itself. In fact, after the therapist had directed the focus toward the
patient who began the dialogue, the therapist initiated a shift back to Ms. B by asking
her if she could consider how she was managing her feeling of being disliked. This en-
sured that he kept to another component of the MBT model—namely, attending to
current emotional states.
In joining with the patient, the therapist often uses his or her countertransference
experience, as in this example in which the therapist stated that he felt that Ms. B had
been trying hard and that he had difficulty in knowing what to do or say when things
seemed to go nowhere. It is not appropriate to say this if it is untrue. The authenticity
of the statement, possibly the essential element of this intervention, is paramount. Pa-
tients with BPD rapidly sense insincerity and rightly react strongly to it. In this case,
the therapist’s statement about his own current experience was strongly felt and once
more emphasizes the therapist’s open involvement in the group.
Countertransference
In Chapter 3, Bateman and Fonagy distinguished between complementary and concor-
dant countertransference to clarify this concept (see the subsection Countertransference
under Intervention Process, in Chapter 3). It is often stated that groups “dilute the trans-
ference” and thereby also countertransference responses. However, the kind of groups
we are referring to are repeatedly burdened with nearly unbearable emotional states that
challenge the very foundation of the group. Extreme self-destructiveness, destructiveness
toward others, rage, despair, and hopelessness all activate similar states in others, and in
concert, they act as powerful antimentalizing forces. The therapist is in no way immune
to these forces. Typically, current mental distress in at least one member of the group is
brought into the group, activating a range of fears and anxieties and old scenarios, which
attack the mentalizing efforts of the therapist. A short vignette from the previous group
will illustrate these dynamics:
The group had recently acquired a new member, Ms. E, age 24. In the fourth session,
she described a long-lasting incestuous relationship with an uncle. After this confession,
Ms. E seemed to be welcomed by the group as a member with a traumatized background

similar to that of several other group members. After that, she was a bit more talkative
but mostly remained a listener. A month later, Ms. E came to the group session with a
tearstained face and looking miserable. The therapist gave his usual messages; waited for
some moments to give someone else an opportunity to respond, which did not happen;
and then commented: “You seem very unhappy, Ms. E. Can you say something about it?”
Ms. E whispered: “It’s awful. I can’t bear it any longer....I’ve nothing to say.” The
group atmosphere became acutely tense, and the other members were aroused, focused,
and deadly silent.
THERAPIST [after a short pause]: That sounds awful, yes, but you could perhaps be
relieved by talking about it here?
MS. E [possibly a bit irritated]: No, I can’t!... I’ve nothing to say.
THERAPIST: Has something happened?
MS. E: No! [mumbles something inaudible]
THERAPIST: What did you say? I couldn’t hear you.
MR. J: How are you doing, Mr. G?
MR. G: Not that bad, could be worse.
THERAPIST: Mr. J, it seems that you interrupted here.
MR. J: Yes, I did, and can’t you see that she wants to be left alone! That should
be respected. But you are forcing her.
[Mr. G and Mr. O agree. Ms. R is nodding.]
MR. J: That makes me mad. I get furious. If it doesn’t stop, I could throw this
bottle into the wall.
MS. N: Mr. J, come on. Are you crazy? Calm down.
MR. J: I’m not crazy. I just don’t like people being forced to do something they
don’t want. People should be respected.
By this time, the therapist was experiencing a range of conflicting emotions,

thoughts, and behavioral alternatives. His initial response to Ms. E was a concordant
transference reaction. She showed profound distress, which activated a normal care re-
sponse (“I’m aware of your distress, and can I help you in some way?”). When this was re-
jected, he made a new gentle attempt. When he was rejected again and possibly received
a nonverbal signal of “Stay away!” he became frustrated but felt that it was important to
keep up the conversation in some way. Then came the attack from Mr. J, which was im-
mediately supported by the two other men and followed by the threat of throwing a bot-
tle. Suddenly, there was a complementary countertransference. The therapist found
himself in the role of a brutal and disrespecting perpetrator. He disliked this and, follow-
ing his gut feeling, would have liked to say to Mr. J: “Get out of here. I don’t accept
threats. Come back when you accept the mentalizing purpose of the group.” He was also
about to suggest to Mr. J that he thought that he might be wanting to protect Ms. E in the
same way that he, Mr. J, wished he had been protected himself. But the therapist realized
that this would have strayed from the model because it was outside the mentalizing ca-
pacity of Mr. J at that moment. Both responses were unexpressed, as were his fears and
anxieties about Ms. E, who had a history that the group did not know very well of several
severe suicide attempts.
The therapist was now stuck in a situation in which a possibly suicidal patient would
not talk, and fellow patients were forbidding him to do anything about it. What should
he do? The therapist needed a pause to recover his mentalizing abilities. He was rescued
by Ms. N, who challenged Mr. J (“Calm down”) and voiced alternative perspectives in co-
alition with Ms. I on the current event and on situations in general when people become
so overwhelmed that they “lose their tongue.” Gradually, the therapist found his voice,
too, and the entire group session then revolved around how to understand, tolerate, and
behave in situations like the first 5 minutes of the group. The tension was high all the way
through, particularly when dealing with the issue of anger perceived as threat, and the
therapist thought that this corresponded to the war going on in Ms. E’s mind. The good
news was that she did not leave the group.
The next session, Ms. E, who had been hospitalized following suicidal feelings,
came to the group. It took yet another session to deal with all aspects of this event. In-
terestingly, Ms. E could now describe her mental state a bit more. In her experience, it
was not so much that she was unwilling to speak but more that she felt that she simply had
no words.
In retrospect, the therapist felt relieved that the members of the group regained
their ability and willingness to mentalize. However, he could see how his countertrans-
ference hate of being controlled by the male subgroup had prevented him from a
proper “rewinding” of the situation to the very start of the session when Ms. E entered
the room with tears pouring down her face. In fact, this introduction to the drama
could have been explored almost from second to second. The therapist could have ac-
knowledged the profound effect this had on everybody, including himself, and might
have voiced his own uncertainty as to how to deal with this difficult situation. Using his
countertransference more actively could have helped the group to accept alternatives
to the rigid accusation of the therapist as “forcing” and “disrespectful” more easily.
Countertransference is the primary focus in MBT group supervision. We strongly
recommend video recordings and a detailed scrutiny of group interactions. Therapists
find it extremely useful to have this second chance to reflect on complicated processes
in which one can all too easily get trapped in the here and now.
Conclusion
MBT group psychotherapy is specially designed for the complicated group dynamics
that arise when patients with severe personality disorders are gathered in groups. It is
combined with individual MBT. “Ordinary” psychotherapy groups, as a single modal-
ity, are composed of patients functioning on a higher level. Consequently, the therapist
can rely on a better group cohesion. Fewer dramatic incidents occur, and when they do,
the therapist has a firm alliance with other, more composed members of the group. The
patients have more realistic representations of one another and the group as a whole.
The atmosphere is warmer and more concerned. More often, members express care,
sympathy, and gratitude for what they learn and receive from one another. The thera-
pist notices regular “moments-of-meeting” (Stern 2004), and the group room can be
filled with deep affection and love. This is not to say that “ordinary” therapy groups do
not contain patients with personality disorders, and many groups have serious prob-
lems with establishing adequate group cohesion.
However, can “ordinary” groups benefit from the MBT approach? On the basis of
Dr. Karterud’s extensive experience in supervising training candidates in group analy-
sis, the answer to the question is “yes.” Above all, candidates benefit from the ability to
characterize the quality of the ongoing process. Candidates regularly have difficulties
with distinguishing “true mentalization” from psychic equivalent thinking, pseudo-
mentalization, and other defensive operations. Consequently, they often feel bewil-
dered about when to intervene, and all too often their response is to wait (“leave it to
the group”). MBT can offer a checklist that enables most therapists to identify to what
extent they are adhering to commonly agreed-on therapeutic principles.
The main effect of supplementing ordinary group psychotherapy skills with the
MBT approach and techniques seems to be a more flexible and confident therapeutic
style. The therapist is better equipped to guide the group through in-depth explora-
tions of interpersonal transactions and is more confident in deciding when it is appro-
priate to sit back and let the group do the work.
Suggested Readings
Hummelen B, Wilberg T, Karterud S: Interviews of female patients with borderline personality
disorder who dropped out of group psychotherapy. Int J Group Psychother 57:67–91, 2007
Ivaldi A, Fassone G, Rocchi MT, et al: The integrated model (individual and group treatment)
of cognitive-evolutionary therapy for outpatients with borderline personality disorder and
Axis-I/II comorbid disorders: outcome results and a single case report. Group 31:63–88,
2007
Kegerreis D: Attending to splitting: the therapist couple in a conjoint individual group psycho-
therapy program for patients with borderline personality disorder. Group 31:89–106, 2007
CHAPTER 5
Mentalization-Based
Family Therapy
Previous chapters have examined the use of mentalizing techniques in the context of
individual therapy and group psychotherapy. In this chapter, we move on to work with
families. It is hardly surprising that mentalizing has become central to therapeutic
work with families; no context is more likely to induce a loss of mentalizing than family
This chapter summarizes work undertaken over several years, aimed at developing a treatment
manual for Mentalization-Based Family Therapy, to which various clinicians have contributed,
including Dickon Bevington, Ephraim Bleiberg, Pasco Fearon, Peter Fonagy, Ellen Safier, Mary
Target, and Laurel Williams.
107
interactions. Here, relationships tend to be at their most fraught, their most loving,
and their most intense emotionally, so the stage is set on a daily basis for interactions
that potentially stimulate a loss of mentalizing in one or more members of the family.
We begin by discussing some aspects of mentalization relevant to families, then outline
the structure of Mentalization-Based Family Therapy (MBFT), and finally illustrate
some of the techniques used in MBFT to promote mentalizing.
It is widely accepted that the enhancement of mentalization contributes to the ef-
fectiveness of all psychosocial treatments, including family work (Allen et al. 2008).
One major aim of MBFT is to engage the family in discussions of situations relevant to
their problems and to elicit and highlight emerging feeling states and their importance.
The therapeutic approach described in this chapter is suitable for use as a brief inter-
vention aimed at promoting the understanding of mental states and their connections
with one’s own behavior and the behavior of others. MBFT can be used as a stand-alone
intervention, or its concepts and techniques can be used by clinicians to supplement
forms of systemic family and couples therapy that they are already practicing. The
structure of MBFT is outlined in Table 5–1.
Many of the techniques used in MBFT have their base in well-known systemic
practices, so MBFT is not a “new” therapy as such. However, it has a specific focus—
namely, to address mentalizing processes within the family context. It integrates attach-
ment theory with systemic practice, making links between external relationships and
inner worlds, and connecting behavior and interaction patterns with meaning-making.
MBFT focuses on emotions as cues to what goes on in people, and it pays attention to
emotional regulation, seeking to effect change in that capacity. MBFT aims to help
members of a family to maximize the level of mutual understanding that they have for
one another and themselves, helping them to engage with their feelings and related
thoughts. One major specific goal may be to increase the empathic understanding that
parents or other caregivers have for their children and—depending on the develop-
mental stages of children—vice versa.
The major objectives of MBFT are shown in Table 5–2. These objectives are evi-
dently closely linked and can only be considered together as a stance to be taken by the
professionals toward a family. This approach works only if all members of the system
eventually adopt this stance. It is unfeasible to leave it to a single professional to carry
the sole responsibility for adopting the posture described.
The enhancement of mentalizing is the primary focus of MBFT. To this end, for
example, the therapist may repeatedly ask people to speculate tentatively about or label
hidden feeling states of one or another of the family members. Furthermore, the ther-
apist may actively encourage family members to name their own feelings and to reflect
openly on how they may be affected by these and how they might affect others. Good
mentalizing is not only the capacity to read one’s own or another’s inner states of mind
and feeling accurately but also a way of approaching relationships that reflects an ex-
pectation that one’s own thinking and feeling may be enlightened, enriched, and
changed by learning about the mental states of other people (Fonagy and Target 1997).
Mentalization-Based Family Therapy 109
TABLE 5–1. Mentalization-Based Family Therapy (MBFT)
• Addresses mentalizing in the family context

• Integrates attachment theory with systemic practice
• Links external relationships with inner worlds
• Connects behavior and interaction patterns with meaning-making
• Focuses on emotion as a link to understanding mental process
• Attends to emotional regulation
• Increases empathic understanding of parents for children and vice versa
TABLE 5–2. Objectives of Mentalization-Based Family Therapy
1. To consider each person’s involvement in and contributions to the problem behavior of the
symptomatic family member(s)
2. To promote awareness of one’s own mental states and the mental states of others
3. To use mentalizing to strengthen self-control and the capacity to regulate one’s feelings in
the family context
4. To help families and their individual members shift from coercive, nonmentalizing cycles
of interaction to mentalization-based discussions and interactions, aiming to promote a
background of trust and secure attachment between children and parents
5. To promote parents’ sense of competence in helping their children develop the capacity to
mentalize
6. To practice the skills related to mentalizing, particularly communication and problem
solving in the specific areas in which mentalizing has been impeded or inhibited; this will
increase the capacity to make balanced reflective decisions
7. To initiate activities and create contexts in which family, friends, peers, professionals, and
relevant others can engage in mentalizing and in which experimenting with thoughts and
feelings is mutually supported
Strengths of Mentalizing in a
Relational Context
Successful mentalizing is usually detectable in several readily recognizable features of
behavior in the family and other social contexts. Table 5–3 lists some of these features
of successful mentalizing. When considering how one mentalizes successfully in rela-
tion to other people’s thoughts and feelings, we can distinguish 12 distinct character-
istics of relational strengths (Bateman and Fonagy 2006a):
TABLE 5–3. Some features of successful mentalizing of people and relationships
The individual:
• Is relaxed and flexible, not “stuck” in one point of view
• Can be playful, using humor that engages rather than hurting or distancing
• Can solve problems by give-and-take between own and others’ perspectives
• Describes his or her own experience rather than defining other people’s experience or
intentions
• Conveys “ownership” of his or her own behavior rather than a sense that it “happens to”
him or her
• Is curious about other people’s perspectives and expects to have his or her own views
extended by others
1. Curiosity (Cecchin 1987) refers to the attitude of an individual who is genuinely in-
terested in other people’s thoughts and feelings and respectful of the perspectives of
others. It includes an attitude of expectation that one’s understanding will be elab-
orated or expanded by what is in another person’s mind, and it implies an openness
to discovery and a reluctance to make assumptions, or hold prejudices, about what
others think or feel.
2. Stance of safe uncertainty (Mason 1993)—also elsewhere referred to as the opaqueness
of mental states (Leslie 1987)—refers to the open acknowledgment that one can
never know but only guess what other people are thinking. It is “safe” in that this
does not lead to the person becoming totally perplexed or overwhelmed by what
may happen in the minds of others. This confidence is based on a background feel-
ing that the reactions of others are at least to some extent predictable, given the
sense one may have of what others may think and feel.
3. Reflective contemplation is a mentalizing attitude that conveys a flexible, relaxed, and
open approach rather than a controlled and compulsive pursuit of how others think
and feel.
4. Perspective taking is characterized by the acceptance that the same phenomenon or
process can look very different from different perspectives and that these tend to
reflect each individual’s different experiences and history.
5. Forgiveness is a mentalizing strength that bases the comprehension of the actions of
others on understanding and accepting their mental states. An example of this is the
management, if not dissipation, of one’s anger toward a person who has behaved of-
fensively once one has understood that the other person acted in that way for a par-
ticular reason, such as a significant personal loss.
6. Impact awareness is another important aspect of successful mentalization. It refers to
the appreciation of how one’s own thoughts, feelings, and actions may affect others.
7. A trusting attitude is seen as a mentalizing strength because trust is at the core of
secure attachment. Importantly, the opposite of a secure attachment is a paranoid,

fearful stance (not some form of nonattachment), which is incompatible with men-
talization.
8. Humility (moderation) in relation to one’s capacity to know and understand some-
one else, and willingness therefore to be surprised and learn from others regardless
of status, follows from many of the strengths described earlier.
9. Playfulness and (self-mocking) humor may be expressions of humility and are key
components of the therapeutic mentalizing attitude.
10. Willingness to take turns articulates an approach of “give-and-take” in interactions
with family members and significant others. This includes being able to make one-
self available to be understood and taking an interest in extending one’s under-
standing of the other person’s thoughts and preoccupations.
11. A belief in changeability is implied in the mentalizing stance because minds can be
changed, generally imbuing a sense of optimism into the therapeutic enterprise.
12. A willingness to assume responsibility and accept accountability, finally, is implied in the
intentional stance of mentalizing because one’s actions are generated by one’s own
thoughts, feelings, wishes, beliefs, and desires, regardless of whether one is fully
conscious of them at the time of the action.
Difficulties in Mentalizing
Mentalizing problems will emerge in a variety of contexts and with differing severity
and presentations. These occur along a spectrum from relatively mild and specific dif-
ficulties to highly destructive nonmentalizing attitudes that may have long-term effects
on the mentalizing capacity and well-being. Mentalizing strategies also may be under-
used or applied erratically if other demands or high levels of perceived stress are present
or if a family member or a relationship has a circumscribed “blind spot.” At the more
extreme end of the spectrum, one or more family members may consciously or uncon-
sciously misuse mentalization in their dealings with others.
In the course of MBFT, we pay particular attention to situations in which specific
problems with mentalizing occur. For example, in an acrimonious parental separation,
one parent who is otherwise highly sensitive to the child’s feeling states may find it par-
ticularly hard to tune into the child’s feelings and thoughts about loss of the parental
couple, perhaps because of ongoing hatred of the other parent. As a result, the parent is
unable to mentalize that aspect of his or her child’s life.
Such specific loss of mentalization may be associated with stress: when exposed to
great pressure, most people tend to lose their capacity to think about the thoughts and
feelings of others. For example, quite dramatic temporary failures of mentalization can
arise in individuals and families during emotionally intense interchanges. Such lapses
can also occur merely in response to thoughts and feelings that trigger high arousal and
antimentalizing reactions. Under such circumstances, grossly inaccurate or even seem-
ingly malevolent feelings can be attributed to others, and feelings of resentment and
mistrust grow in the relationship context. The representation of the mind of another
can literally be obliterated and replaced by an empty or hostile image. For example,
when a parent becomes convinced that his or her child is being deliberately and mali-
ciously provoking, the parent’s mind becomes closed to seeing the child in alternative
ways. Or a parent who endured physical or sexual abuse may temporarily lose the ca-
pacity to mentalize when faced with a reminder of his or her own (past) states of help-
lessness, anger, or shame. The child’s distressed response may act as an additional
reminder.
In other situations, a parent may be temporarily preoccupied with other important
concrete issues in his or her life, such as a crisis at work, and this may propel the parent
into a nonmentalizing frame that gets carried into the family life. This state may fluc-
tuate, preventing the parent from being attuned to the child’s feeling states at certain
times. In such a scenario, the child, who usually has had good experiences of feeling
thought about and understood, is suddenly confused by the parent’s apparent emo-
tional unavailability. The problem can be compounded further if the parent is incapa-
ble of appreciating the child’s disappointment and confusion. Other specific family
problems with mentalizing can arise from the child’s obscuring his or her own mental
states, making the parent’s task of “mind reading” difficult. This difficulty can arise for
a wide range of reasons, such as with the arrival of a new stepparent or in the course of
limited visitation rights, when the nonresident parent simply lacks the contextual in-
formation necessary to make sense of the child’s state of mind. In both of these cases,
the parent’s understandable inability to mentalize the child can nevertheless leave the
child feeling that he or she is not understood, limiting any motivation for making him-
self or herself available to be understood.
Some background conditions can increase the frequency with which nonmental-
izing family interactions arise. Long-standing mental health problems can compromise
mentalizing in families in several ways. A parent with schizophrenia, particularly with
repeated episodes of the illness, will find it difficult to take perspectives, develop and
model a trusting attitude, or be able to take turns, and will have strong, unshakable be-
liefs that will impede curiosity and reflective contemplation. A child in such a family
may respond to this from early on by “hypermentalizing”—being a precocious men-
talizer—as part of the development into a “young carer.” Other children appear to dis-
engage from the mental state of adults. In both scenarios, an interest in the child’s own
mental state decreases as a consequence of the parent’s impaired mentalizing.
When a parent has major depression, the child may be overactive in stimulating the
parent, not into a mentalizing attitude but rather into action, to break through oppo-
sitional behaviors as a way of making the parent connect, even if only via disciplining
and other nonmentalizing actions. Some children may adopt a stance analogous to that
of their parents, shutting down and opting for not thinking as the least painful way of
coping with emotional neglect. Parents with high levels of arousal, such as those with
chronic anxiety states, can find themselves excessively engaged in the child’s mental
world, anxiously loading the child with their own anxious preoccupations. The child,
who does not understand the source of severe anxiety, can be perturbed by it and search
for an explanation in his or her actions and thoughts, engaging in excessive mentaliz-
ing. In a sense, similar processes appear to take place in the parent and the child, almost
in parallel but failing to inform each other directly.
When these dyadic processes take place in a family context, it is inevitable that it
will affect everyone, with others attempting to mentalize the relationship in question.
Another family member, faced with a dyadic nonmentalizing interaction and attempt-
ing to understand the two parties, will run the risk of being only partially understood by
one or both parties. Each nonmentalizing person is likely to understand only some as-
pects of the onlooker’s stance: those that correspond to his or her own perspective. At
the same time, each person in the dyad will feel invalidated by those aspects of the on-
looker’s stance that describe the mind state of the other, as though the onlooker has
taken sides in opposition to him or her. In that way, the onlooker is recruited to the
nonmentalizing interaction because the onlooker feels that he or she has been heard
only partially by each of the protagonists. In this way, a nonmentalizing dyad becomes
a triad. Gradually, the system can recruit other members of the family as well as pro-
fessionals.
Another systemic perspective on mentalization failure is the experience of the in-
dividual faced with nonresponsive minds. When faced with family members who can-
not respond to his or her inquiring or curious mind, the person will give up, reinforcing
the hopelessness of all concerned and resulting in a “circular” or cyclic hopelessness.
For example, a girl who is depressed may experience her thoughts and feelings about
herself as entirely real and, as a result of the lack of interest in her state of mind that she
experiences from her caregivers, is deprived of the perspective that would allow her to
think differently about herself or others. In the absence of relational mentalizing
strengths, such as curiosity or reflective contemplation and perspective taking, pessi-
mism about the possibility of her feelings changing takes over. A feeling of hopelessness
is taken to be “physical reality” by the child the moment it is experienced, and it cannot
be treated as just a thought, which could then be challenged cognitively. The parents of
a depressed child or adolescent may identify with their child’s predicament—for exam-
ple, because they all may feel that having few friends is a hopeless situation or because
the child’s behavior may be experienced by them as an expression of their own failure or
incompetence. Just as mentalizing engenders more mentalizing, nonmentalizing can
engender further nonmentalizing in a family context.
In families with poor boundaries between the generations (often described as enmeshed;
e.g., Minuchin 1974), forms of intrusive mentalizing can take place. The separateness of
minds is not respected within the family: a family member strongly believes that he or she
knows what another member thinks and feels. In such cases, the family discourse may sound
as if everyone is mentalizing well, but paradoxically, this does not have the usual conse-
quence that people feel they are understood. This form of interaction can be described as
pseudomentalization (see Fonagy et al., Chapter 1, in this volume). Family members’ stories
fail to connect with one another, which may incite each family member to redouble efforts
to have his or her view accepted by the rest of the family. In consequence, more and more
unjustified assumptions are made about other people’s mental states: family members invest
a lot of energy in thinking or talking about how other family members think or feel, but
their interpretations bear little or no relation to other people’s reality. The result is that
mentalization is experienced as being obstructive and confusing, and this can lead to certain
members of the family avoiding further mentalization efforts altogether.
If a member of the family “leaves the field,” becoming unavailable for mentalizing
within the family system, other family members may respond in kind, showing more ex-
treme nonmentalizing by taking on a stance that directly attacks mentalization. Statements
indicating this kind of extreme nonmentalizing could include the following: “You are trying
to drive me crazy”; “Your grandma is in league with your father against us”; “You provoked
me”; “You don’t care about whether your dad is here or not”; “You don’t care about me”;
“You would be glad if I were dead.” Such statements generate further arousal that is incom-
patible with mentalization and can lead to nothing but further nonmentalizing cycles. Any
attempts to discuss the meaning of such statements are almost certain to fail because such
statements make sense only in a nonmentalizing world. A therapist who attempts to ques-
tion the meaning of such statements is therefore inadvertently contributing to the nonmen-
talizing cycle and will at best achieve pseudomentalization.
At the extreme end of the nonmentalizing spectrum is the misuse of mentalization. Here,
understanding of mental states of self and others is not directly impaired but is misused to
further an individual’s interest at the expense of the well-being of the family or one of its
members. For example, a parent might use a child’s current mental state (e.g., sadness) as
ammunition in a marital battle (e.g., “Whenever you visit your father, you feel so sad after-
ward; don’t you think you should stop seeing him?”). In these situations, the child might ex-
perience mentalization as aversive because being understood occurs in the context of being
manipulated. In such cases, a child’s feelings are typically exaggerated or distorted in the in-
terest of the parent’s unspoken intention or attitude. Another example might be a father
who claims that he objects to his wife working because it makes the children feel neglected,
but the true cause of his objection is that his wife’s work requires him to be more involved at
home, leaving him less time for himself.
Another misuse of mentalization is coercion against the child’s thoughts. This involves the
parent undermining the child’s capacity to think by deliberately humiliating the child for
her or his thoughts and feelings. For example, the parent exposes the child’s sexual feelings
in a family gathering in a belittling and insensitive manner, disclosing what the child might
have confided in private. These phenomena are most pernicious in the context of abuse,
when the abusive party may falsely maintain that the child “fell down the stairs—I never hit
you” or that the child “enjoyed it when I touched you like that,” for instance. This kind of
misuse of mentalization may undermine the child’s capacity to mentalize, not simply be-
cause it directly contradicts the child’s own reality but because the child may be unable to
construct a bearable image of the thoughts that the parent must have had in order to make
such confusing statements.
Session Structure for Mentalization-Based

Family Therapy
The structure of the MBFT sessions is summarized in Table 5–4.
The main aim of the first session of MBFT is to clarify the reason for referral, to
agree on the purpose of the assessment and therapeutic work, and to develop a mutually
agreed-on care plan with the following elements:
• A brief description of the treatment model

• A commitment by each participant (family and therapist) to participate collabora-
tively in the therapy, including an assurance that family members will inform the
therapist if they cannot attend a treatment session
• An agreement on the number of sessions and the duration of treatment (six sessions
lasting 1 hour, at weekly or fortnightly intervals, to start with, with a review session
after six sessions)
For each session, an agenda is created jointly, with each family member suggesting
what should be covered in the session. Each person’s views are obtained, usually start-
ing with the youngest family member, with the parent(s) asked last. The family is then
invited to find a way of deciding and agreeing on which of the topics or issues should be
the focus of attention. Intersession homework tasks may be set, with the aim of main-
taining the momentum of change between sessions. These tasks should represent a
continuation of a theme that has emerged in a session, and they should be developed
jointly by the therapist and the family members. Feedback should be sought and dis-
cussed in subsequent sessions. When applicable, this will include discussion of the rea-
sons that the homework task may not have been carried out. This is not done in a
didactic or an admonishing style but from a stance of genuine interest and curiosity. In
this scenario, the therapist takes the view that if the family members have not carried
out the task, they must have had a good reason, rather than assuming that it was a sign
of resistance. On occasion, the therapist may ask the family to consider doing specific
activities or tasks in the session.
During MBFT sessions, the therapist thinks and talks continuously about the
thoughts and feelings of the members of the family and the relationships between
them. The therapist acknowledges and positively notes different perspectives, repeat-
edly and explicitly checking that he or she has properly understood what somebody
means (e.g., “Let me just check that I’ve got this right”). In this way, the therapist shows
that he or she cannot know what a member of the family feels without asking a question
to find out. The therapist helps family members to communicate and express what they
feel by, for example, stopping the conversation to ask “naïve” questions about what the
person feels he or she cannot say or explain. A mentalizing element is added to linear or
blaming statements such as “He’s always trying to wind me up!” by inquiring, “And do
you feel that he is being deliberately annoying?” The therapist may ask “triadic men-
talization eliciting” questions, such as asking one of the family members to say some-
thing about the relationship between another two people (“What do you think it was
like for your mom when you had a tantrum in the car?” or “How do you think your par-
ents felt toward each other while you were shouting?”). “What if” questions are also
used. For example, a child who had a tantrum because he or she wanted the parents to
stop the car might be asked, “What would you have felt like if she had stopped the car?”
and the parents might be asked, “What did you think he would think and feel if you did
stop?”
In Table 5–5, we summarize the generic trajectory of MBFT interventions. The in-
terventions move from orienting questions to creating an agreed-upon language about
affect, specifying and clarifying the interpersonal and emotional contexts of important
events, and ensuring that mentalizing strengths are highlighted and the family mem-
bers are taken a step further in their attempts at understanding the mental states un-
derpinning actions. Because the stance of the therapist is also meant to model good
mentalization, the sequence of “stop, replay, explore, and reflect” would be used to ad-
dress any instance of nonmentalization. This is vital because a key effective component
of the treatment is reviewing the process by which mentalization was lost or aban-
doned. Unless the therapist “stops” to consider the feelings and thoughts at the mo-
ment before the loss of mentalization, the therapist will be at risk for colluding with the
family in taking a nonmentalizing stance toward a specific issue.
Generating Hypotheses and

Making Formulations
During each session, the therapist generates and modifies a working hypothesis that is
based on the observed difficulties the family members have when interacting or com-
municating with one another and speculates how the target problem may be related to,
and maintained by, difficulties with mentalization. The “target problem” is what family
members and the therapist have jointly agreed to work on. The working hypothesis is
shared with the family. The following main questions inform hypotheses: “Which
mentalizing problem will seem most relevant and plausible for the family to tackle?”;
“Which mentalizing problem may be implicated in leading to, maintaining, or exacer-
bating the target problem?”; and “How amenable is this mentalizing problem to a brief
intervention?”
The preliminary working hypothesis is shared with the family in a collaborative
manner in order to work on the identified difficulties. This can be done by, for example,
identifying a strength the family has shown (such as caring about one another), fol-
lowed by selecting a mentalizing difficulty and describing this in some detail. All this
can be linked with examples from previous sessions, and connections should be made
TABLE 5–4. Trajectory of Mentalization-Based Family Therapy interventions
• Check for understanding (“Am I understanding that correctly?”)

• Identify affect (“What were you feeling at that point?” instead of “What happened next?”)
• Explore emotional context (“What other situations come to mind when you feel or experi-
ence this?”)
• Define interpersonal context (moment-to-moment exploration of problematic episode;
identify affect)
• Identify and explore positive mentalizing
• Provoke curiosity about psychological motivations for actions
TABLE 5–5. Session structure of Mentalization-Based Family Therapy
Initial sessions
Clarify the reason for referral
Agree on the purpose of the assessment and subsequent therapeutic work
Develop a mutually agreed-on care plan
Subsequent sessions
Create an agenda jointly with each family member
Obtain each person’s views starting with the youngest family member, with the parent(s)
asked last
Invite the family to find a way of deciding and agreeing which topics to focus on
Consider intersession homework tasks
Offer feedback from previous sessions and about homework
between the mentalizing difficulties of each family member. These comments are then
linked directly to the referred problem, not causally but as something that makes things
difficult. The formulation is presented to the family in a validating way as representing
an effort to cope and to keep connections within the family. The therapist also should
point out that changing seemingly automatic, nonmentalizing responses is very diffi-
cult because it involves giving up familiar patterns, however painful those patterns are.
Therapeutic Work: The Five-Step Loop

We have emphasized that mentalizing therapists take an inquiring and respectful stance
in relation to other people’s mental states, conveying the idea that understanding the
feelings of others is important, including what those feelings might be and what
thoughts, meanings, and related experiences are attached or attributed to them. Ther-
apists communicate this to the family as a whole and help individual family members to
make sense of what feelings each person is experiencing while also focusing on the ways
in which miscommunication or misunderstanding (or lack of understanding) of these
feelings can lead to interactions that maintain family problems.
In practice, this requires therapists to strike a careful balance between creating a
therapeutic context that allows the family to interact “naturally,” including actively
eliciting habitual and possibly problematic family interactions around difficult issues,
and offering direction and intervening at critical moments. Given that the MBFT
model postulates that nonmentalizing interactions are unlikely to produce significant
changes in family interactions, simply allowing these interactions to occur is unlikely to
be therapeutic. Therefore, once therapists have a clear idea of the core mentalizing
problems and appropriate examples of related interactions to work with, they should
intervene and shift attention away from nonmentalizing processes. One major aim of
MBFT is to highlight the missing perspective for each family member and how this
leads to the behavior of others not being fully noticed and understood.
The five-step loop intervention technique (Table 5–6) is a pragmatic framework
for devising mentalization-based interventions and for connecting the therapist’s ob-
servations of family interactions with the family members’ underlying feeling states and
related thoughts. It is an in vivo tool for change, with four different types of activities:
observing, checking, mentalizing the moment, and reviewing. The five-step loop is a
framework that allows therapists to structure sessions. It is like a route map for thera-
pists to follow. We refer to it as a loop because it is not a linear progression but a re-
cursive process of reviewing, leading to new observations (reviewing) of mentalizing,
leading to checking and newly observing, and so on.
As a first step, during any stage of any session, the therapist makes a tentative state-
ment (observing) about an interaction between family members that the therapist has
observed in the “here and now” of the session (e.g., “I notice that whenever Dad talks,
Johnny [son] looks anxiously at Mum. Has anybody else noticed this? Or am I just
imagining this?”).
The immediate checking for consensus (“Has anybody else noticed this?”) of this ob-
servation, which is of course a highly specific and deliberate punctuation of an other-
wise complex interaction sequence, is very important in ascertaining whether what the
therapist has observed resonates in the family system. In this example of the second
step, the therapist first identifies and highlights an interaction that (to him or her) ap-
pears to be related to some mentalization difficulty. The therapist then checks his or
her observation by inviting the family and its individual members to connect with it but
also gives them the chance to dismiss it. For example, some or all family members
might say that they had no idea what the therapist was talking about. This should then
lead the therapist to reflect on the validity of the observation in view of the feedback ob-
tained. The therapist also might speculate about the possibility of—and potential rea-
sons for—family members defending themselves against the therapist’s observation.
TABLE 5–6. Mentalization-Based Family Therapy five-step intervention loop
1. I notice that (observing interaction):

—You both raise your voices and that Ann turns her head to the wall.
—In your family, everyone talks at the same time.
2. Is that the way you see it? Is that an issue for you? (checking for consensus)
3. What do you think Pete is feeling now? (mentalizing the moment)
4. Dad feels this and Mom that—do you recognize this as something that happens at home?
(generalizing)
5. So what happened? (reviewing)
If some family members acknowledge and engage with the therapist’s observation,
then the important third step of mentalizing the moment is taken. The therapist models
a mentalizing stance, showing respect for and curiosity about the minds of others. This
attitude conveys that learning about how others are thinking and feeling is enlighten-
ing: “What do you think this is about? What do you imagine Johnny is feeling that
makes him behave like this? And how does this affect others? Dad, what do you make of
it? Maybe I got it all wrong—what do you think, Mrs. Jones? I wonder, Dad, what it
feels like for you when Johnny looks at Mum in this way? What do you think it feels like
for Johnny? If one could see thought bubbles come out of your wife’s head, what might
be in there about how she thinks Sally feels right now?” This invitation to undertake
emotional brainstorming encourages family members to voice feelings, with the ther-
apist then facilitating discussions between family members rather than merely leaving
the action between the therapist and individual members of the family: “Let me see if I
got this right—are you saying that when your dad does talk, it makes you feel a bit lost,
and you look at Mum because she is worried? Do you think she is, or does anyone here
have a different view? Can you all discuss this with one another?”
To encourage mentalizing by each member of the family, a whole range of different
mentalizing techniques (see below) can be used. Overall, it is the therapist’s task to slow
down the interactions between family members, questioning or expressing a specific
interest in exactly what each person is feeling as this interaction unfolds. This tempo-
rarily pauses the flow of exchanges between family members and permits further re-
flections all around. At some stage, the therapist will attempt to help family members to
begin generalizing (the fourth step), moving away from discussing the specific interac-
tion and widening the “lens.” Family members are invited to provide some more gen-
eral observations and reflections on how similar interactional patterns tend to evolve
spontaneously at home and what feeling states these elicit: “So, we saw that when Dad
talks, Mum feels anxious, and Johnny picks this up. Maybe this is the only time it ever
happened, but maybe it isn’t. Can you talk together about whether you recognize this as
something that happens at home or elsewhere?” What has been observed in the here
and now of the session is “looped out” into real-life situations in an attempt to identify
and address typical problem situations. This leads to family discussions of situations
relevant to their problems, and the focus remains on eliciting and highlighting emerg-
ing feeling states and how these express themselves in behaviors. The therapist actively
encourages family members to label their own feelings, to reflect on what that must be
like for them: “You may want to find out how feeling leads to doing”; “...how a few
snowflakes can launch an avalanche”; or “...how a little feeling can get out of control.”
The fifth step, often toward the end of a session, is reviewing what this experience
has been like for everyone. One looks back and checks the feeling states of each indi-
vidual family member. This helps to evaluate how a new and emotionally charged ex-
perience has registered with the different individuals, and it provides an opportunity to
reflect together about what happened and the possible consequences: “What did you
make of what happened? Can you talk together about what this was like for each and all
of you? Are there any conclusions you can draw from this?”
Mentalizing the Moment

In this section, we describe specific interventions that can be used to promote mental-
ization during a session. In Table 5–7, we list the techniques used in MBFT to freeze the
moment and to encourage mentalization.
Simmering down is a useful technique when feelings run high and people’s ability to
mentalize is at risk for being impaired. This is the case when, for example, family mem-
bers blame one another (with rigid statements such as “You never...” or “You always...”)
and can only see their own point of view. During such escalations, in an effort to help
family members to recover some degree of successful mentalization, the therapist may
press an invisible “pause button” and encourage everyone to halt their respective
monologues. On occasion, the therapist may even have to stand up and use his or her
hands and arms, like the conductor of an orchestra in disarray, and ask for momentary
silence—and then encourage all concerned to engage in a step-by-step reflective review
of how things escalated. In individual therapy, this has become known as the mentaliz-
ing hand, when the therapist puts up his or her hand like a police officer stopping traffic.
It is accompanied by a rewind of the session just as it is in family therapy. The change in
behavior and the insistence on a rewind of the sessions are deliberate moves to block
unhelpfully spiraling and seemingly mindless interactions between family members.
Another way to encourage mentalization is to consider negotiating tight time-
frames for each family member to express what needs to be expressed, including
thoughts or feelings. The technique of “60 seconds each” invites taking turns and en-
forces temporary listening. Using an actual stopwatch can lighten things up, with fam-
ily members expressing themselves during the allocated time slot until the therapist
says, “Time is up; next please.” Therapists themselves also at times get caught up in
heated exchanges or feel paralyzed by the family’s dynamics. The therapist may con-
TABLE 5–7. Techniques for mentalizing the moment
• Simmering down
• Disentangling feeling states
• Marking
• Individual resonating
• “Columbo”-style curiosity
• Searching for positives
• Mini role-plays: experimenting and rehearsing
• Enacting problem scenarios
• Weighing pros and cons
• Subtitling
sider getting up and stating: “Sitting here in the midst of it all makes my head spin. It
stops me from having useful ideas. I need to clear my head. I think I’ll take a short
break; I’ll be back in 5 minutes. Feel free to take a break as well or continue arguing if
you need to.” Creating a reflective space for the therapist to literally clear his or her
head for new ideas and direction outside the consulting room is at times necessary and
useful.
Disentangling feeling states is a technique that can be used before things get too
heated and when some evidence of successful mentalization remains. The therapist can
state: “I am totally lost in terms of where everyone was coming from. I can see that ev-
eryone here has strong feelings, and this is important. But it also looks as if everything
is getting a bit mixed up and that it is difficult to know what belongs to whom and
whether people can understand the feelings of others or even their own. I suggest that
we try to break it down a bit. So, what is it that you, Dad, are feeling right now? .. .
Johnny, did you know that’s what your dad was feeling?”
The technique of marking is used to highlight a significant interaction sequence
and the associated feeling states. The therapist asks: “So, what word or sentence comes
to mind when you think about this?” Family members are encouraged to find a word or
phrase that becomes some form of mantra that family members can recall after sessions,
when similar stuck interactions evolve. Examples are tango, malignant clinch, top dog,
doormat, playing first fiddle, the knight in shining armor, and playing the fool. Intrasession
events are exported to the home setting, as a form of takeaway.
In individual resonating, the therapist checks with each person about exactly how he
or she is affected by other people’s statements or actions and asks family members to
empathize with what other people were feeling.
“Columbo”-style curiosity means investigating observed or reported interactions in a
seemingly naïve, if not “stupid,” and rather slow way. The Columbo-inspired therapist
frequently mentalizes aloud, entering the arena of safe uncertainty (Mason 1993), shar-
ing any hunches and observations as he or she investigates.
Searching for positives implies actively looking for examples of good mentalization.
Once identified, these examples are positively connoted and enlarged, with the aim of
deepening people’s ability to connect feelings, thoughts, and intentions.
Mini role-plays can be used to experiment with new ways of relating to each other
around feeling states and rehearsing different outcomes. Swapping roles for a few min-
utes (e.g., a mother putting herself in the position of her child and the child imperson-
ating the mother temporarily) will place each in a different position in which the other’s
feeling states can be speculated about and experienced. This is a way of experimenting
with perspective taking and has the effect of connecting family members with one an-
other’s feeling states.
Enacting problem scenarios (Minuchin 1974) is a good way of observing family inter-
action and gives glimpses of how problematic behaviors develop or get stuck. Such en-
actments are set up deliberately, with the therapist asking for the problematic situation
to be demonstrated in vivo:
“Let me see what it is that you have to do or say for Mary to have the sort of temper tan-
trum that you find so difficult to cope with. What would you have to do or say now?”
“Perhaps you and your husband could think now about an issue that you feel you might
have an argument about . . . maybe money, the children, your mother-in-law. . . . What
would you have to say to get him or her going?”
“What do your mum and dad mostly argue about? Can you suggest their favorite topic
to them?”
It is surprising how well people know which button to press, despite their frequent
claims that they have “no control whatsoever” over what happens. Knowing how to
make things happen is the first step to considering what to avoid to ensure that these
things do not happen!
Weighing pros and cons is about inviting family members to consider the advantages
and disadvantages of doing or not doing something about these feeling states: “Before
going into how and what you are going to do, think about the pros and cons of doing so.
What is against taking that course of action? What might be for it?”
The technique of subtitling uses the cinematographic prop of providing subtitles
for films made in a foreign language, and it can be used effectively for the purpose of in-
creasing mentalization processes: “Imagine that you did not understand what Bill said
and that you had to make sense merely by looking at Mum’s face and listening to the
sound of Dad’s voice. What do you think you would understand? If you were a film-
maker, how would you subtitle what you saw? If you were deaf and could not hear what
was being said, what sense would you make out of what you saw?”
Mentalization-Enhancing Activities
Specific mentalization-enhancing tasks and activities are designed to develop the men-
talizing skills of each family member and to alter the way the family interact as a whole.
The inverted role activity is designed to engage the family in seeing that other people
have difficulties, too, and that they might be able to help with finding a solution. The
child identifies a situation for the parents to be in, such as going to bed, doing house-
hold chores, or going to school on time. The child then listens to the parents struggle
with the task and is subsequently encouraged to help the parents out, or consult to
them, by telling them what to think, say, and feel. At some point, the therapist encour-
ages the parents and child(ren) to reflect on how they think and feel in both similar and
different ways. To make this activity more playful, the metaphor of a film set can be
used, with an imaginary camera and “roll” and “cut” commands. The therapist’s main
role is to facilitate the role-play and subsequently encourage family members to reflect
on their own and others’ experiences, with the aim of appreciating both the similarities
and the differences of one another’s minds.
In the feeling finder game, family members are invited to create a story that centers
around experiencing feelings. A storyteller, usually an adult or a teenager, is identified
during the first round. Stories can reflect current issues, or they can be fantastic tales.
At each significant moment in the story, the storyteller says, “And that made me feel?”
The listeners then have to find the facial emotion or word that they think fits the sit-
uation. The storyteller then tells the child what he or she actually felt. Each time the
person gives the same answer as the storyteller, the person moves one space on a
“snakes-and-ladders” board. When the person does not get the same answer as the sto-
ryteller, it is important to help the person understand what led to these different an-
swers. The main aim is for each to work out what the storyteller was thinking and
feeling at various significant moments and to compare notes subsequently.
The frozen statues game is another version of the same game. The therapist asks each
person, one at a time, to get up and to “make a frozen picture or statue” of a particular
emotion such as being very anxious, feeling sad, feeling happy, feeling loving, and feel-
ing angry. Family members are asked to look at the pictures each has made and, at a
later stage, to speculate about the stories and emotions contained in each of them. Cap-
turing these on a digital camera and reviewing them later can lead to further reflective
discussions. The purpose of this activity is to highlight how individual the mentalizing
process can be.
The feeling and doing activity aims to explore how different people respond to their
inner feelings. At the suggestion of the therapist, each family member expresses a range
of emotions in turn, and everyone is asked to remember all the different feelings. The
therapist, who participates actively in the game, then asks everyone to imitate one par-
ticular emotion displayed by one family member (e.g., scrunching nose when cross) and
also to state what other family members do when they feel cross. The next stage of this
activity is modeled on the “hot potato” game, with the aim of the person catching the
potato (or ball) being to hold on to it for as little time as possible and, once the task is
completed, pass it on to another person in the room, including the therapist (who also
encourages everyone to go faster and faster). The family member calls out an emotion
and throws the ball, and the catcher has to act out how the thrower shows this emotion.
The catcher can then throw the ball to anyone else in the family, and the process con-
tinues. Once the game is over, the therapist asks what this was like for each person, and
the family then discusses how people may see themselves displayed in others.
In the thought pause button activity, the family identifies a problem scenario, usually
concerning the child and some behavioral issue. The therapist then sets up the activity
by instructing the family to enact this. Just before the child performs the problematic
action, the child presses the “pause button.” With the pause button on, one member of
the family takes the child’s place, and the child walks away to “stop and think.” The
child then tries to come up with many reasons that he or she should not do the action.
Every few moments, the parent says, “I’m going to do it,” and the child has to say, “No,
stop and think,” and continues to brainstorm reasons. Finally, the child tells the parent
all the reasons he or she came up with, and the parent praises the child by saying,
“Those are great reasons; I’m not going to [insert action here] after all.” The purpose
of this activity is to highlight how mentalization can be maximized when stressful or
difficult situations are slowed down.
Brainstorming is designed to help parents to support their child in thinking about
alternative ways of dealing with important situations and experiences in his or her life.
The idea is that the therapist models finding alternatives and then progressively hands
over the task to parents, during the session or between sessions. The therapist picks a
problematic situation that the child has described and then asks the parents and siblings
to think of as many alternative ways of acting as possible. For each of these, the child
scores a number between 1 and 10, depending on how plausible that alternative might
be. The task is about brainstorming different possibilities and letting the child decide
whether any of them are interesting or worth exploring.
The guess your feelings game is an activity that starts with picking a relatively neutral
event. Cards are distributed with emotions written (or displayed) on them. The
“guesser” has 10 questions to surmise what the others are feeling, without asking this
directly. Family members also can use charades as a way to express specific feelings re-
lated to familiar scenarios. Everyone is subsequently encouraged to say whether and
how any displayed feelings connected with their own experiences. The purpose of this
activity is to practice mentalizing with family members by using a relatively neutral
event.
In mind-brain scanning, each family member is given a large piece of paper with a
diagram of a cross-section of an adapted human brain, containing more than 10 larger
and smaller “ventricles” (holes) (see Figure 5–1). Father is told, for example, “Imagine
this is your daughter’s brain or mind. Put in the holes all the thoughts and feelings you
think she has at the moment. Put the big feelings and thoughts in the big ventricles and
the smaller ones, or secret ones, in the smaller holes.” The mother can be given the
FIGURE 5–1. The image used in the “mind-brain scanning” activity.
same task, and the daughter, Mary, could be asked to imagine how her mother might
“see” Mary’s mind-brain. When everyone has completed the task (5 minutes), the three
different “brain scans” can be displayed on a wall and compared. This can be followed
by a discussion about how accurately each family member can “read” the mental states
of others. This task has many different variations, including speculating about how the
mind-brain might have looked before a specific event or how it might or should look in
6 months’ time.
Body scanning is another way of externalizing feelings and thoughts. Each family
member in turn can lie on a large piece of paper, and one person draws the external
body contours. People can then use different-colored pens to mark where on their body
they experience specific feelings and accompanying thoughts. This can then be dis-
cussed. Alternatively, family members can speculate where the other might experience
strong emotions and talk about contexts within which these occur.
Intersession Activities and Tasks

The purpose of setting and carrying out mentalizing tasks between sessions is to keep
the momentum gained within a session and give the family more opportunities to build
on new experiences and new approaches to mentalization at home. The therapist needs
to involve the family in formulating any intersession activities and tasks, and they
should arise “organically” during sessions. The family is encouraged to decide when
the task should be done, and this is entered into a formal family diary. Each practice ac-
tivity is expected to take about 20 minutes and is to be repeated two to three times dur-
ing the week. A place in the home should be decided on beforehand, ideally one that has
a table to sit at with enough chairs for everyone.
Making a story is a task requiring a family to schedule two to three times each week
when everyone sits down together. One person records, one observes (if there are more
than three people), and two converse. One tells the other an elaborated personal story,
lasting no longer than 5 minutes, about something that happened during the day. The
person listening tells it back, using “you”; the narrator corrects the story; and then the
listener repeats it again. The observer takes 2 minutes to describe what he or she saw.
This should be positive if possible (e.g., “I saw you describe yourself well, and I thought
you conveyed it well; it was interesting”), and it is recorded in a special notebook. The
rationale is that families bond through stories, and this creates understanding and men-
talizes relationships. This activity highlights the importance of having a little special
time together for sharing thoughts and feelings.
Solving a problem is a practical exercise. The family is asked to do something to-
gether (e.g., build something with blocks, do a jigsaw puzzle, discuss where they are go-
ing for an outing on the weekend, plan a family meal). This is followed by a period of
reflection, including how it felt. Each family member reports on how he or she thought
the others were finding it; then each person comments on and, if necessary, corrects the
others’ perceptions. The discussion must be focused on the task and must not be di-
verted onto past conflicts or other events. In this way, the family practices observing
one another’s behavior and feelings at home.
Arguments tend to be the fabric of family life. Therapeutic arguments aim to create
contexts of “successful and skilled” arguing instead of reverting to blocks such as refus-
ing to talk. The therapist playfully elicits common behaviors in the family that tend to
sabotage “positive” disagreements (e.g., storming out, stonewalling, dominating the in-
teraction, or threatening physical harm). The family is encouraged to set some ground
rules (or 10 “Family Commandments”), such as people should always listen when
someone else speaks, no one walks out, no tantrums, and no blaming. The family cre-
ates a document, “Argument Rules and Regulations,” and they agree on a sign for time-
out, when everyone stops. The arguments are recorded in the family notebook and re-
flected on in the subsequent session. The aim of this work is to highlight how argu-
ments undermine mentalizing and that the family needs to practice resolving issues
without stopping one another’s capacities to reflect.
Conclusion
MBFT can be used in family work with children but also in couples therapy and with
families containing only adult members. MBFT concepts and techniques also apply to
multifamily group work because in this setting, multiple perspectives are present by
TABLE 5–8. Basic Mentalization-Based Family Therapy clinical model
• Key proposition: emotional and behavioral problems are essentially relational in nature.
• Consideration, interpretation, and appraisal of mental states (in self and other) are essen-
tial for healthy relationships.
• Families and individuals vary in their capacity to mentalize for a multitude of reasons (e.g.,
early experience, genetics, current stressors).
• Problems with mentalizing create distressing and stressful family interactions that further
undermine mentalization.
• These interactions give rise to relational problems that undermine family coping, creativ-
ity, and resilience.
virtue of six to eight families attending with similar problems and issues (Asen 2002).
Eliciting and sharing very different perspectives, seeing oneself mirrored in others, and
checking one’s perceptions continuously all happen naturally in multifamily work. The
basic clinical model for all these contexts is summarized in Table 5–8.
Do we need a new therapeutic approach? MBFT is a distinctive model and not
merely an eclectic mix. We believe it is systemic in essence, deriving its ideas and prac-
tices from a variety of diverse systemic approaches, including structural family therapy
(Minuchin 1974), the Milan systemic approach (Selvini Palazzoli et al. 1980), strategic
therapy (Haley 1963), functional family therapy (Alexander and Parsons 1982), narra-
tive approaches (White and Epston 1990), and reflecting teams (Andersen 1987).
MBFT is different from, but also has plenty in common with, other more recently
emerging family therapy approaches that emphasize the importance of attachment the-
ory (Akister and Reibstein 2004; Byng-Hall 1991; Dallos 2006; Diamond and Sique-
land 1998) or that attempt to bridge the systemic and psychodynamic worlds (Flaskas
2002; Fraenkel and Pinsof 2001). MBFT is not a new treatment per se, but it spans the
often seemingly opposing internal psychodynamic and external systemic worlds. It
does so by integrating important concepts from the fields of attachment theory and
mentalization with the systemic approaches alluded to earlier. MBFT is a splendid ex-
ample of what “good” mentalization can achieve.
Suggested Readings
Akister J, Reibstein J: Links between attachment theory and systemic practice. J Fam Ther 26:2–
16, 2004
Byng-Hall J: The application of attachment theory to understanding and treatment in family
therapy, in Attachment Across the Life Cycle. Edited by Parkes CM, Stevenson-Hinde J,
Marris P. New York, Routledge, 1991, pp 199–215
Dallos R: Attachment Narrative Therapy. New York, Open University Press, 2006
Diamond GS, Siqueland L: Emotions, attachments and relational reframe. Journal of Structural
and Strategic Therapy 17:36–50, 1998
Flaskas C, Pocock D: Systems and Psychoanalysis: Contemporary Integration in Family Ther-
apy. London, Karnac, 2009
CHAPTER 6
Mentalization-
Informed Child
Psychoanalytic
Psychotherapy
I n this final chapter on techniques, we describe individual psychotherapy for children

and linked work with their parents and discuss how it makes use of principles and tech-
niques derived from mentalization-based treatment (MBT) for adults. In Chapter 5 of
this book, Asen and Fonagy discussed Mentalization-Based Family Therapy (MBFT)
for those children and their families who need only short-term therapy (<20 sessions)
because their mental health problems are relatively straightforward, and short-term
professional support will put them back on track. MBFT, formerly known as Short-
Term Mentalization and Relational Therapy (SMART), is designed to cultivate family-
based skills in mentalizing in about 6–12 sessions (see Chapter 5 and Allen et al. 2008,
pp. 254–255). However, for some children and their families, short-term treatment is
129
not sufficient. Often, the children have struggled for too long while developing com-
plex mental health problems along the way, and they are too deeply invested in using
nonmentalizing as a means of protecting themselves from anxiety. Their families have
adjusted to their difficulties in nonmentalizing ways and often are either too absent or
present but too disorganized to be able to engage in a genuinely family-oriented ther-
apeutic process. In this chapter, we focus mainly on treating these problems that are
unlikely to respond to short-term treatments in children, who may benefit from a
longer-term approach informed by ideas from MBT (e.g., Fonagy et al. 2002b).
The overall goal of mentalization-based therapy for children (MBT-C) and their
parents is to enable the child to mentalize and ensure that he or she is capable of inter-
pretative self-regulation (Table 6–1). In principle, the child would have the capacity to
postpone, modulate, and regulate emotional reactions and also have a coherent sense of
self with a feeling of agency. Having mental representations of oneself and of others
generates a subjective conviction that a person’s behavior belongs to him or her, in con-
trast to the passive feeling derived from prescribed procedures that are activated by
concrete, context-dependent cues. Behavior is no longer something that comes over a
child: the child is its owner (Bleiberg 2001). This sense of internal coherence and self-
organization is indicated by the child’s ability to tell coherent autobiographical sto-
ries—that is, to give valid accounts of how internal states generated act on self and oth-
ers and gave rise to chains of subjective experience.
We outline the MBT-C techniques that we have developed for a particular group
of children and their parents (Verheugt-Pleiter et al. 2005, 2008). Developmental is-
sues are very much at the core of our thinking. We therefore begin with the reasons for
our focus on school-age children and their developmental issues. We then define the
target population, describe the frame of the therapy, and explain the therapist stance
and intervention techniques that can be used at various stages of the therapy.
Developmental Considerations
A therapy for children needs to strategically consider the different developmental
milestones that children face to provide sufficient support in cases of developmental
breakdown. Overarching therapeutic objectives may be applicable across developmen-
tal milestones, but even here strategies will vary as a result of the demands of a certain
developmental stage. For instance, the objective of MBT is to facilitate the emergence
of a coherent self. This applies to all ages. Nevertheless, depending on the child’s age,
different strategies will be necessary to meet the same objective. For infants, the foun-
dations are laid for the development of a coherent self when the infant or toddler feels
securely attached and not disorganized or disoriented in his or her relationship with a
caregiver. In middle childhood, children’s experience of self-coherence moves to a
more representational level and integrates aspects of previous developmental stages.
Their sense of self builds on their feeling of confidence in caregiver availability when
Mentalization-Informed Child Psychoanalytic Psychotherapy 131
TABLE 6–1. Overarching aims of mentalization-based therapy for children (MBT-C)
MBT-C aims to enable the child to mentalize and ensure that he or she is capable of interpretative
self-regulation. Thus, the therapist’s aims are:
1. To facilitate the emergence of a coherent sense of self
2. To foster the capacity to handle emotional reactions
3. To enhance the conviction that the child is the owner of his or her behavior
distressed, their handling of autonomy bids, and their initiative in playing with others.
A new developmental issue needs to be incorporated into their self-concept at this age.
The broader social network gives them the opportunity to consider their own mastery
of skills in comparison to that of others; in Eriksonian language: feeling industrious
versus inferior (Erikson 1963). The therapist will encounter these developmental issues
during interventions and in play situations. Distortions to such normal developmental
processes of hierarchically increasing complexity can take place at all levels (Fischer
and Pare-Blagoev 2000) and are incorporated in a distorted and more representational
form during latency.
We have developed a treatment manual for children between ages 4 and 12 years.
We focused primarily on this age group for four main reasons (Table 6–2). First, de-
mand for mental health care from caregivers for this age group, particularly for boys,
was relatively high. Second, a retrospective study of psychoanalytic treatment found it
to be particularly effective for seriously disturbed children younger than 12 years com-
pared with older children (Fonagy and Target 1996b). Third, developmental epidemi-
ology research has repeatedly shown a turning point in the pattern of pathology after
age 12 years. Thus, the logic of prevention would point us to preadolescence as the pe-
riod when reducing risk for adolescent and subsequently often life-course disorders
may be most efficient (Beardslee et al. 2003; Kim and Cicchetti 2010). Fourth, we have
to own up to some pragmatic considerations related to obtaining consent. In this age
group, research consent is easier to obtain; we approached several children and their
parents and asked them to participate in a project aimed at improving therapeutic skills.
At the end of the project, we had gathered material from 62 therapy sessions and ab-
stracted descriptions of 186 interventions (Verheugt-Pleiter et al. 2008).
In psychoanalytic theory, middle childhood (4- to 12-year-old children) tradition-
ally has been described as the latency period. Latency refers to the subsiding of the tur-
bulent passions of the oedipal phase and the dormant period of those passions. The
implied process of disengagement from parents is called decathexis. The success with
which the new social tasks of the child during latency may be accomplished depends to
some extent on the degree to which the child is supported to disengage from sexual
concerns and go on to freely and creatively explore the social world that is beginning to
open up beyond his or her primary objects, and to engage in this world playfully and
diligently, learning new skills and amassing information. However, for a child who is
TABLE 6–2. Reasons for the focus on 4- to 12-year-olds
• High demand for care from parents and teachers

• More effective to treat children younger than 12 years
• Distinguishable developmental period
• Informed consent easier to obtain
sexually overstimulated or is under constant physical threat, this broadening may be

fraught with intense anxieties. Such a child may use characteristically rigid patterns of
defense to bring anxieties under control, which may make the child appear timid or ob-
sessional (Waddell 1998).
Turning toward the world does not reduce the importance of relationships with
those who care for the child. From the viewpoint of attachment theory, the child’s re-
lationship with the primary caregivers does not become weaker in this period but
changes in quality. Bowlby (1982) observed a normative decline in the frequency and
intensity of specific attachment behaviors directed to the attachment figures (e.g., cry-
ing). Second, attachment behaviors will be terminated by a wider range of conditions;
for example, a telephone call may suffice. Third, there may be a change in the set goal
of the attachment system, with mental representational availability (a mental sense or
image of a responsive parent) rather than physical proximity of the attachment figure
becoming the set goal (Sroufe et al. 2005). Open communication, parent responsive-
ness to the child’s needs, and the potential rather than the reality of the parent’s physical
accessibility to the child are becoming more important than literal proximity (Table 6–3).
The child’s expectations and beliefs regarding attachment figures become important
markers of attachment (Kerns et al. 2005).
Thus, it is a cornerstone construct of attachment theory that dependence on ex-
ternal figures should be successfully replaced by stable and secure internal representa-
tions of the imagined actions of these figures ultimately encoded in relatively abstract
high-order representations (Fonagy et al. 2008). Individual or episodic experience of
self with another aggregates into a higher-order generalization of the way self normally
interacts with a specific other, which in turn creates a generalized representation of self
with a particular category of others. This is precisely the point when the concept of
mentalization becomes useful. The child’s emerging understanding of himself or her-
self and others as agents in the environment begins certainly at birth (Onishi et al. 2007;
Rochat 2009), if not before, and was thought to be more or less consolidated by age
5 years (Wimmer and Hartl 1991) but is now considered to be in development until
well after adolescence (Blakemore 2008). Five different levels of the development of
agency and selfhood may be distinguished following the “developmental line” (Freud
1963) of mentalization: 1) the self as a physical agent, 2) the self as a social agent, 3) the
self as a teleological agent, 4) the self as an intentional mental agent, and 5) the self as a
TABLE 6–3. Developmental changes in attachment behaviors for 4- to 12-year-olds
• Direct attachment bids decline

• Attachment security can be restored with a wider range of conditions
• Mental availability instead of physical proximity is important
representational agent and the emergence of the autobiographical self (Fonagy et al.
2002a). By the beginning of latency, unless development is disrupted by severe social
adversity, children are likely to have developed a working capacity to read their own and
other people’s minds.
Target Population
The target population for MBT-C is children whose capacity to mentalize may be in-
adequate in important developmental areas (Verheugt-Pleiter et al. 2005). As described
in clinical accounts by Fonagy and Target (Fonagy and Target 1996a, 1997, 2000,
2007a; Target and Fonagy 1996), some of these children may function too much in the
psychic equivalence mode, whereas others function mainly in the pretend mode, and
some operate alternately in one or the other of these modes without being able to in-
tegrate them. Alongside children who have had developmental problems from a very
young age are children who are unable to mentalize in a particular area (Bateman and
Fonagy 2006a). The latter seems to be more common in children who have had trau-
matic experiences. When these traumatic experiences involve the attachment system,
more developmental areas seem to be disturbed (Allen 2004). These children develop
disorders that involve entire modes of mental function, so psychic processes of fantasy,
feeling, thinking, and wishing can be impaired (Fonagy et al. 1993). These children
deal with their affect in a primitive manner and make frequent use of projective iden-
tification and splitting.
Diagnosis alone cannot be used as an indicator to recommend treatment with
MBT-C. In adults, MBT was first developed for patients with a borderline personality
disorder (BPD) (Bateman and Fonagy 2004). Neither DSM-IV-TR (American Psychi-
atric Association 2000) nor ICD-10 (World Health Organization 1992) allows us to
speak explicitly of BPD in children up to age 18, although the term emergent personality
disorder has entered common usage (Chanen et al. 2008; Miller et al. 2008; Sharp and
Romero 2007). Child psychoanalysts have for many years written about children who
had what was termed serious early pathology. The term borderline child also was used to de-
scribe many of these children (e.g., Bleiberg 2001; Frijling-Schreuder 1969; Van
Delsen and Meurs 2004; Verhulst 1981). The picture that emerges from these writings
shows considerable overlap with a description of children who, in our view, are most
likely to benefit from MBT-C. Bleiberg (2001) summarized the vulnerabilities of these
so-called borderline children: unstable sense of self and others, subjective dyscontrol
and hyperarousal, feelings of loneliness and vulnerability to separation, and rage (Table
6–4).
Although neither DSM-IV-TR nor ICD-10 distinguishes a borderline disorder in
children (Cummings et al. 2000), both define disorders that point to the potential value
of MBT-C. These children might show a mixture of Axis I and Axis II problems (Fon-
agy and Target 1996b; Meurs and Vliegen 2004). Our own clinical experience led us to
include the following DSM-IV-TR diagnoses: pervasive developmental disorder
(PDD); Asperger’s disorder; and disruptive behavior disorders such as attention-defi-
cit/hyperactivity disorder, oppositional defiant disorder, and conduct disorder (Ger-
ritzen 2003). With respect to Axis II, Bleiberg (2001, pp. 8–9), in addition to BPD,
focuses attention on children with narcissistic personality disorder who will prototyp-
ically “organize their sense of self around an illusory conviction of perfection, power, or
control.” These children also might need to learn to mentalize about the states of mind
of self and other.
Classification on the basis of DSM-IV-TR is not sufficient to assign a child to
MBT-C because current diagnostic classifications rarely correspond to specific under-
lying dysfunctions or disturbed brain processes (Insel et al. 2010). The kind of mental-
ization problem open to MBT-C is relational in its origin (even if associated with
genetic vulnerabilities), and the context of dysfunctional attachment relationships
brings the problems into clearest relief (Bateman and Fonagy 2006a). Some children
with the heterogeneous DSM diagnoses listed earlier (e.g., conduct problems) may or
may not manifest consistent problems with mentalizing and other forms of social cog-
nition, depending on the extent of psychosocial involvement in their causation and the
social context within which the child is assessed (Sharp and Fonagy 2008b). If a child
has mindblindness, as is described to be the case with autism (Baron-Cohen et al. 2008),
then an intervention aimed at mentalizing about oneself and other persons may not be
beneficial (Fonagy and Sharp 2008).
In line with the severe criticism of psychiatric diagnostic nosology advanced by In-
sel and colleagues (2010), we eschew the use of traditional labels for disorders and focus
on what, from a diagnostic standpoint, looks like a somewhat heterogeneous group of
children, who nevertheless in our view have a common developmental problem asso-
ciated with the mental processes of social cognition. Rather than speak of “borderline
children,” as they are sometimes referred to in psychoanalytic and classic child psychi-
atric literature, we prefer to speak of children with mental process disorders (Fonagy et
al. 1993) to stress that a dysfunction of social cognition is linked to (caused by but also
causing) a disorganization in primary relationships. This approach does not automat-
ically yield simplification because a wide range of mental processes are vulnerable to
dysfunction, depending on the area in which the child’s development has stopped and
the regulation profile that the child uses (Greenspan 1997). Greenspan (1997) advised
drawing up a regulation profile for the child, and he suggested paying special attention
to possible problems in sensorimotor regulation. This of course links closely to
TABLE 6–4. Characteristics of children with borderline problems
• Unstable sense of self and others

• Subjective dyscontrol and hyperarousal
• Aloneness and vulnerability to separation
• Rage
Source. Bleiberg 2001.
Gergely and Watson’s emphasis on the social biofeedback processes that emotion un-
derstanding might entail, in which the marked aspect of early mirroring is considered a
powerful aspect of arriving at the capacity to regulate bodily experience (Gergely
2007). It is also important to determine whether the child is functioning mainly in pre-
tend mode, in which internal experiences fail to link with external reality; functioning
mainly in psychic equivalence mode, in which the seriousness of the external world is
overwhelming for the child; or, as is most commonly the case, alternating between
these states, feeling at liberty to contemplate any kinds of perspectives in relation to be-
liefs, desires, and affects but then suddenly experiencing these (in the psychic equiva-
lence mode) as physically real and immediately feeling terrorized by the compelling
quality of the experience.
Frame of the Therapy

In any type of individual treatment for children, even in physical medicine, it is impor-
tant that children feel they have both parents’ permission to entrust themselves to the
therapist. The first step is a meeting of the parents with the parent counselor (also
sometimes referred to as parent worker) and the child therapist, at which MBT-C is ex-
plained. Parents have many questions, one of which is always how long the therapy will
take. As in classic psychoanalytic therapy (Sandler et al. 1980), only a rough estimate
can be given, but parents’ commitment to long-term therapy at a prespecified fre-
quency of treatment is important. It is certainly not easy, in an emotional or a practical
sense, to entrust a child to another person two or more times a week, and the therapist’s
explicit awareness of this difficulty is likely to strengthen commitment. Similar chal-
lenges surround the implications of therapeutic confidentiality and discussion of the
possibility of the child’s temporary negative emotions about and even reluctance to at-
tend therapy.
MBT-C is an entirely new field of treatment, and no agreement yet exists about the fre-
quency of sessions. As in patients with BPD, ample clinical evidence indicates that in indi-
viduals with severe affect regulation and attachment difficulties, “less can be more”
(Bateman and Fonagy 2008a; Chiesa et al. 2003; Kernberg et al. 2002). MBT-C is often
recommended for children whose primary difficulty is with attachment issues, so therapists
assume that a high frequency may be needed to be able to work on their disturbed manner
of forming relationships, with the therapist acting as a new attachment object and providing
a corrective emotional experience (Alexander and French 1946). However, when children
have great difficulty in regulating their anxiety and anger, they soon become overwhelmed
by their supposedly therapeutic relationship because of the stimulation of a maladaptive at-
tachment process. In our experience, an average of two sessions a week for about 18 months
is optimal for developing an attachment relationship without being too overwhelming. The
key consideration is the iatrogenic potential of intensive therapy, and it is important to con-
sider carefully just how much contact the child is able to cope with. The sobering consid-
eration of the potential for harm may prevent us from assuming a simple dose-response
relationship.
The setting must enable the child to feel safe and comfortable. Apparently unimpor-
tant features of the physical environment can have massive significance for a nonmentaliz-
ing child. The setting must be not only stable but also resistant to emotional turmoil and
sufficiently soundproofed so that neither child nor therapist fears humiliation following
storms of emotion. The waiting area, often the battlefield of psychological and physical re-
sistance, can acquire great significance. The tensions for parents in relation to the child’s
impulsive behavior, unpredictable response to the therapist’s arrival, ambiguity about re-
sponsibility for behavioral control when both therapist and parent are present, and implicit
criticisms felt from other parents and even the therapist, all challenges within the MBT-C
framework, are to be welcomed as ideal opportunities for showing the advantages of stating
mental states explicitly, the relief that normally comes from a clear statement of the putative
subjective experience of the participants in a complex social interaction, the normalization
of subjective reactions, and so forth. MBT-C therapists must feel able to act with openness
and clarity in these situations. If they experience awkwardness in relation to their own role,
they should make this explicit, sharing the dilemma with the parent and modeling the use of
mentalization in solving problems generated by emotional crises. The presence of other
parents in the waiting room should in no way impede this process of clarifying subjective
experience. The implicit demand for privacy in this context serves mostly to mask the com-
mon reluctance to be clear about one’s own thoughts and feelings.
Contemplating Failure and

the Need for Peer Supervision
Part of the mentalizing approach is to be aware of the possibility that in certain contexts, at
certain times, the capacity to mentalize will be beyond our reach. This recognition helps us
reframe the experience of therapeutic failure. Ideally, the objective of MBT-C might be for-
mulated as the development of the ability to express feelings and thoughts adequately and to
adopt this capacity in the service of the formation of a coherent sense of self (e.g., Bateman
and Fonagy 2004). In children, this will not always be either possible or indeed necessary.
Sometimes the parents are simply not up to mentalizing the child despite the counselor’s
best efforts. Sometimes the child’s situation with frankly deeply hostile parents is such that
the therapist feels that the effort to help the child understand the actions of the parents is
tantamount to emotional maltreatment. When progress is minimal and the forces mar-
shaled against thinking about feelings appear persistently insurmountable, it is far better to
recognize this fact than to insist on the physical reality of meeting, as if the physical pres-
ence of the child in the therapy might in some magical (teleological) way by itself guarantee
a developmental shift to mentalizing. The MBT-C approach is to wind up the treatment
and to suggest to the child that treatment can be restarted at some later point (“multiple-
entry ticket”). If the therapist runs into limitations in the child, it can be helpful to suggest
forms of treatment that are more physical, such as psychomotor therapy or manual therapy,
or that are more active, such as drama therapy or creative therapy.
To ensure that therapists do not find themselves facing failure too often, a protocol
that supports the therapist’s focus on mental states is essential. We recommend regular
peer supervision meetings with colleagues, not just at moments in a treatment when
progress seems to be flagging. Ongoing meetings with a group of colleagues to think
about and discuss moments of routine difficulty give everyone space to think about
challenges and to refocus on the general technical principles of the treatment. Another
advantage of peer supervision is the opportunity for shared thinking about the child’s
feelings and thoughts; under pressure to provide answers, to solve the myriad of prac-
tical problems in our young patient, we might find that we can no longer hold on to a
child’s subjective experience, that we have become solution focused rather than men-
talizing. Mostly, we have managed to get entangled in a relational web of our own men-
tal creation (a long-winded way of restating Freud’s countertransference notion). By
observing the child through our colleagues’ eyes when discussing the child with them,
it is easier to identify these transference processes as we observe what they assume
about our thoughts and feelings in the consulting room. As in mentalization-based
therapy for adults (Bateman and Fonagy 2006a), peer supervision meetings in MBT-C
have proved to be both necessary and helpful with this group of children. Peer super-
vision normalizes feelings about our own work. The dynamics of supervision from a
wise master may be inspiring, but this approach also runs the risk both of moving us
further away from normalizing our experiences and of shifting our therapeutic subjec-
tivity into a pretend mode: rich and complex within its own terms but having little to do
with physical reality.
Therapist Stance Toward the Child and

His or Her Significant Others
We have identified four key aspects of the mentalization-based child therapist’s ap-
proach to parents and children: a not-knowing stance, an emphasis on process over
content, a playful attitude, and the integration of significant adults.
The Not-Knowing Stance

The so-called not-knowing stance (Bateman and Fonagy 2006a) (Table 6–5) requires the
therapist to try to find out how the child thinks and feels by actively showing willingness to
learn about the child’s perspective. This therapeutic attitude is discussed elsewhere (see the
section Don’t Worry and Don’t Know, in Chapter 3), and in essence, the stance is exactly
the same with children. Attempts to explain to the child that what the child thinks he or she
is thinking is in fact not what the child is really experiencing are simply counterproductive
when the therapist’s goal is to improve mentalizing. If a child is functioning in the psychic
equivalence mode, he or she will not be able to relate to what the therapist offers as a pos-
sible alternative feeling because the experienced feeling is overwhelmingly real. Further-
more, in that state of mind, the mere statement of a possibility might make it feel real. For
example, if the therapist were to state in a “knowing stance”: “In fact, I think that you are
very angry with me because...,” the child might feel accused and react accordingly. It is
better to approach the child with an attitude of curiosity and active questioning to show that
one considers the child to be someone with his or her own intentions. In that way, the dif-
ferentiation between the therapist’s own mental states and the mental states of the child can
be maintained, and the child is invited to mentalize. The use of detailed questions that re-
state the therapist’s understanding is important because these show the child that the ther-
apist views the child as a separate individual, whose inner world the therapist cannot know
directly.
Actively referring to possible feelings and thoughts that might be implied by the child’s
behavior can enhance the mentalizing process when this is done in a playful way and with-
out attempting to deterministically pin down mental states. It communicates that it is pos-
sible to think about another person’s thoughts and feelings but also that you are never sure
and have to find a way of dealing with the uncertainty. Sometimes children believe that
adults know exactly what they think. Differentiating is always useful. Guessing games can
be a good way to show the child how to handle the fact that you do not know what another
person feels or thinks but that the child might like to understand. When the therapist can
talk about his or her own mistakes in understanding the child and can reflect about these,
this also gives the child space to mentalize. This can be especially helpful for children who
are very anxious about making mistakes.
In the treatment of severely disturbed children, sometimes the therapist feels unable to
hold the child in mind. In working with a child who was rarely seen as a separate individual
by his or her own caregivers, the therapist can find himself or herself in a situation of great
uncertainty and insecurity. The therapist may feel pushed by the child’s behavior into the
role of rejecting the child and—unknowingly at the time—find his or her mentalizing ca-
pacity blocked: this is an enactment. The best way to deal with a situation like this is to take
responsibility for misunderstanding and admit to the original “not knowing” that gave rise
to the misunderstanding and the “not knowing” that was entailed in the failure of self-
recognition. By taking responsibility for rejecting or not understanding, the therapist vali-
dates how the child feels. By admitting to not knowing why he or she did it, the therapist
normalizes and models “not knowing.”
TABLE 6–5. Not-knowing stance of therapist
• Willingness to learn the child’s perspective

• Attitude of curiosity
• Active questioning
• Active reference to possible feelings and thoughts
• Raise the possibility of thinking about wishes and longings of another person
• Ability to talk about his or her own “mistakes”
• Ability to hold the child in mind
The Process Is More Important Than the Content

In child therapy, the content of the exchanges is often less important than the process of
loosening or engendering flexibility of thoughts and feelings. The therapist moves with
the rhythm of the child. Gradually, the therapist can help the child to discover that rep-
resentations can be shared, can be played with, and can be changed. This promotes
mentalization in the child.
The therapist’s mentalizing of his or her own experiences in the session can some-
times help to show the child how to handle difficult feelings. The countertransference
can be used productively because the therapist can give a real-life demonstration of
how a vicious circle of not understanding and not being understood can be broken by
verbalizing a sequence of his or her own internal activities. Clarifying what the child
said (“I am a little slow this morning; let me see if I heard what you said correctly...”)
also helps in verbalizing internal states; adopting a playful attitude is a way of offsetting
the feeling of being overwhelmed by experiences.
In keeping with the emphasis on process, like MBT for BPD, MBT-C cautions
against too much detailed use of transference as a vehicle for offering insight or helping
the child to understand why he or she is the way he or she is. Transference interpreta-
tions as classically thought of in child psychoanalysis (e.g., Klein 1960) are out of the
question as long as a child is functioning in the psychic equivalence mode. An inter-
pretation, particularly an interpretation in the context of the child’s relationship to the
therapist, runs the risk of shifting the child into pretend mode by appearing to invali-
date his or her overt experience: “You may be throwing bricks at me right now, but this
is really because you are so frightened of needing me too much!”
It is important to remember that many children with personality problems become
very anxious in intimate relationships because of the paradox in their disorganized attach-
ment system: the person you most want to be with is at the same time the one who scares
you most, and the fear of this person makes you need to be with him or her in an even more
urgent way. Therefore, too much emphasis on the therapeutic relationship too early in the
therapy often leads to panic. Basically, if the therapist always tries to keep the different
perspectives of child and therapist in mind and places the child’s perspective in the privi-
leged position over his or her own, safety will be increased.
It is generally better not to focus on the therapeutic relationship too early because this
triggers too much anxiety. It can be more useful to talk about other relationships, such as
between the figures in the play setting. This is a form of displacement (e.g., Verheugt-
Pleiter and Zevalkink 2005). In fact, the therapist needs only to be “good enough” at rec-
ognizing the child’s state of mind. A mismatch also can lead to a fruitful exchange as long as
the therapist retains a not-knowing stance. It is important that the therapist feels free to ab-
sorb whatever comes up in the relationship.
The most important question is how the therapist can help the child in the here and
now of their new relationship to make the transition to a truly representational level. If the
child can name an affect within the relationship, then the therapist and the child can follow
this up, clarifying; spelling out; identifying implications; pointing to complexities and sur-
prising aspects; linking with other feelings about the same person or different feelings in re-
lation to others; and being ready always to be surprised, edified, corrected, entertained,
concerned, incredulous, or just finally “put right” on something, but always together with
the child, side by side (not sitting opposite), trying to see from the child’s perspective and al-
ways showing that the mind is not a place where you want to go on your own.
In practice, a great deal of work will go into carefully following and exploring what the
child exhibits in his or her current behavior or mood. The shared experience can lead to
recognition and acknowledgment, thus forming the basis for the child to start thinking
about his or her own behavior or mood. In this type of child therapy, aggression is often
central. When children feel they have experienced humiliation or some other threat to their
sense of self, a temper tantrum may be the only way to restore a subjective experience of co-
herence, to reintegrate the self (Kohut 1972). But in the absence of a coherent mentalizing
self-narrative, fragmentation can occur for trivial reasons, when the other person’s inten-
tion is poorly understood, or when the child feels threatened by something he or she does
not understand that is happening inside him or her. Verbalization is no panacea to a non-
mentalizing child, who may well regard the verbalization as an attack. Making the child fo-
cus on the therapist’s experience (“When children shout at me like you are doing at the
moment, I cannot concentrate and think about what they are saying at all, even though I
want to”) may well be easier than having to process some complex (even if accurate) account
of how the child comes to be feeling so angry and monstrous. Luckily, in child therapy a lot
can be worked out by using play.
Playful Attitude
Children in MBT-C often cannot play at all: they cannot or dare not think in pretend terms.
They are extremely focused on the physical reality outside of themselves, and they are
overly sensitive to the emotional reactions of others. They are caught in the psychic equiv-
alence mode of mental functioning, taking their thoughts and feelings more or less literally.
Because they cannot perceive themselves as an entity from the inside out, they are forced to
perceive themselves from the outside by means of enactments (Bateman and Fonagy 2004).
Sometimes these children go through a curious process of complex self-reflection.

They create themselves in the other person (a kind of reverse transference), and once they
have forced the other to do something they actually felt but also could not quite verbalize,
they are better able to control the experience. This process is quite dramatic and conse-
quently is well described in many psychoanalytic texts (Bion 1962; Jacobs 1986; Winnicott
1972b) but as far as we are concerned, it is poorly understood. Children often appear to
deal with their deep anger, frustration, or profound anxiety by projection. Historically,
these feelings may have been observed by them in others and internalized because they oc-
curred predictably in response to certain of their own feelings. We have observed the ex-
perience created as a mixture of an intense feeling that is thought to be coming from within
(i.e., of the self) but also feels strangely alien and discontinuous with self-experience. MBT
calls this the “alien self” (Fonagy et al. 2002a).
Other children in MBT-C emphasize the pretend mode of mental functioning and feel
an undeserved confidence in their knowledge of and access to mental states. They claim to
have no difficulty in mentalizing and often surprise their therapist by their apparent in-
sights. The apparent paradox is that lengthy internal state–focused discussions make little
headway in terms of progress in the child’s sense of general well-being. MBT uses the term
pretend in the sense of not genuine to describe such mentalizing (Target and Fonagy 1996).
But this has not been the most fortuitously chosen word because it overlaps with pretense,
a key staging post in the acquisition of mentalizing. In child development, pretend playing
(pretense) is a significant developmental step because it indicates that the need for imme-
diate action can be replaced by mental activity (Reddy 2008). In normal development,
“playing with reality,” perhaps in part at a parent’s initiative, may be a hallmark of the emer-
gence of mentalizing at around age 2–3 years. As observed by Judy Dunn and others (2000),
pretending together as a family appears to make the mental world real because it is clearly
independent of physical reality yet socially shared (and thus to be taken seriously).
Fostering this type of function in a therapeutic setting seems to us worthwhile. It
can be important, for example, to dramatize play so that the child is encouraged to
move more into pretense; the therapist is an active commentator, reacting to the child’s
play and trying to invite the child to expand during important moments. The therapist
might try to move a child’s repetitive play to a higher level by commenting on the gen-
eral pattern. For instance, when the child has lined up about 20 cars and is not sure
about adding the bus, the therapist could say: “Are you thinking about including the
bus with the cars or starting a new row? What would the children in the bus think of it?”
Recognition of the Importance of

the Integration of Significant Adults
When children are in MBT-C, the parents are always offered parental guidance. Inev-
itably, almost, the parents of a child with behavior or emotional problems will be ex-
periencing difficulties in their relationship with the child. For MBT-C to succeed, it is
essential that the parents gain trust in their own capacity to help the child. Take the ex-
ample of a child who refuses food. The parent may be unable to form an inner repre-
sentation of the possible intentions behind the child’s negative behavior because of the
emotional arousal that surrounds it, because of the tumultuous emotional history of
their relationship, because the child’s experience is genuinely bizarre and difficult to in-
tegrate with a normative understanding of behavior, because the parent has general dif-
ficulties with mentalization, or all of the above. Parental guidance is intended to
promote the parents’ capacity to mentalize regardless of the origin of the problem and
in this way promote that of their child as well. Mentalization facilitates mentalization.
The integration of all the important adults around the child is vital for success in
MBT-C. The confusion of systems considering the child’s thinking and feeling must,
we assume, make the child’s state worse. An agreement about the importance of a sup-
portive, clear, and consistent child-rearing climate that sees the child in the same or
similar ways is key to the effective management of these children. The child therapist
and the parent counselor must not present different perspectives, at least during the
early phases of treatment. Other agencies and child-care workers, the school, and child
safeguarding services also should be involved, not in a perfunctory, tokenistic way at a
superficial level but at the level of trying to create a shared representation of the child’s
internal experience when seen from a range of perspectives. This work in and of itself
is likely to be of great benefit in the care of the young person. Of course, it is thoroughly
nonmentalizing to state this as an objective, without giving any suggestions as to how it
might be achieved. In our experience, the systems involved in looking after the best in-
terests of a young person are sometimes spectacularly limited in their capacity to envi-
sion the mental world of the person in their charge. In some cases, the child’s internal
world may be apparently split off and become the sole responsibility of the therapist; in
other cases, the therapist’s perspective may be disrespected and unwelcome. No alter-
native exists to a single-minded commitment by the therapist to consider as her or his
patient group not just the child and not just the parents and the family but the entire so-
cial care system that is engaged in working with the child and to try to identify failures
of mentalization at all levels of this complex and sometimes remarkably dysfunctional
system.
Mentalization-Based Therapy for

Children: Techniques
In our manual, we arranged the identified interventions into three groups: 1) attention
regulation, 2) affect regulation, and 3) mentalization. In the here and now of a new at-
tachment relationship, the therapist can offer a form of containment and will encour-
age mentalization by mirroring the child’s mental states and processes in a manner that
is contingent, congruent, and marked. Recognizing the child’s mental state and apply-
ing the appropriate technique from one of the three groups might help the therapist to
be as congruent with the child’s internal state as possible. It might reduce the pressure
experienced by a beginning therapist to remember that failures of interpersonal under-
standing, if appropriately followed up, represent ideal opportunities for mentalizing.
In describing the treatment, it is tempting to assume a hierarchy in the techniques.
Any child first must be capable of calm sensorimotor regulation, so that he or she is no
longer overwhelmed by vehement affect states before the child can start to recognize
and regulate affects; thus, this would seem to be the right order in therapy as well.
However, reality is not so clear-cut. A child in the latency period is significantly differ-
ent from an infant. In certain fields, development has proceeded, whereas in specific ar-
eas, it has stagnated. Developmental processes seldom proceed at an equal pace on all
fronts. The therapist must allow himself or herself to be surprised by what comes up in
the relationship.
MBT-C is not a therapy that proceeds linearly. Some children can mentalize better
at the start of therapy, and the intensification of the attachment relationship then causes
a predictable loss of mentalization, particularly in a child with disorganized attachment.
This is not a significant problem. We can all revert to earlier modes of mental func-
tioning in certain domains. What is therapeutic in MBT-C is 1) the identification of the
loss of mentalizing as it occurs and 2) not allowing the child to continue in a nonmen-
talizing mode for too long but confronting nonmentalizing and replacing it with a
more adaptive mode of thinking about self and others in a social (attachment) context.
Inevitably, the therapist works by trial and error. However, just as in typical develop-
ment, it is crucial for the perception of the self as agent that the relationship be restored
quickly and, if possible, that the therapist and the child come to see how the interrup-
tion occurred.
Table 6–6 gives examples illustrating how one might consider reacting to the loss
of mentalizing and the emergence of psychic equivalence and pretend modes to work
toward recovering mentalizing in preschoolers, younger-latency children, and older-
latency children. These techniques are explained more fully in the interventions de-
scribed in the following subsections. For more illustrative examples, we refer readers to
our published treatment manual (Verheugt-Pleiter et al. 2008).
Attention Regulation
The main goal of attention regulation techniques is to help the child’s capacity for
effortful control move the “searchlight” of the internal state monitor, consciousness
with advantage, in the direction of greater control of internal state (Eisenberg et al.
2004; Posner et al. 2002), to circumvent impulsive action and replace it with the rec-
ognition of feelings, wishes, needs, and desires. We should note that effortful control
(the ability to inhibit a dominant response to perform a subdominant response; Posner
and Rothbart 2000) has been linked to the quality of the parent-infant relationship both
theoretically (Fonagy 2001b) and empirically (Fearon and Belsky 2004; Mundy and
TABLE 6–6. Play in psychic equivalence and pretend modes and possible
interventions
Psychic equivalence mode Pretend mode

Preschoolers
Characteristic play Play is often very wild and destructive The child plays in a secluded
because feelings can become too world; for instance, a farmhouse.
real. Playing with wild animals, Play has a rigid and monotonous
etc., often leads to murder and character and is often rather
destruction. Things might break. boring.
Interventions For instance, the therapist says, To enrich the emotional content,
“Does the little lion get a bit the affect of animals or puppets
frightened of all this fighting?” can be verbalized. Attention
Attention regulation: attuning and regulation: attuning and making
making contact. Affect regulation: contact. Affect regulation: giving
playing within boundaries. reality value. Mentalization:
comments on mental contents
and processes.
Younger-latency children
Characteristic play Losing is not acceptable. Play often The child draws butterflies over
gets obstructed because of too much and over again or performs
tension when feelings get too real. other activities with almost no
progress in the drawings or in
contact development.
Interventions For instance, the therapist verbalizes For instance, after also drawing
her or his feeling of disappointment butterflies, the therapist tries to
at losing and joy in playing. start a new project together and
Attention regulation: making adds bees, asking what the
contact. Affect regulation: giving butterflies think about them
reality value. Mentalization: (and similar interventions as
comments on mental processes. described above for
preschoolers).
Older-latency children
Characteristic play Board games can become rather The child plays without affect and
chaotic and lead to throwing pawns rather compulsively during a
if, for instance, the goose ends up in board game.
the well.
Interventions The therapist talks about mental For instance, the therapist adds a
processes in play figures, for bit excitement to the game while
instance, the feelings of the goose in confirming his or her qualities in
the well. Attention regulation: board game rules. Attention
making contact. Affect regulation: regulation: intentional behavior
giving reality value. Mentalization: and own style. Mentalization:
comments on mental processes. comments on mental processes.
Is the child able to regulate impulses, focus attention, and

listen to others conformant with his or her developmental phase?
Normal
sensorimotor Context (persons,
regulatory emotions, stress,
capacities Hypersensitive Not sensitive Normal for age developmental phase)
Sound
Light
Touch
Temperature
Movements in space
Gross motor skills
Fine motor skills
FIGURE 6–1. Assessing the child’s sensorimotor regulatory capacities.
Neal 2001). In therapy, children who were overregulated were stimulated to become a
bit more playful and to show more intersubjectivity (Tronick 2007). Controlling im-
pulsiveness, developing or learning primary mental content, and incorporating the
framework of a reciprocal relationship are the three basic elements of the earliest reg-
ulation processes. To get an impression of the child’s attention regulation abilities, we
use a profile that provides a structure for the MBT-C treatment approach in this do-
main (see Figure 6–1).
When a child has little ability to mentalize, the therapist will start by working with
the child on paying attention to his or her inner self. Children need help both to pre-
vent their being overwhelmed by severe anxiety and to create a state of calm and alert
regulation. Here we use the term attention in a broad sense. We refer to the ability to
control impulsiveness, something that can be learned in a safe relationship. We know
that self-control and the ability to focus attention are related (Bateman and Fonagy
2004). The early attachment relationship in which the mother diverts the child’s atten-
tion from an impulse that presents itself with great urgency in the child ultimately en-
ables the child to internalize this capacity of the mother’s. The ability to gain control of
impulses that arise from within is an essential precondition for the capacity to mental-
ize, which involves giving priority to a mental state over a physical reality. The reverse
is true as well: without stable internal representations, it is impossible to have firm con-
trol of affect. The creation of a safe social space is important for this ability gradually to
develop, especially when social context has undermined its maturational emergence.
The techniques that encourage the development of attention skills have in com-
mon an effort by the therapist to turn the child’s attention inward, for example, in the
first instance, by aiming it at the therapist’s regulation model. The therapist aims to
make the child less dependent on sensory input from the external world so that the
child can follow a more internally dictated set of priorities. The core idea is that of
Freud (1927)—that “the ego is first and foremost a body-ego”—in other words, the
mind is embodied, rooted in the body (Fonagy and Target 2007b).
These facets of enhancing the foundation of mentalization take place within quite
a specific style of communication between therapist and child. Although we distinguish
four types of intervention, they have a common interactional theme running through
them. The style of therapeutic communication we propose here owes much to the pi-
oneering work of the late Stanley Greenspan (1997) and the complex set of therapeutic
protocols he identified in the treatment of developmentally delayed children. Perhaps
less obvious influence is to be found in the therapeutic style of guiding the child’s atten-
tion. Throughout this section, we refer to drawing the child’s attention to various as-
pects of his or her experience, and we know that joint attentional processes, focusing
the parent’s and child’s attention on the same external object, are critical components
of the development of cognition (Tomasello 1988), including mentalization (Baron-
Cohen et al. 2008). But how this mechanism of shared attention extends to learning
about subjective states has not crystallized for us until recently. Yet it clearly justifies the
way we work as therapists with children with developmental anomalies and explains the
constraints we work with as we try to expand their understanding of their internal ex-
periences.
We are indebted to the remarkable discoveries of Csibra and Gergely (2006) for
the slightly educational tone of the interventions we come to recommend, for which we
make no apology. These developmental scientists, who are primarily concerned with
infant cognition, identified as a basic mechanism for the acquisition of social under-
standing the child’s specific readiness to learn about aspects of the world that can be dis-
covered only through social contact. Scientists and philosophers have puzzled over the
question of how humans acquire culture for many centuries (Tomasello 1999). Csibra
and Gergely suggested that culture is socially transmitted via a specialized learning
mechanism they term the pedagogic stance, which involves the child and parent in a very
specific state of readiness to teach and learn, and which is different in quality from all
other interactions they engage in (Gergely and Csibra 2005). Attuned caregivers be-
have toward and speak to children in such ways that the children gradually conclude
that their behavior may be best understood if they assume that they have feelings,
wishes, ideas, and beliefs that determine their actions, and that the reactions of others
can be generalized to other similar beings. The caregiver is biologically prepared to act
in the role of the teacher, the pedagogue. The theory of human pedagogy (Csibra and
Gergely 2006; Gergely and Csibra 2005) proposes that early emerging triadic commu-
nications about referent objects, such as parents pointing to and naming something, are
often best conceived of as serving a primarily epistemic function whereby the child ob-
tains reliable, new, and relevant information that constitutes universally shared cultural
knowledge. Adults produce special pedagogic communicative cues for which infants
show specific receptivity. These are cues of “ostensive communication.” The teacher
must not only transmit knowledge to the learner but also alert the learner that he or she
is teaching and that the communication is being specifically addressed to the learner.
The pedagogic stance is an intersubjective state that the child enters into following
initiation by the parent. A sequence of learning is triggered by ostensive cues from the
parent, which may be the child’s name, eye contact, the raising of eyebrows, a widening
of the eyes, a slowing of intonation (“motherese”), or, most commonly, contingent re-
sponding to the infant (Gergely 2007; see Csibra and Gergely 2006 for a review of
evidence of very early sensitivity and preference for such cues by human infants).
Ostensive cues are assumed to trigger a specific receptive attentional and interpretive
attitude, the “pedagogic stance,” in the infant. These biological triggers when the par-
ent is focusing on the child engender a mind-set that signals to the infant: The next
piece of information is 1) relevant for you and 2) part of your developing understanding
of human culture, your social world, and your understanding of others and yourself
(Fonagy et al. 2007). This evolutionarily highly protected mechanism, evident in phe-
nomena such as social referencing, when the child looks to the parent to learn about the
parent’s perception of the dangerousness of a situation, is what must be triggered in the
child as we create a foundation for the acquisition of self-knowledge and self-under-
standing.
By activating the child’s pedagogic stance through repeated experience with ostensive
cues such as “marked” affect-mirroring (contingent feedback reactions from the child-
attuned therapist emulating the child’s early attachment environment), the therapist can
1) teach the child about the existence of internal subjective emotion states, 2) lead to the
child’s internalization of the therapist’s marked mirroring displays as second-order repre-
sentations associated with the child’s (inferred) primary self-states, and 3) introspectively
sensitize the child's attentional system to the presence of internal referents in the self
(through the process of social biofeedback). The activation by the therapist of the peda-
gogic stance in key respects constrains the therapist’s actions, so at key moments he or she
(mostly unconsciously but purposefully) adopts biologically prepared ostensive cues, in-
cluding specific intonation patterns, turn-taking, and contingent reactivity when the triadic
communication involves an external object but also when the focus of pedagogy is the
child’s internal state. We argue that talking to the child about subjective experience extends
MBT-C to include in its domain internal states of the self. Two critical changes in process-
ing are achieved: 1) second-order representations of internal self-states are created (second-
order representations are representations of mental states that symbolically organize con-
stitutional or physical self-states associated with an emotional experience), and 2) the atten-
tion system may be socialized toward an introspective monitoring direction. Thus,
awareness, cognitive access, and subjective internal self-states become part of this now-
extended domain of mentalization. In the following subsections, we list four prototypical
instances of this process in action in certain important moments of child therapy.
Accepting the Child’s Regulation Profile and

Attuning at the Same Level
The first phase of development is about gaining confidence in the ability to lead one’s
life in a calm, regulated, and interested manner and to feel safe with the workings of
one’s body, specifically the perceptual and motor systems. Problems in this phase ex-
press themselves in a feeling of being overwhelmed, or of disintegration, and in at-
tempts to achieve omnipotent overcontrol. This becomes apparent in the very first
phase of therapy. The therapist will then seek ways to help the child to feel calm. All the
interventions within this group aim at the regulation of arousal and impulsivity.
Greenspan (1997) calls them prerepresentational interventions, by which he means
that they are based on the assumption that a child does not yet have detailed mental
representations of affects. This group of interventions requires the therapist to adjust
any reactions to the child’s mental functioning level and to create an atmosphere of ac-
ceptance, in which the child can feel free to explore some aspect of his or her tense and
often impulsive inner world.
Abnormal regulation processes influence development in numerous ways. The
therapist will be better able to help the child become calm if the therapist understands
the child’s specific regulatory pattern. The therapist can then adapt his or her responses
to the child’s specific regulation profile and attempt to find a pattern that will best help
this child to focus his or her attention and to use his or her energy. If the child, together
with the therapist, can gain some empathy for the child’s problems, they can work out
some of the child’s basic assumptions. For example, the child may assume that you im-
mediately get up, leave the room, and slam the door if you feel uncomfortable with
something. Step by step, the therapist can help the child to gain more alternative ex-
periences. These interventions are appropriate to the child’s behavioral level and per-
spective and not to his or her presumed feelings because the child does not yet have
these at the ready: he or she will freeze up or become agitated if asked about emotions
too quickly. This category involves the following possible therapeutic techniques.
First, attention to the content of the child’s play or activity and the introduction of
structure in the play or story may be needed. The therapist goes along with the rhythm
and content of the child’s activities. The emphasis is more on creating patterns of being
together than on what is actually said. Rhythmically, often repetitively, doing the same
thing together is reminiscent of a children’s song. The introduction of structure during
a game or story that is in danger of becoming unstructured is meant to refocus the
child’s attention. As long as the therapist joins in the child’s game, when a child is in
danger of becoming worked up, the therapist can try to weave in some sort of structure
that can help the child to regain control.
Second, the therapist may focus attention by naming or describing aspects of be-
havior that can express a physical sensation. In this category, a physical sensation is not
regarded as a metaphor for something mental. The fact that the body is something a
person can give some thought to, something another person might be interested in, can
be seen as a building block for the development of self as agent (Fonagy and Target
2007b). If his or her body is something a person can think about and can share thoughts
about, he or she is working toward the regulation of physical processes. This can then
be extended to naming or describing mental content (cognitions and feelings). The
therapist can focus attention on aspects of behavior and ascribe a possible expression of
emotion or cognition to them as a first step toward highlighting an inner experience.
For example, “So, when I make a medal for you, then we have proof that you won this
game. And every time we see the medal, we can think about your winning mood!”
Third, the therapist may name or describe having anxiety and feeling threatened.
This involves directing attention to unsafe situations in which a person can feel threat-
ened and anxious, and to how to deal with them. For example, during play, the therapist
shows that one of the puppets is in danger or that he or she can express anxiety in a play-
ful manner during board games. Another approach is to name or describe a state of an-
imosity to show the child in a playful manner that anger may be present but that the
anger does not necessarily have a direct effect on behavior. This category also may in-
clude drawing the child’s attention to the fact that the same object can evoke opposing
feelings. For example, by adopting a playful attitude, the therapist offsets a child’s whin-
ing, pestering, and cheating without touching the child’s narcissism. It is more along
the lines of “Let’s pretend we’re cheating” instead of “We’re cheating.” This engenders
a sense of the two of them together instead of “You’re cheating; I caught you, and I’ll
get you back.” With such an intervention, the therapist not only protects the child’s
self-esteem but also creates an experience of sharing the child’s emotional and physical
rhythm. The aggression is therefore not discussed as such: the attention paid to the an-
ger is used to interest the child in interaction.
Working on the Ability to Make Contact

Many children with profound mentalizing problems have difficulties with feeling a link
to another person: this aspect, too, soon emerges in therapy. Many children cannot say
in words that they feel empty or without any ties. In such a case, the therapist watches
for signs of connectedness such as a smile or a quick glance. Working on the capacity to
make contact, especially with withdrawn children, first and foremost means incorpo-
rating oneself into the child’s play. In this way, one shows the child that it is possible to
stay connected and even start to feel better about an unpleasant mood or undifferenti-
ated affect. The subtle message is that it is better to experience strong, overwhelming
affects within a relationship than to feel withdrawn from all contact. At these moments,
it is often not yet possible to experience the painful affect states at a representational
level. Three techniques are identified.
First, the therapist should strive to maintain and introduce continuity in contact
with the child. Sometimes maintaining contact will require verbalizations without
naming or describing behavior or feelings. Many children experience little continuity
in their contact with others. If the child has a hard time retaining images from previous
sessions, a reference to them by the therapist may be experienced as criticism and is in-
terpreted to mean that the therapist is not responding to the child’s perspective. The
therapist can still show that he or she is thinking about what the child says and does. In
the long run, this can provide a form of continuity for the child.
Second, the therapist should work actively to create a safe environment. Within the
context of a permanent and safe framework, the therapist ensures that the good relation-
ship continues: the therapist protects the child from too much frustration, chaos, and ex-
citation. The therapist ensures that the affect does not become overwhelming and that
the child does not hurt himself or herself or get into difficulty in some other way.
Finally, at this level, the therapist may explicitly name or describe social interac-
tions. Naming or describing what can take place between people is an important way to
prepare for the development of the ability to put oneself in another’s place. The ther-
apist can encourage the child to imagine or picture this, provided that he or she man-
ages to respond at the child’s mental functioning level. The therapist can ask aloud, as
if to himself or herself, while playing with the figures in the dollhouse or the soldiers or
knights in the castle, what is going on between two of them: “I wonder if this soldier is
really so merciless as he seems. I would not be surprised if he also enjoys riding the
horses together with this other knight. What do you think about him? And what about
the other fellow?”
Working on the Basis for Intentional Behavior

A third group of interventions focuses on simple intentional gestures—the exchange of
nods, frowns, and other social signals that also define boundaries between people. Take,
for example, the very young child who uses sign language to show that he or she wants
to be picked up: if the parent responds to this intention, an initial feeling of self will ac-
quire validity and credibility. Although very young children do not yet have verbal rep-
resentations, they have circles of communication that are opened and closed. The child
reaches, opening the circle. The parent picks him or her up in response. If the child
then smiles, the circle is closed again. If the circle cannot be closed again, this may have
a disorganizing effect (Greenspan 1997).
In the therapy situation, the therapist’s style must not hamper the child. A therapist
who is too still or withdrawn can further disorganize a child or make him or her in-
tensely angry. The therapist can convey continuous regulation and acceptance through
gestures and make interaction possible by opening and closing communication circles
in this nonverbal area. If the child is withdrawn, he or she can easily draw the therapist
into a game of wait-and-see. If the child has a real problem in this area, the therapist
should respond with properly distributed warmth and attention. The therapist’s facial
expression may become a bit livelier, the way a parent will intuitively do with a child
who is too overwhelmed to be able to answer verbally. But the child’s disorganization
also can be passed on to the adult, so the adult needs to be able to regulate himself or
herself and to make use of this during contact with the child.
We identified joining in with the child’s activities visually or in gestures as one

technique for working on creating the basis for intentional behavior. Nonverbally, the
therapist will note all communicative or potentially communicative gestures and re-
spond with regulation and acceptance. It is important to pay particular visual attention
to the child’s activities—for example, very intently following the child’s actions visually
or physically (e.g., in gestures) engenders a nonverbal involvement, and the child gets a
clearer idea of what he or she wants. By exaggerating attitude, facial expressions, or in-
tonation, the therapist can present or express difficult feelings, thus promoting their ac-
ceptance. Use of moderation is not necessary. The therapist’s facial expressions do not
need to be repressed. The child may be able to use these reactions as part of social ref-
erencing and gain a better understanding of what he or she wants.
Giving Reality Value to Preverbal Interactions by

Taking the Child’s Own Style Seriously
Rather like the way a toddler uses a complex behavioral repertoire in a preverbal fash-
ion to express psychological feelings such as dependence and independence, pride and
admiration, envy and competition, love and care for others, here a presymbolic com-
plex sense of self and other is established within an attachment relationship. When the
gesture system does not work, it leads to fixated views and attitudes. Greenspan (1997)
described how many enactments take place in this field.
It is an obvious tactical error to start discussing feelings when they are not yet rec-
ognized by the child at a behavioral level. Sometimes, there is only a vague somatic ref-
erence (tense muscles, stomachache). The therapist should patiently ask about the
source of the child’s discomfort and invite the child to talk about his or her physical sen-
sations. If interaction occurs with respect to the behavioral level, the corresponding af-
fects can emerge as well. If the parents have not really seen the child as a person in his
or her own right, and if they have given too little time to the pedagogic stance in rela-
tion to subjective states, the child has had too little opportunity to link his or her own
inner sensations to an affective state or to a representation that is not perceived to be
true or real. The child first must experience affective states at the level of behavior and
gestures before he or she can create mental representations of them. The affects first
must be given reality value, and the therapist can help in this respect. This often in-
volves naming intensities, pointing out behavioral sequences that are important to the
child, and communicating admiration of the child and his or her behavior as the very
first form of helping the child to start to see his or her own qualities accompanied by ap-
propriate ostensive cues. Two specific techniques are presented.
First, we identified the technique of directing attention to describing behavior. It is
important that a child comes to see that he or she is viewed as an independent person,
as the pilot of his or her own behavior. By redescribing a behavioral sequence from his
or her own perspective, it can become clear to the child, for example, that responding
in a certain way is very understandable, even if it was a tantrum or panic.
A second therapeutic technique is to focus on the child’s qualities. This means

pointing out to the child things he or she is good at. These are often qualities the child
has not yet been able to think about in this way. Explicitly discussing the child’s qualities
is a way of justifying or confirming his or her sense of self.
Affect Regulation
In some therapies, a great deal of work on attention regulation with judicious use of os-
tensive cues may need to be done before feelings can be appropriate foci for therapeutic
work. An important component of the acquisition of affect regulation capacity is the
validation of the child’s emotional experience, which, as identified earlier, is a funda-
mental part of establishing the child’s sense of agency through ownership. In the ther-
apy, it is important to help the child perceive his or her affects and through judicious
contextualization implicitly (or sometimes explicitly) validate these as appropriate.
This continues the project of shared attention to subjective states that, we have argued,
is the cornerstone of rekindling the mentalization process.
It is sometimes extremely difficult and always a delicate matter to verbalize affect in
MBT-C—children often take a verbalization of feeling as an attack, hold their hands
over their ears, or appear to regard verbalization as an invitation to enact rather than
contemplate. We have found that what have been termed analyst-centered interpretations
(Steiner 1994) can work well with this group of children. Talking about what the child
experiences to be the therapist’s feeling might be paradoxically easier to process, re-
gardless of the requirement for second-order theory of mind. It is clear that the child
has available the capacity for understanding affect but loses it under the emotional
pressure of contemplating his or her own state of mind. Thus, it can be paradoxically
more appropriate to the child’s need to consider what goes on in the therapist’s mind.
This refers to using an intervention such as: “You seem to see me as quite cold and with-
out many feelings....” The therapist tries to contain the child’s attributions in this way,
and once his or her own emotional reactions (e.g., feeling rejected) can be named as
well, it will lead to integration and to the experience of being understood.
The therapist must try to get a good idea of the most important affects. Sorting out
the antecedents of an affect is an important technique. The therapist will help the child
to describe the feelings that introduce or accompany a behavior pattern that has been
identified and discuss the consequences that strong feelings can have, both for the child
and for others (Bateman and Fonagy 2004). The ability to step back and to observe sub-
jectivity is a crucial skill that paves the way for mentalizing, which has been recognized
in other therapeutic orientations as mindfulness (Choi-Kain and Gunderson 2008; Se-
gal et al. 2002). Mindfulness requires boundaries, and combining reflection with play-
fulness and markedness lends the necessary scope for this.
It is always essential to keep an eye on an active sense of connection between the
therapy and the child’s real feelings if pseudomentalization is to be avoided. Sadly, no
magical alternative exists to the therapist remaining curious, ever alert, and ready to
validate the child’s genuine affective experience. One method of avoiding a common
drift into pseudomentalizing is for the therapist to quickly take responsibility for hav-
ing been part of creating the child’s emotional state. “I must have done something be-
cause you suddenly seem to me to be feeling sad.” Through this “benign split”
(Bateman and Fonagy 2004) within the therapist, he or she contains the child’s often
overwhelming affects and gives them back in a somewhat more comprehensible form.
This is possible only if the therapist plays along—even when engrossed in the child’s
projective identifications, he or she remains open to their nature, intensity, and color.
Playing Within Boundaries

Playing safely is a prerequisite for affect regulation. Exaggeration and dramatization
offer important opportunities for children to get to know their emotional life and to ex-
periment with boundaries: what is inside and what is outside. Four techniques may be
identified.
First, the introduction of fantasy in play is a therapeutic intervention because pretense
can be viewed as a vehicle for the representation of wishes, intentions, and feelings. A child’s
need for immediate action will be lessened if symbols can be used. Second, the therapist can
focus on separating fantasy and reality by actively making remarks on the difference be-
tween possible fantasies and reality. Third, the therapist needs to set boundaries in play if
the rules and the structure of the therapeutic situation are under pressure. Children’s nor-
mal play is far from analogous to free association (although perhaps that latter phrase is a
misnomer) but is largely concerned with setting rules and boundaries precisely to ensure
that the play situation can be free to serve as an effective vehicle for speculative mental
states. Thus, by setting boundaries in play, the therapist facilitates rather than constrains the
emergence of mentalization. Unbounded play is fertile soil for nonmentalizing: psychic
equivalence, teleology, and pretend mode mentalization. Bleiberg (2001, p. 68) speaks of
“reflective” limit setting of mentalizing caregivers in opposition to caregivers who react
with a standard and automatic “no.” This is, of course, the therapist’s approach as well.
Genuine bounded pretense appears to maximize the child’s native cognitive capacities, in-
cluding the ability to mentalize, by removing the constraints of serious implications from
cognitions (Flavell 1999; Reddy 2008). Fourth, the therapist can join in the pretense be-
cause the therapist’s participation can create a transitional thinking space for some children.
(If children are stuck in the pretend mode, this is not a good technique because it might
encourage pseudomentalization.) The therapist can help expand the child’s mentalizing—
for example, by asking what the other should do in the game. As an active commentator,
the therapist can bring the drama to life more easily and even be part of it now and then.
Giving Reality Value to Affect States by

Implicit and Explicit Validation
The validation of emotional experiences is very important to all of us, but the thera-
peutic context sometimes may be the first time the child has this experience. If the
relationship with the therapist has become safe enough, the child can gradually start to
internalize the function of the therapist as the representative of affects (a contingent,
marked mirror of emotional experience). At stake is the internalization of the function
and not of the content. We assume that this capacity, to internally represent emotion, is
present in all children as a potential at birth. Experience of mirroring is essential to re-
kindle a natural process and counteract a hypothesized block in the natural practice of
this function. Kick-starting this labeling function can lessen the constraint of fixed
meaning and generate alternative ideas about the meaning of feelings in relation to the
self and others without fixed, unthinking, rigidly held schemas coming to dominate the
interpretation of interpersonal action. Two main techniques may be highlighted.
First, giving reality value to the affect state of a play figure is a possible therapist in-
tervention. Verbalization of an affect is complicated. Many small steps may need to be
taken, and the connection with the child’s perception and the genuine not-knowing
stance of the therapist are crucial. Sometimes a feeling can be named through an inter-
mediary—a figure in the play situation—or as a feeling of the therapist. Exaggeration
opens the door to a playful approach and makes it easier to start accepting difficult feel-
ings. In the play situation, the therapist can play the child who makes the mistakes by
verbalizing feeling unhappy when making so many mistakes. The therapist may show
the child how one might deal with having feelings of failure and being unhappy about
it. This encourages the child to start feeling these types of emotions.
Second, the therapist can clarify and elaborate the child’s affect state. This involves
identifying feelings in a wondering, curious way that a child is perhaps not yet able to
name but that the child clearly shows. It may be essential to link affect with context or
with the child’s prior experience, current behavior, or background mood. The risk is as-
suming subjective equivalence or the universality of the language of emotion. We are so
used to verbalizing affects that we can make too many assumptions about anxiety or
grief or anger being equivalent experiences for all of us. Mentalizing for the child is not
the same as the child being helped to mentalize. Clarifying and contextualizing affect
ensures that the therapist confirms the child’s actual experience rather than allowing
the two of them to be carried away by their understanding to draw implications that
surely take the therapeutic couple into the land of pseudomentalization.
Mentalization
It will be clear that the regulation of affects changes once children have learned to men-
talize—that is, when they are aware that not only they themselves but also others have
an internal world with feelings, thoughts, and desires. An autobiographical self refers to
the ability to have multiple representations of oneself with a historical causal concept of
self, integrated into an autobiographical self-representation. Not all forms of mental-
ization have to do with affective experiences, but during therapy, affective experiences
tend to be central. We discuss interventions intended to encourage thinking about
mental states and mental processes.
Comments on Mental Contents: Interpretive Mentalizing

Commenting on mental contents means making remarks on what the therapist thinks
that the child might be fantasizing, thinking, or wishing. This is what has been termed
interpretive mentalizing in MBT. In MBT-C, interpretive mentalizing can take several
forms.
First, the therapist can comment on mental content during play, altering the con-
text of play so that playing can take on greater emotional and mental content, for ex-
ample, by helping the child to think about psychological traits of play figures. Second,
the therapist can discuss thoughts and feelings of attachment figures. This can promote
differentiation between attachment figures and also contributes to creating object re-
lations. Third, the therapist can comment on the mental content that the therapist in-
fers from the child’s behavior or play when the feelings are present with reasonable
clarity and when the therapist marks this with a phrase such as: “The sense that you give
me by the way you handle that animal is that you are not pleased with how she behaved.
Did I get that right?” Fourth, the therapist can broaden content in a positive way, add-
ing implications to what the child might have had in mind. We refer to this as adding an
alternative perspective. The interpretive mentalizing follows a phrase such as “Another
way of understanding this might be....” Presenting an alternative perspective becomes
increasingly important as the child’s thinking in the sessions becomes better established
and more structured. This is important in the child’s growing understanding of how
other people might see a piece of their behavior or how someone’s behavior may be un-
derstood in a variety of ways.
Reflection on Mental States Underlying Behavior:

Complex Interpretive Mentalizing
Complex interpretive mentalizing involves consideration of mental phenomena such as
remembering, forgetting, fantasizing, and wanting and the relations between them.
The therapist will help the child to make the links between different affects, themes,
and representational areas—for example, the link between loss and aggression or be-
tween dependence and withdrawal. Once a certain level of affect regulation and men-
talization has been achieved, the child can be challenged to see different perspectives
from his or her own, often rigid, views. “Playing with reality” starts to become a reality.
Timing remains important. If the therapist makes such remarks too soon or at times of
high emotional arousal, then they may be taken as an attack.
First, the therapist can identify for the child certain states of mind as possible mo-
tivators of the child’s behavior. Second, the therapist can actively verbalize a wish or an
intention in pretense. Therapists may articulate a wish or an intention of a fantasy or
play figure when it is not yet possible (e.g., because it would be experienced as an in-
trusion) to link it to the child. In addition, the therapist can verbalize a wish or an in-
tention of the child directly, verbalize thoughts about the mental life of others who have
significance for the child, and help the child learn to put himself or herself in another’s
place. Third, the therapist can stress the individual character of the child’s mental
world, emphasizing that a child can do things, want things, invent things, and be his or
her own and independent person.
Comments on Interactive Mental Processes:

Mentalizing the Transference
Mentalizing the transference revolves around interventions such as: “You think I didn’t
notice that you were laughing at me.” These interventions move in the direction of rec-
iprocity in the contact. The object of therapy is for the child to learn to communicate
instinctively. Communicating affects also implies that a feeling is expressed and that
this goes along with an expectation of how the other person will receive it. This reci-
procity, and the ability to reflect about it, is the goal. Ultimately, the object is “mental-
ized affectivity” (Fonagy et al. 2002a; Jurist 2005)—that is, the emotional experience is
concurrent with reflection. For many children, this probably will be possible in only
brief episodes (a moment of self-reflection tells us that most of us find this a hard po-
sition to attain in some cases, even after many years of therapeutic work on ourselves).
This level of complexity permits the child’s relationship with the therapist to be af-
fectively mentalized—thought about at the same time as being an intense source of
feeling. In a sense, the MBT-C therapist offers himself or herself as a developmental
object. The therapist will try to discover what significance he or she has (whether we
call this a transference object or just a person whom the child has come to know very
well) in the child’s life. If the therapist can understand something about the relationship
with the child, this can be ideal material in fluid moments of therapy for communica-
tion to develop between them about the feelings they have (or fear the other has), the
reasons for these, and how this might link to the child’s other relationships with parents
and friends. The communication about the therapeutic relationship has the potential
for correcting misunderstanding and stating the obvious. The latter carries more risk
than the former. Stating the obvious should always be marked by the therapist: “I know
you expected me to say this, but just indulge me once more....” Ideally, the therapist
should not say things that are predictable and of no interest to the child. This has little
to do with MBT-C and is simple compliance with Gricean conversational maxims
(Grice 1989) to which children are extraordinarily sensitive and can be cruel and un-
forgiving. The therapist who bores the child risks losing the alliance.
By contrast, as we have pointed out earlier, confusion and misunderstanding are al-
most to be encouraged as opportunities for mentalizing in relation to identifying their
source. If the child becomes entangled in his or her own associations, the therapist
helps by saying, “I’ve lost the thread,” thus inviting the child to differentiate actively.
Because the transference is usually a fairly undifferentiated experience but does have
great intensity, a lot can be learned here. The various patterns of relationships come
clearly into focus and can be investigated. If the therapist is truly neutral, the child can
identify, reflect on, and ideally give up old patterns and start practicing with new ones.
Structure is thus not formed by resolving conflicts but by learning on the basis of the
current relationship (Greenspan 1997). Nevertheless, it can sometimes be better to
work “in displacement” because the therapeutic relationship triggers the disorganized
attachment system. Too much proximity can be too disturbing, whereas too much dis-
tance can give the impression of indifference. In play, usually many opportunities are
available to work in displacement.
Conclusion
Two main features differentiate MBT-C from the adult version of MBT. These are at-
tention regulation and developmental issues.
Problematic development at ages 4–12 often has its roots in the transition from be-
havioral to representational models. This developmental characteristic of middle
childhood implies a need for more interventions at a prerepresentational level, which
we called attention regulation. Attention regulation requires the therapist to adopt spe-
cial qualities of communication for which we have borrowed the phrase ostensive cues,
implying an almost infant-appropriate method of capturing the child’s attention for a
triadic communication (joint attention to a shared object). As the therapy takes hold,
the shared object in MBT-C increasingly becomes the child’s subjectivity. Creating the
intersubjective state of the pedagogic stance focused on the child’s subjectivity requires
contingent congruent responding from the therapist. This capacity may be a prereq-
uisite of all psychological treatments, but it is absolutely essential if attention regulation
is the goal of the intervention in children with severe developmental difficulties. If the
therapist does not pay enough attention to these behavioral aspects and moves too
quickly to more sophisticated techniques required to address problems of affect regu-
lation, then the therapist’s relationship with the child can easily become meaningless,
and pseudomentalization comes to dominate the process. Work on attention regulation
involves many small steps, which we have tried to clarify by identifying several different
techniques. Misunderstandings in subtle communications need to be addressed at this
basic level to restore basic trust in the child before verbalizing affects or mentalizing
about feelings, wishes, and so forth. The therapist’s not-knowing stance is essential in
this phase and is a central mechanism in the therapeutic process.
Developmental issues are central in providing psychotherapy to children. At this age,
providing therapeutic help in gaining a coherent self aims at the development of autonomy
as in more secure expectations about what the child can do and can regulate. The therapist
also aims to help the child to develop more secure expectations about what to expect from
peers. Stimulating the child’s ability to reflect on different relationships is essential during
middle childhood; the development of this capacity is a developmental milestone.
Research findings from developmental psychology and psychopathology provide
some support for this mentalization-enhancing approach in working with children with
substantial clinical problems. However, the clinical evidence needs to be substantiated
with an empirical study of the effectiveness of MBT-C for children and their parents.
Suggested Reading
Verheugt-Pleiter JE, Schmeets MGJ, Zevalkink J: Mentalizing in Child Therapy: Guidelines for
Clinical Practitioners. London, Karnac, 2008
CHAPTER 7
Brief Treatment
Jon G. Allen, Ph.D.
A s the current volume attests, treating a wide range of psychiatric conditions with
various modalities, regardless of time frame, requires that patients and clinicians be en-
gaged in the activity of mentalizing: namely, perceiving and interpreting the behavior
of self and others as conjoined with intentional mental states such as thoughts and feel-
The authors thank several colleagues who have contributed to the development of the mental-
izing exercises described herein: Efrain Bleiberg, Toby Haslam-Hopwood, Brad Kennedy, Jen-
nifer Markey, Noelle McDonald, and last but not least, April Stein, whose original idea it was to
incorporate exercises into the educational program. In addition, the authors thank Patricia Daza,
Thomas Ellis, and David Jobes for their comments on an earlier draft of this chapter.
159
ings. Hence, in addition to characterizing an evidence-based therapy for borderline

personality disorder, we have come to regard mentalizing as a key common factor in
diverse psychotherapeutic treatments (Allen 2008a; Allen et al. 2008). We believe that
the mentalizing perspective, with its anchors in attachment theory and research, has
the potential to enrich psychotherapists’ use of brief treatments, regardless of their
particular theoretical framework.
Our application of mentalizing to brief treatment contexts has evolved in part from
our development of psychoeducational interventions designed to jump-start mentaliz-
ing (Allen et al. 2008; Haslam-Hopwood et al. 2006). As depicted in Figure 7–1, we
launch the treatment process by imparting basic knowledge about mentalizing, but we
are keenly aware that declarative knowledge must be transformed into procedural
knowledge: patients must not only understand the concept of mentalizing but also
practice doing it. Accordingly, we have emphasized throughout our writings that the
mentalizing approach focuses more on cultivating mental processes (i.e., mentalizing
skills) than on discovering or altering particular mental contents (e.g., specific insights).
Fundamental to our approach is a mentalizing stance toward mental states in self and
others—a nonjudgmental attitude of curiosity, inquisitiveness, and open-mindedness.
Challenging the view of the therapist as an expert mind reader, we explicitly construe
mentalizing as a Columbo-like “not-knowing” stance. Linehan (1993a) advocated a
similar stance in relation to inquiring about self-injurious behavior: “the therapist must
play the role of naïve observer, understanding nothing and questioning everything”
(p. 260). As the similarity to Linehan illustrates, in advocating this mentalizing stance,
we are not claiming anything new; on the contrary, we have characterized our focus on
mentalizing to be “the least novel approach imaginable” (Allen and Fonagy 2006, p. ix).
Although our approach is not new, we are convinced that consciously attending to
mentalizing—and helping patients to do so—has the potential to enhance what we psy-
chotherapists have been doing (less deliberately) all along.
As much as we emphasize mentalizing processes, we also recognize that there can
be no process without content and—especially in brief treatments—the patient and cli-
nician need a formulation of the key problems that can serve as a focus for treatment. As
Figure 7–1 illustrates, process and content are intertwined, insofar as the mentalizing
stance on the part of patient and therapist is required to generate and refine a clinical
formulation. Conversely, having a clear understanding of key difficulties helps the pa-
tient to mentalize in the course of grappling with these difficulties.
As Figure 7–1 also indicates, in our view, a therapeutic alliance in relation to men-
talizing is an optimal outcome of brief interventions rather than a starting point. That
is, to the extent that the brief intervention is successful, the patient will be motivated
to use mentalizing in interpersonal and intrapersonal problem solving and will have
acquired some skill in doing so. Thus construed, brief mentalizing interventions can
be viewed as the initial phase of longer-term treatment—be it mentalizing-focused
therapy or otherwise. This phase-oriented approach characterizes our practice with
patients who struggle with chronic and severe psychopathology and extensive comor-
Brief Treatment 161
Mentalizing
stance
Mentalizing Mentalizing
education alliance
Problem
formulation
FIGURE 7–1. Model of mentalizing in brief treatment.
bidity, including personality disturbance. With more circumscribed problems, how-

ever, relatively brief mentalizing interventions may be sufficient to provide patients
with enough traction on key difficulties to enable them to proceed with ongoing
problem solving on their own. Such progress might occur, for example, in brief Men-
talization-Based Family Therapy (Fearon et al. 2006; see Asen and Fonagy, Chapter 5
in this volume).
To underscore the potential value of brief mentalizing interventions for therapists
with diverse theoretical orientations, we show how the mentalizing perspective can be
integrated with other brief approaches, illustrated by motivational interviewing and in-
terventions for acute suicidal states. The remainder of the chapter is organized accord-
ing to the model presented in Figure 7–1. First, we review how we educate patients
about mentalizing; second, we present a variety of exercises that provide patients with
an opportunity to practice mentalizing; and third, we explain how a mentalizing for-
mulation can serve as a focus for brief treatment. Recognizing that the mentalizing al-
liance we envision as the optimal outcome of brief interventions is a collaborative
effort, we conclude the chapter with a discussion of some challenges clinicians are likely
to face in implementing this mentalizing approach.
Brief Treatments From

a Mentalizing Perspective
In this section, we discuss two brief approaches that are highly compatible with our men-
talizing perspective. After a consideration of motivational interviewing to draw attention
to the role of mentalizing in treatment engagement, we explore suicide prevention to il-
lustrate the potential synergy between mentalizing and brief cognitive therapy interven-
tions in a context that poses particular challenges to therapists’ mentalizing capacity.
Motivational Interviewing
Motivational interviewing (Miller and Rollnick 2004) gained a foothold as a brief in-
tervention to boost motivation for change in persons with substance abuse disorders
and health-related problems. More recently, the approach has been expanded to a
wider range of psychological disorders (Arkowitz et al. 2008b). Akin to the way we
present mentalizing in this chapter, motivational interviewing was developed to pro-
mote treatment engagement and treatment adherence, particularly for patients who
have felt “stuck” (Arkowitz and Miller 2008). As with mentalizing, motivational inter-
viewing can be used as preparatory to longer-term treatment, as a stand-alone treat-
ment, or in combination with other treatment approaches such as cognitive-behavioral
therapy, or it can be viewed more broadly as a style of treatment (Miller and Rollnick
2004). This style has much in common with our view of mentalizing (Allen et al. 2008):
motivational interviewing does not aspire to be a distinct “school” of therapy, and the
spirit of the approach is more critical than any specific techniques (Arkowitz and Miller
2008). A central facet of the spirit is the patient-therapist relationship in which em-
pathy is central. As we also have done (Allen et al. 2008), Miller and Rollnick (2004)
credited Rogers’s (1951) focus on empathy as foundational to their approach. The
treatment relationship is envisioned as a collaborative partnership as contrasted with a
more authoritative, prescriptive, expert-patient relationship (Arkowitz and Miller
2008). Precisely paralleling what we call the mentalizing stance, motivational interview-
ing requires a “spirit of curiosity” on the part of the therapist (Westra and Dozois
2008).
The primary goal of motivational interviewing is to enhance the patient’s intrinsic
motivation to change rather than endeavor to instill motivation from the outside. The pa-
tient’s autonomy is respected, and the aim is to promote a sense of agency or self-efficacy.
The power struggles that might result from blaming the patient for being “resistant,”
“unmotivated,” or “noncompliant” are avoided; instead, resistance is reframed as “ambiv-
alence” about change, and both sides of the ambivalence are explored with an attitude of
acceptance and curiosity (Arkowitz et al. 2008a). Reasons not to change are explored as as-
siduously as are reasons to change, in the belief that an open-minded, nonjudgmental
stance will avoid provoking opposition and instead evoke the patient’s intrinsic motivation
to change. In contrast to Rogers’s (1951) client-centered therapy, motivational interview-
ing is directive insofar as the therapist focuses attention on the decisional balance (i.e.,
ambivalence about change as evident in weighing the relative advantages of various alter-
natives) with an eye toward evoking an experience of dissonance between the patient’s val-
ues (e.g., success in a career) and the patient’s current behavior (e.g., continued alcohol
abuse). Motivational interviewing is also directive in efforts to elicit “change talk”—most
specifically, commitment to change (Arkowitz and Miller 2008). When the patient is
committed to making change, the therapist provides practical help with planning and
strategies to do so, typically as a menu of options from which the patient chooses what
might work best (Westra and Dozois 2008).
Brief Treatment 163
In summary, the main point of contact between motivational interviewing and a

mentalizing-focused approach is the collaborative endeavor to promote treatment en-
gagement by maintaining a spirit of curiosity and inquisitiveness.
Intervening in Suicidal States

Suicidal states of mind can be likened to traumatic experiences in that both entail feeling
alone in the midst of unbearable emotional states (Allen 2001). The experience of aloneness
derives from an absence of mentalizing: a suicidal person lacks a sense that anyone is
thinking about his or her mind. Hence, mentalizing the patient’s suicidal state—and help-
ing the patient to do so—is the first priority for the therapist. Yet the prospect of suicide
challenges the therapist’s capacity to maintain a mentalizing stance: “suicidal threats by a
patient may create anxiety in a therapist as well as imply professional failure (shame) and
thus serve to partially or fully arrest the therapist’s capacity to adequately contemplate the
mental state of the patient” (Bateman and Fonagy 2006a, p. 81).
In the face of anguish and anxiety, structured approaches to elucidating suicidal states
benefit therapists and patients alike (Allen 2011). Jobes’s (2006) Collaborative Assessment
and Management of Suicidality (CAMS) requires that the mentalization-based treatment
(MBT) therapist imagine sitting side by side with the patient rather than opposite the pa-
tient (see Bateman and Fonagy, Chapter 3 in this volume). In the CAMS protocol, the cli-
nician and patient literally sit side by side as the clinician assists the patient in completing
the Suicide Status Form. As a prompt to mentalizing, patients rate the extent of their cur-
rent distress in five domains: psychological pain, situational stress, agitation associated with
an urge to take action, hopelessness, and self-hate. For each of these domains, patients also
provide a brief narrative description of their experience. The assessment encompasses the
essential territory of mentalizing: patients consider the extent to which their suicidal state
relates to thoughts and feelings about the self versus thoughts and feelings about others.
Taking ambivalence for granted, patients are asked to spell out their reasons for living,
along with their reasons for dying; they also fill in the blank in the following sentence: “The
one thing that would help me no longer feel suicidal would be ________.” The assessment
goes on to evaluate a range of risk factors and to devise a treatment plan, but the initial in-
tent is to establish an empathic (mentalizing) relationship that invites the patient to consider
postponing suicide—always a long-term option—to give treatment a chance.
CAMS and mentalizing can be contrasted with more coercive approaches that insist
on no-suicide contracts, notwithstanding the ineffectiveness of such contracts (Rudd et
al. 2006), which, in effect, ignore that an agreement forged in a mentalizing state of mind
will be of little use when the patient is in a nonmentalizing, suicidal state (Bateman and
Fonagy 2006a). Therapeutic empathy with patients’ ambivalence is consistent with the
motivational interviewing approach to suicide (Britten et al. 2008; Zerler 2008), which
aims to promote treatment engagement while avoiding exacerbating resistance.
Brief cognitive therapy for suicidal patients (Brown et al. 2006; Wenzel and Beck
2008; Wenzel et al. 2009) also can be viewed as a mentalizing-promoting intervention.
Having a structured intervention with a clear conceptual framework helps the clinician
to mentalize: “This knowledge has the potential to ground the clinician in the midst of
a session that is likely characterized by intense affect or acting-out behavior” (Wenzel
et al. 2009, p. 77). The cognitive model orients the clinician to a range of dispositional
factors (e.g., psychiatric disorder, impulsivity, impaired problem-solving abilities, per-
fectionism) that make patients vulnerable to suicide in the context of acute stress. Two
suicide-specific cognitive vulnerabilities warrant clinical focus: hopelessness and a per-
ception of emotional pain as being unbearable, exemplified by convictions such as
“This will never get better” and “I can’t take this anymore” (Wenzel and Beck 2008,
p. 194). This cognitive model overlaps with mentalizing in focusing on not only cog-
nitive content but also cognitive processes: specifically, cognitive constriction that takes
the form of attentional fixation—a preoccupation with suicide as the only escape from
emotional pain. Attentional fixation is antithetical to mentalizing (i.e., flexible and re-
flective thinking). In addition, the suicidal state entails the nonmentalizing mode of psy-
chic equivalence (Fonagy et al. 2002a): suicidal persons lose the sense that their thoughts
and feelings represent reality in a particular way and instead equate their mental life with
reality (e.g., by losing sight of the crucial distinction between feeling hopeless and being
hopeless).
Despite its brief therapy (10-session) format, the cognitive approach is compre-
hensive in developing a detailed narrative of the suicidal crisis and placing the crisis in
a developmental context as well as devising a treatment plan that addresses emotion
regulation and coping strategies, including a safety plan. From our perspective, how-
ever, the relapse prevention intervention involving guided imagery (Wenzel et al.
2009) is particularly noteworthy in its potential to help the patient mentalize in the
midst of suicidal states as long as the exercise is done when the patient is mentalizing.
First, the patient vividly imagines the suicidal crisis and reexperiences the painful emo-
tions. Next, the patient goes through the same sequence but imagines using coping
strategies learned in therapy. Finally, the patient imagines a future suicidal crisis that
entails implementing effective coping. This imaginative rehearsal could help the pa-
tient to mentalize and thus make use of a safety plan when mentalizing is most needed
yet most difficult: namely, in the midst of a suicidal crisis.
We view attachment as being primary in treatment, such that structure and tech-
nique are valuable insofar as they facilitate a mentalizing therapeutic relationship. We
aspire to help patients experience the painful emotions associated with their suicidal
state in the context of an attachment relationship in which they are no longer alone but
rather have a sense of their mind being held in mind. This therapeutic process fosters
emotion regulation by providing an attachment relationship in which patients can
achieve narrative coherence (Holmes 2001) in relation to their suicidal state. Narrative
coherence counters a core experience in suicidality: an intrapsychic collapse of self-
cohesion concomitant with self-hatred, which is associated with the intrusion of a de-
structive, alien self-representation stemming from a history of traumatic attachment
relationships (Bateman and Fonagy 2006a; Fonagy et al. 2002a). The establishment of
Brief Treatment 165
a mentalizing attachment relationship is crucial, not only to help patients through

acute suicidal states but also to diminish their chronic vulnerability to these states.
Educating Patients About Mentalizing

We initiated our psychoeducational intervention with the aim of developing a thera-
peutic alliance in hospital and residential treatment on the basis of a straightforward
premise: if we want patients to do something—mentalize—then we should explain to
them what we want them to do and why we think doing this will help them. We have
prepared some written materials for clinicians to use for the purpose of educating pa-
tients: an explanation of mentalizing and its development, “What Is Mentalizing and
Why Do It?” (in Allen et al. 2008, as Appendix to Chapter 10, “Psychoeducation”), and
a summary of the psychoeducational curriculum, Mentalizing as a Compass for Treatment
(Allen et al. 2003). We have discussed this psychoeducational program elsewhere (Allen
et al. 2008; Haslam-Hopwood et al. 2006) and summarize it here.
We explain mentalizing simply as attending to thoughts and feelings in self and
others. Thus, we let patients know that mentalizing involves being aware of what is on
one’s mind and how the mind works—and similarly for the minds of others. We note
that empathy entails awareness of thoughts and feelings in others and that if we were to
extend the concept of empathy to include the self—as we advocate doing—we would
capture much of the territory of mentalizing. We use a shorthand phrase for mentaliz-
ing: “holding mind in mind.” We also advocate the mentalizing stance as an ethos for
the entire milieu of treatment programs while acknowledging that maintaining this
stance is a challenge for clinicians and patients. We are all vulnerable, not only to failure
to mentalize but also to distorted mentalizing. We give a simple example of making un-
warranted assumptions with a sense of certainty: “My boss doesn’t say hello to me. This
means he doesn’t like me. I rant at someone unnecessarily. Later, I ruminate about the
effect of my rant.”
We explain the fundamental principle for the development of mentalizing in at-
tachment relationships: as stated earlier, in the context of secure attachment relation-
ships, mentalizing begets mentalizing. Conversely, we also discuss how attachment
trauma—the extreme of nonmentalizing interactions—can undermine the develop-
ment of mentalizing. The discussion of attachment trauma underscores how mental-
izing is vulnerable to disruption in the face of intense emotions, often associated with
threats in attachment relationships. We emphasize the importance of mentalizing emo-
tion by using the idea of “pushing the pause button” in the midst of intense emotional
arousal—self-monitoring, reflecting, and refraining from mindless reflexive action. We
propose that the pause button of mentalizing allows us to move from rigid response
patterns to flexible problem solving.
We associate a range of psychiatric disorders with mentalizing impairments, and
we present this relationship as a vicious circle. Psychiatric disorders impair mentaliz-
ing, and mentalizing impairments contribute to the development and maintenance of

psychiatric disorders. In a seminar-like atmosphere, we involve patients in brainstorm-
ing about the reciprocal relations between psychiatric problems and mentalizing im-
pairments, illustrating first with substance abuse. Plainly, intoxication and withdrawal
impair mentalizing (e.g., promoting obliviousness to mental states in self and others);
conversely, mentalizing impairments are conducive to substance abuse, for example, by
contributing to problems in emotion regulation and to difficulty with interpersonal
problem solving and stressors in relationships. Next, depression includes distorted
mentalizing (e.g., negatively biased thinking) and isolation, impairment of executive
functions, and apathy—all of which compromise mentalizing. In discussing anxiety, we
note that the fight-or-flight response is antithetical to mentalizing.
We find it most challenging to discuss personality disorders because these diag-
nostic labels—borderline personality disorder, most conspicuously—have plainly pe-
jorative connotations among patients and professionals alike. We introduce the
discussion of personality disorders by illustrating those that represent exaggerated per-
sonality traits, such as paranoid personality. For each such personality disorder, we
draw a continuum, putting the disorder at one end and its maladaptive opposite at the
other end, noting that mentalizing entails maintaining a flexible balance between the
two rigid extremes. For example, we put paranoia at one end of the continuum and gull-
ibility and naïveté at the other end and discuss distorted mentalizing associated with
each extreme. Then we discuss how mentalizing represents the middle ground, for ex-
ample, being prudent and cautious about extending trust.
Borderline personality disorder requires a different level of discussion because this
complex syndrome does not lend itself to an exaggerated trait model (Fonagy et al.
2003). Earlier, in the context of suicidal states, we explained how the activation of at-
tachment needs (e.g., sensitivity to abandonment and threats that portend disruption in
the relationship) generates unbearable emotional states along with impaired mentaliz-
ing; the vulnerable individual resorts to self-destructive ways of reducing the emotional
tension through action, which exacerbates disruptions in the attachment relationships
in a vicious circle (Allen 2001).
Finally, we discuss how treatment interventions, ranging from medication and psy-
choeducation to individual, group, and family therapy, are intended to promote men-
talizing. We emphasize the need to facilitate mentalizing under “battlefield conditions,”
as our colleague psychologist Toby Haslam-Hopwood once put it. One example of such
conditions is clinical rounds, in which the patient meets with the members of the core
treatment team for 15-minute periods twice weekly. Our colleague refers to these
rounds as “mentalizing extravaganzas” in that these meetings require all participants to
mentalize—each individual holding his or her own and everyone else’s minds in mind,
typically in the midst of strong emotions. For example, patients are liable to feel para-
noid, put on the spot, or interrogated when privileges are at stake or their treatment-
defeating behavior is being confronted. Similarly, family work—because it involves
conflicts in key attachment relationships—entails maintaining mentalizing under bat-
Brief Treatment 167
tlefield conditions. We acknowledge to patients our view that mentalizing becomes

most difficult just when one most needs to be able to do it (i.e., under such emotional
conditions) and that practicing and strengthening mentalizing in these circumstances
are at the core of treatment. Hence, from our perspective, milieu treatment, as well as
various modalities and brands of therapy, exercises mentalizing capacity. As we discuss
next, we also have devised several specific exercises to provide practical experience in
mentalizing. We use these exercises to link the explicit (declarative knowledge) with the
implicit (procedural knowledge).
Mentalizing Exercises
The range of exercises that have the potential to promote mentalizing is virtually lim-
itless, contingent only on the creativity of clinicians and patients. In previous publica-
tions, we have described some mentalizing exercises to be used in psychoeducational
contexts (Allen et al. 2008; Haslam-Hopwood et al. 2006). In this section, we describe
all the exercises we have developed at the time of writing (see Table 7–1 for an over-
view). Additional exercises intended to facilitate the development of a problem formu-
lation are described in the next section.
Mentalizing Personality
Who Am I?
Patients first list a half-dozen objective facts about themselves (e.g., age, schools they
have attended, occupation, marital status, pets they have). They are asked to include the
kinds of facts that they might use in social situations to describe themselves. Next, pa-
tients are asked to describe themselves without including any such facts but rather by
considering aspects of themselves that relate to their mental states or personality traits.
They might include typical ways of thinking or feeling, moods, wishes, or fantasies.
This exercise shifts the focus from external-objective to internal-subjective factors.
Group members are invited to comment on the match or mismatch between the pa-
tient’s self-description and their own perceptions of the patient. The following group
process illustrates this:
Ms. J, a 25-year-old woman, was admitted for evaluation and treatment of long-standing
difficulties in interpersonal relationships and problems “sticking to anything.” She re-
ported a long history of depression and anxiety and stated, “Everyone has given up on me
because I am such a bitch,” adding, “I’ve even given up on myself.” Ms. J attended the
mentalizing group with the hope that she would begin to understand the reasons for her
feelings and actions as well as the effect of her behavior on herself and others in her
world. Consistent with her reaction to most other groups, Ms. J initially scoffed at the
syllabus, stating, “I’ve been through all this before—what good can talking about this
stuff do for me?” Despite her derogatory attitude, however, she quickly became involved
in this exercise; she listed her “credentials” while minimizing her ability to “do anything
right.” When asked to describe herself without these facts, however, Ms. J’s attitude en-
tirely changed. She was the first group member to volunteer to describe her attributes:
“bitchy, angry, frustrated, and hard to like but really a baby, needy, dependent, scared,
fragile, spoiled, a real mess—I need help!” Through her self-description, she and other
members of the group (including staff members) began recognizing her conflict: she
longed for closeness and comfort but acknowledged that her fear and vulnerability led
her to drive people away by being pushy. The group discussed how their view of her
shifted and recognized their difficulty in mentalizing her—that is, in seeing her more
vulnerable side. This process allowed Ms. J to be more real in the group, to become more
curious about what drove her. We used this opportunity to emphasize how the recognition
of conflict is a sure sign of effective mentalizing (Haslam-Hopwood et al. 2006, p. 263).
What Makes Me “Me”?

Participants list one or two attributes that they think differentiate them from other
group members. Each member spends a few minutes describing “what makes me ‘me’”
and contrasts the characteristic with those of other members of the group. Participants
talk about how their distinguishing characteristics developed over time and what fac-
tors contributed to this development. Participants also explore commonalities with
other group members. Other group members comment on each member’s self-
perception of his or her sense of distinctiveness. Participants also may talk about what
they have in common with their family members as well as their differences.
Understanding Moods
Each member of the group is asked to describe the prevailing mood of someone the
member knows well and with whom he or she has a relationship (e.g., close friend,
mother, father, partner). Participants are encouraged to recognize that moods are com-
plex by asking them to describe in detail what they mean by sad, sullen, hostile, cheer-
ful, and so forth. Then they are asked how they explain the chosen individual’s
prevailing mood, how it affects their relationship, whether the mood stems from cur-
rent or past experience, if they have noticed anything that affects the mood, and if they
can help the person change his or her mood. In addition or alternatively, participants
can be asked to identify their own prevailing mood and to answer a parallel set of ques-
tions. Then others in the group can be asked if they agree with the person’s self-
perception; as always, differences in perception merit special exploration.
How My Mind Works

Participants are asked to think about their thinking and feeling through a series of
questions such as: How does what I think affect my feelings? How does what I feel af-
fect my thoughts? What effects do my thoughts and feelings have on my desires and
Brief Treatment 169
TABLE 7–1. Overview of mentalizing exercises
Mentalizing personality Role-playing

Who am I? Observe nonverbal interactions
What makes me “me”? Empathic listening
Understanding moods Replay a difficult interaction
How my mind works Anticipatory role-playing
Identify the falsehood Monitoring and improving mentalizing
Understanding self through other Keep a log
Imaginative/symbolic mentalizing 90–10 reactions
Interpret a photograph Push the pause button
Tell a story Mentalize for better or worse
Draw my mind Mentalizing in family relationships
Mind in music Compare perspectives
Identify with an object The feeling hot-potato game
Find the metaphor The trading places game
Mentalizing interpersonal interactions Mentalizing in mother-infant
and relationships
interactions
Reflect on a key attachment relationship
Understanding distress
Mentalize a scenario: arriving late
Understanding different emotional states
Mentalize a scenario: withdrawing from of the infant
closeness
Quality of attachment task
Just the facts
Emotion regulation and attunement task
Future interactions
Developing a problem formulation
Mentalizing and core issues
Mentalizing: progress on core issues
motivations? What do I think others think of me and feel about me? How do my
thoughts and feelings affect my relationships?
Identify the Falsehood

Each patient is asked to list five or six personality traits, including one that is not true of
him or her. Cleverly embedding a falsehood that is likely to be opaque to others (e.g.,
masked shyness or subtle manipulativeness) requires mentalizing. Having generated
the list, the patient reads it out loud to the group; while the patient remains silent, other
group members try to identify the false characteristic, and they give reasons for their
choice. Group discussion focuses on differences of opinion among group members and
on consistencies and inconsistencies among personality traits within an individual that
obscure or highlight the falsehood.
Understanding Self Through Other

Each group member selects another group member and describes how he or she thinks
that person actually sees him or her. Group members are asked to consider basic aspects
of how people see one another as well as more complex psychological characteristics (e.g.,
smart, capable, caring). The person whose mind is being described is not to comment on
the accuracy until the group has explored the portrayal. When the group has articulated
the description, the person selected is asked to give his or her actual understanding of the
patient. The group discusses how differences in understanding might have developed.
Next, participants can be asked how someone who they think loves or dislikes them sees
them. Then they are asked to characterize how that person would describe them if the
person were in the group now. They are to consider how the person has come to that
opinion and how the patient contributed to the development of that viewpoint.
Imaginative and Symbolic Mentalizing Activities

Interpret a Photograph
A photograph of a person is selected from a magazine. Each participant writes down
1) what atmosphere is communicated by the picture, 2) what the person is feeling, and
3) what the person is trying to communicate. Responses are discussed in relation to the
components of mentalizing. Differences in interpretation among various members of the
group are highlighted, and the reasons for these different interpretations are explored.
Tell a Story
This exercise—one of our favorites—is derived from projective testing, which detects
individual differences through interpretations of ambiguous stimuli. Any stimulus that
lends itself to multiple interpretations could be used, including photographs, drawings,
and paintings. We use stimuli from the Object Relations Technique (Phillipson 1955;
Shaw 2002), which depicts shadowy figures engaged in ambiguous interactions (e.g., a
pair of figures that has been seen as sharing an intimate moment, mourning over the
death of their infant, or after a fight in which one stabbed the other). Patients jot down
a basic plot or brief story about what they see happening in the picture, including the
thoughts and feelings of the characters. We write the gist of each interpretation on a
large blackboard. The leaders highlight individual differences and some common
themes. This discussion shows starkly the subjectivity entailed in interpreting ambig-
uous interpersonal situations; we propose that, analogously, many daily interpersonal
situations can be seen from multiple perspectives. We discuss how individual differ-
ences in current states of mind and past experiences may influence interpretations of
the pictures. Quite often, a patient’s story will reflect something about his or her cur-
rent treatment experience (e.g., a patient near discharge from the hospital might tell a
story about someone who is apprehensive about a new challenge). We sometimes add a
Brief Treatment 171
twist to the task by asking patients to write down how they feel at the moment before we
start the storytelling task. Then, after we have reviewed all stories, we ask patients if
they can connect what they wrote about their state of mind with the story they told.
A set of stories on a blackboard provides a field day for mentalizing. We engage the
group of patients in interpreting selected stories of their choosing. Again, this process
illustrates different perspectives on the meaning of the same story. Patients’ interpre-
tations will vary, depending on how well they know the storyteller. Just as the story tells
something about the mind of the storyteller, the interpretation tells something about
the mind of the interpreter. Often, after hearing others’ interpretations, storytellers are
surprised about the meaning of their stories about which they had been unaware before
the telling (“It just looked like that!”). As with mentalizing more generally, the spirit of
inquisitiveness and curiosity is more important than the content; we state that we are
more interested in the process of interpreting than in finding the “right” interpreta-
tion—which does not exist. We explain to interpreters that their task is to develop a cre-
ative dialogue with the storyteller, such that they are exploring possibilities together,
much like the collaborative spirit that is necessary for successful treatment encounters.
Clearly, patients’ willingness to engage in this reflective, exploratory task is indicative
of their psychological mindedness and capacity to engage in a psychotherapeutic treat-
ment approach. We find that most, but not all, patients dive into this exercise eagerly.
One young man, for example, protested, “This is a bunch of bullshit. It reminds me of
what I hated about English class.” He was not an ideal candidate for expressive psycho-
therapy yet not necessarily a bad candidate for mentalizing. The mentalizing therapist,
crucially without prejudice, takes an interest in the patient’s sense of what is bullshit.
Draw My Mind
In addition to verbal metaphors, patients can be asked to make drawings representing
their state of mind or experience of treatment, and then group members can make in-
ferences about the artist’s state of mind as represented by the drawing.
Mind in Music
Akin to the way we use drawings, we invite patients to bring in a musical excerpt and to
play it for the group (e.g., on a boom box). Group members then brainstorm about
what the musical selection might signify about the patient’s state of mind or experience.
Identify With an Object

Group members are asked to find an object that represents their experience of self, such
as in the two following examples:
Mr. G brought a piece of Plasticine. He related the Plasticine to his progress in treatment
because he felt that he had become more flexible in his thinking. Group members, how-
ever, wondered if he might have a problem in allowing himself to be stretched and
changed in relation to others’ will and demands. Mr. G acknowledged that this problem
occurred in his relationship with his girlfriend. He was able in a later part of the group to
reconsider a planned absence from the group the following week for the purpose of tak-
ing care of his girlfriend’s needs. He now thought that he could attend the group and
spend time with his girlfriend that day. Mr. G was aware of rigidity in his “mentalizing
style.” He noticed that although he was generally more able to consider other people’s
needs, he tended to give priority to his own and others’ needs in a rather black-or-white
fashion. Staff members were aware of his fraught relationship with his mother whom he
often placated or soothed in alternation with venting his own uncontainable frustration
and fears in the family. This group discussion led him to consider a compromise with his
girlfriend as an option.
Ms. K brought a large empty tin of chocolates. She explained that she chose the tin be-
cause it looked colorful and lively on the outside but was empty inside. The group gave
her feedback that, indeed, she looked very nice and was always well-dressed; some mem-
bers went on to remark that they had not noticed that she felt so empty inside. Ms. K was
very surprised to hear that people were not aware of how she felt inside. She realized that
her cover-up was very effective—perhaps too effective. Ms. K became aware that even
though she was using a mask to conceal her inner states, she expected that people would
nonetheless know how she felt. She was able to consider with the group that she was
bound to feel disappointed and neglected by people by presenting a lively persona while
concealing her feelings of emptiness. Ms. K and the group thought about ways of letting
people know how she felt in such a manner that she would be responded to in a support-
ive way.
Find the Metaphor

In a similar vein to the projective stories, patients are asked to think of a metaphor or
simile that exemplifies some aspect of their experience. Patients can be asked to find
metaphors for their current state of mind; their current experience of treatment; or
some facet of the treatment program such as individual psychotherapy, family work, or
clinical rounds. As with the projective stories, simply creating the metaphor requires
mentalizing, and interpreting others’ metaphors—or one’s own—is a further act of
mentalizing. As with stories, others’ interpretations sometimes make patients aware of
meanings they had not considered in generating their metaphors. Metaphors range
from mundane (e.g., “stormy weather”) to idiosyncratic (e.g., “bubbles in a jar with no
lid”). Fruitful metaphors pertain to relationships in the milieu. For example, “gray and
red” symbolized a patient’s argument with her treatment team, after which she felt
numb and then enraged. A patient characterized his depression as being like “the drain
in a roomful of energy,” capturing his fear that he depleted the energy of persons sur-
rounding him. We sometimes ask for metaphors reflecting patients’ hope, examples of
which are “a sliver of sunlight coming in between the window shade and the window
sill,” “a yellow rose growing in the sand,” and “an expanse of ocean with no obstacles.”
Brief Treatment 173
Mentalizing Interpersonal Interactions

Reflect on a Key Attachment Relationship
Participants talk to the whole group about a close relationship and are asked to consider
the following:
• How they and the other person engage in mind reading

• The extent to which they keep each other’s mind in mind
• What motivates each of them
• How their moods affect what each one thinks of the other
• What assumptions each makes about the other
• How each one can be overly imaginative and engage in distorted mentalizing about
what the other thinks and feels
The mantra for the latter part of this discussion is: when in doubt, check it out.
Mentalize a Scenario: Arriving Late

The group is divided into East and West subgroups. They are given this scenario:
Two friends have arranged to meet for a drink, after which they will see a movie. The East
person is 30 minutes late when he arrives at the meeting point. The West person was on
time and waited for 30 minutes.
The East group representative is asked the following: How do you feel about ar-
riving late? What do you think of yourself at this time? What do you think your friend
will be thinking and feeling? How would you likely behave in this situation? What
might you say when you arrive? The West group representative is asked the following:
How do you feel about waiting? What do you think of yourself at this time? What do
you think your friend will be thinking and feeling? How would you likely behave when
your friend arrives? What might you say when he arrives? Other group members are
invited to explore how they might have responded or behaved differently in each of
these roles and to think about the reasons for these differences.
One of the group members, Ms. D, was shocked to realize that her lateness might have
any effect on others. However, she retreated from this insight, claiming that she was “ge-
netically wired up” to be late and that people who knew her did not expect anything dif-
ferent from her. The group challenged this assumption. Yet Ms. D resisted this
challenge, contending that there was no point in acting differently, even if she could, be-
cause any changes would not last anyway. Group members who noted that she was often
late arriving to the group challenged her to arrive on time in the future. Despite protes-
tations, Ms. D arrived on time for each of the following groups. The group warmly wel-
comed her efforts. She subsequently made big strides in the group by virtue of becoming
actively engaged and committed to the group. She reported that pausing and reflecting
helped her to monitor her reactions in times of stress, and she was able to notice her ten-
dency toward paranoid thinking. As the group came to the end, Ms. D indicated that she
wanted to celebrate the end of the group because she had felt like part of a group of peo-
ple and experienced “normal human feelings.” This attitude was distinctly different from
her usual sense of isolation and her expectations that she could not change and would in-
evitably be disappointed.
Mentalize a Scenario: Withdrawing From Closeness

As in the previous exercise, the group is divided into East and West subgroups. They
are given this scenario:
One person in a close relationship has withdrawn from his or her relative, partner, or
friend. The East group represents the person who withdrew, and the West group repre-
sents the partner.
The representative of the East group is asked the following: What sorts of things
made you withdraw? How does withdrawing make you feel about yourself? What are
your thoughts and feelings about the person from whom you withdrew? What are your
thoughts and feelings about yourself in this context? What response do you anticipate?
The representative of the West group is asked the following: What sorts of things will
make someone withdraw from you? How does the withdrawal make you feel about
yourself? What are your thoughts and feelings about the person who withdrew from
you? What are your thoughts and feelings about yourself? What response do you an-
ticipate you will make? Other group members are invited to explore how they might
have responded or behaved differently in each of these roles and to think about the rea-
sons for these differences.
Just the Facts

This task is an extension of the “Who am I?” exercise described earlier, in which pa-
tients describe themselves in terms of facts and then mental states. In the current ex-
ercise, patients are asked to think of a particularly meaningful or emotionally charged
interaction they experienced and to write down a description of that situation contain-
ing only the objective facts—devoid of mental states. For example, a patient stated that
she had been riding in a car with her mother, and then her mother pulled to the side of
the road and insisted that the patient get out of the car, after which her mother drove
away. Patients read their descriptions, and then group members make inferences about
the mental states of all the individuals involved. The patient who presented the facts
then comments on the extent to which others’ inferences fit his or her own experience
and considers the potential validity of other points of view. An example illustrates:
Brief Treatment 175
Ms. A, a 35-year-old professional woman, stated these facts to the group: “I went into
clinical rounds to talk to my team about taking a pass to go shopping, and they told me I
couldn’t go.” Group members first inferred that Ms. A’s primary feeling was one of anger.
They hypothesized that she might feel angry in the context of feeling let down and dis-
appointed. One member suggested that the anger also might be a way of covering up
feeling rather humiliated because she—an adult professional—was being told that she
could not go to a shopping mall. Another group member took the conversation into the
arena of control by suggesting that Ms. A’s anger also might be a reaction to feeling vul-
nerable and impotent.
After further discussion, Ms. A was asked to give feedback to the group. She stated
that the group feedback she had received was accurate, but she had come to recognize an-
other important feeling only in the course of this discussion: she was also relieved that the
team had declined her request. Although she had been making excellent progress, she
was still feeling somewhat unsteady. She was pleased not only that her team had recog-
nized this unsteadiness but also that they were willing to risk her ire and disappointment
in telling her of their concerns (Haslam-Hopwood et al. 2006, p. 264).
Future Interactions
This exercise extends “Just the facts” to a future interaction to evoke what we call
anticipatory mentalizing (as contrasted with mentalizing about current and past experi-
ences). Patients think of a potentially problematic interaction that they anticipate in the
future and write down what the situation will be (e.g., talking to a spouse about filing
for a divorce). After hearing the facts of the patient’s situation, group members antici-
pate possible mental states that the individuals might experience. The exercise is in-
tended to help patients prepare for potentially stressful interactions. The following
account illustrates:
Mr. S, a 47-year-old physician, had been admitted for treatment of depression and ad-
diction to Valium, which he had been self-prescribing. Mr. S told the group that he was
planning to telephone his medical practice partner to inform her about his substance
abuse problems. Initially, the group anticipated that his partner might be angry with Mr.
S for self-prescribing, but the focus quickly shifted to the possibility that her anger might
reflect significant concern for Mr. S’s well-being and health. The group also supposed
that Mr. S would be anxious about making this call, fearing his partner’s anger. Alterna-
tively, another group member suggested that Mr. S might be eager to make the call to
bring his problem out in the open. A group member who knew him quite well anticipated
that Mr. S would be ashamed because he had always placed such a high priority on being
strong and perfect. Another member speculated that Mr. S might feel a sense of accom-
plishment in being able to throw off the mantle of perfection by admitting his faults and
asking his partner for help.
Mr. S reported that the whole discussion was helpful because he had felt stuck in
shame, and the dialogue opened his mind to a wide range of feelings, such that he could ap-
proach the call with an open mind and greater curiosity (Haslam-Hopwood et al. 2006).
Role-Playing Activities
Observe Nonverbal Interactions
This exercise is simple but challenging. We ask two group members to volunteer to sit
in front of the group and to interact for a few minutes without speaking. The volunteers
typically find this difficult to do, and some try to resort to attempts to write notes. After
a brief observation period, the rest of the group members try to infer what each volun-
teer had been thinking and feeling. Sometimes significant relationship patterns are re-
enacted. For example, a young man and woman volunteered, and the group observed
how she made repeated and only falteringly successful efforts to engage his attention,
after which she withdrew and seemed to give up. As she later explained, this brief in-
teraction recapitulated a recent frustrating romantic relationship in which she felt that
she invested more than her boyfriend, who rarely reciprocated; she ultimately gave up
and broke off the relationship.
Empathic Listening
In this simple, therapy-like role-play, one patient is instructed to listen attentively while
another talks about an emotional experience, usually something stressful or disturbing.
The listener then talks about his or her own thoughts and feelings while listening, as
well as his or her understanding of the other person’s experience. The person who
spoke comments on the listener’s understanding and on his or her experience of the in-
teraction.
Replay a Difficult Interaction

In this exercise, a patient volunteers to role-play a stressful interaction he or she re-
cently had with someone, such as a romantic partner or family member. After some dis-
cussion, the individual switches roles to play the other person. After playing the role of
the other party to the interaction, the patient often gains a new perspective on the other
person’s mental states, and such shifts in perspective are the focal point for the discus-
sion. An example illustrates:
Mr. R, a 21-year-old patient, volunteered a recent discussion he had had with his father,
in which he told his father about his plans to return to college following the completion
of his hospital stay. Mr. R reported that his father quickly became intensely angry, telling
him that his plans were “harebrained” and “evidence of how little you have done in treat-
ment.” After the initial role-playing, the group immediately focused on how scared the
father appeared to be, speculating that his anger was covering up his fear that Mr. R
might relapse into depression at college.
After switching roles, Mr. R stated that he felt a keen sense of empathy for his father,
especially in light of the effect that his suicide attempt had had on his father. He reported
that he wanted to call his father again to give him more details about his discharge plans
Brief Treatment 177
and to ask his father about his concerns. Mr. R reported that this new perspective allowed
him to see that his father was not simply trying to control him but rather that his father
likely shared his own fears about life beyond the hospital (Haslam-Hopwood et al. 2006).
Anticipatory Role-Playing
As a variant on the previous exercise of role-playing a difficult interaction, a patient se-
lects a peer to role-play an upcoming interaction that is likely to be challenging (e.g.,
asking a boss for an extended leave of absence from work). As before, the patient plays
both roles, and discussion is directed toward enhancing the patient’s awareness of the
other person’s perspective. Patients report subsequent to the actual stressful interaction
that the role-play helped prepare them to mentalize when the time came.
Monitoring and Improving Mentalizing

Keep a Log
Each patient in the group writes down a specific recent experience in which he or she
had difficulty mentalizing (e.g., being confused about self or others). The group dis-
cusses the problems to provide help with mentalizing. Once they have understood the
idea, patients keep a daily log of mentalizing problems and bring them into the group
each week. Nonmentalizing on the part of others and examples of mentalizing suc-
cesses also can be included.
90–10 Reactions
Patients are introduced to the idea that painful past experiences in relationships can
intensify their emotional reactions to interactions in the present. This is an empathic
way of construing what is more pejoratively described as “overreacting.” We call these
“90–10” responses: 90% of the emotion comes from the past and 10% from the present
(Lewis et al. 2004). For example, a patient who was exposed repeatedly to violent and
sometimes physically dangerous arguments between her parents might become pan-
icky when she hears a couple bickering at a nearby booth in a restaurant. Patients can be
asked to give examples and to keep a record of 90–10 responses over the course of a
week. They also can give examples of mentalizing: being aware of such reactions at the
time such that they could separate the past 90% from the present 10% after a period of
reflection. Such a move from psychic equivalence (equating present states of mind with
past events) is fundamental in recovering from trauma.
Push the Pause Button

Patients are asked to think of an example of behaving impulsively in the face of a strong
emotion or desire; examples might include self-injurious behavior, reckless actions, or
substance abuse. Then they are asked to give an example of “pushing the pause button”
by mentalizing, which enabled them to refrain from acting on the impulse. They might
be asked to address questions such as the following: What made you impulsive at the
time? If you had acted on your impulse, what would have happened? What stopped you
from acting? How did this help? What did you do instead? What were the conse-
quences of this, and how did you feel about yourself? An example illustrates:
Ms. I reported that she felt really good because she had used the “push the pause button”
technique, and it had worked. She pushed the pause button in an interaction with her
boyfriend. In an earlier group, Ms. I had told the group members that she needed to
think about the way that she interprets her boyfriend’s behavior. Mentalizing, she real-
ized that she needed to see him for who he is rather than confusing him with someone
else from her past.
Ms. I recounted an incident when her boyfriend had returned home late with his
friends. He had been irritable toward her, blaming her for various things. Rather than be-
having in her usual way—feeling blamed and worthless, crying, shouting, throwing
blame back at him, and so forth—she put herself on pause and thought that her boy-
friend’s irritation was not about her or what she had or had not done, but rather that his
behavior was a reflection of his own state of mind. She decided not to react and instead let
him know that she did not want to get involved in his irritation. He left, and she stayed
alone, writing about what she thought was going on. He later returned much calmer, and
they were able to have a blame-free time.
The group reflected on this sequence of events step-by-step, comparing Ms. I’s old
way with her new way. The main discussion points included keeping in mind the distinc-
tion between Ms. I’s mind and her boyfriend’s mind; not assuming that Ms. I was at fault
as she had felt in the past; not taking the blame for others’ abusive behavior; being aware
that how she feels about herself has an effect on how she thinks about herself and vice
versa; and recognizing that when she behaves aggressively, she feels worthless, and in
turn, when she feels worthless, she is liable to cope by engaging in self-harm.
Ms. I realized that her traumatizing experiences as a child had left her vulnerable,
whereas being able to mentalize made her feel strong. She had found a space in herself to
think about self and others in the here and now, as potentially problematic interactions
were unfolding. She was in the process of becoming able to see the present for what it is
rather than being overwhelmed by other people who in the past had been unpredictable,
deceptive, and threatening to her survival. Ms. I’s ability to mentalize in the heat of the
moment in a key attachment relationship reflects what we consider to be the “gold stan-
dard” of mentalizing, a point that we routinely acknowledge when we observe it.
Mentalize for Better or Worse

As depicted in Table 7–2, patients are asked to think of a specific relationship and
situation that presented challenges to mentalizing. In “usual mentalizing,” they indi-
cate their actual or ordinary mentalizing (what they thought and felt and what they be-
lieved the other person thought and felt). Next, in “new and improved mentalizing,”
they try to expand and enrich their self-awareness (e.g., what else they might have felt
that they were not aware of) and imagine other possibilities regarding the other per-
Brief Treatment 179
TABLE 7–2. Structure of “mentalizing for better or worse” exercise
New and
Usual improved Impaired
mentalizing mentalizing mentalizing
Self I think:
I feel:
Other He or she thinks:
He or she feels:
son’s thoughts and feelings. Finally, in “impaired mentalizing,” they indicate how their
mentalizing capacity can break down in the face of difficulties (e.g., strong emotions
such as anger).
Mentalizing in Family Relationships

Compare Perspectives
As depicted in Table 7–3, participants first answer a series of questions about them-
selves, starting with “How do I feel about myself?” First, the group members answer
the questions from the standpoint of the thoughts and feelings they have about them-
selves. Then they are asked to answer the same questions from the standpoints of family
members—father, mother, and siblings. That is, if my father were answering this ques-
tion about himself, how would he answer it? Some patients may be able to deal with such
questions about themselves to some degree but find themselves at a loss to get into the
mind of a family member. At first, they may confuse the task and perceive that they are
supposed to judge how the family member feels about the patient. When they finally
understand the nature of the task, they might realize they do not really know their own
family members as separate people at all. They have trouble, and little experience, men-
talizing about the inner life of others, even those whom they have known for years.
They are almost entirely self-focused. On the contrary, some patients have the opposite
pattern. They avoid dealing with their own inner life on any meaningful level and focus
exclusively on others. Their answers sometimes suggest enmeshment or codepen-
dency.
The Feeling Hot-Potato Game

Fearon et al. (2006) described this exercise used in Mentalization-Based Family Ther-
apy (see Asen and Fonagy, Chapter 5 in this volume). The names of basic emotions
(e.g., scared, angry/mad, happy, sad) are written on different cards. The child goes
through the set of cards, one by one, and models how he or she expresses the particular
emotion in facial expressions (e.g., curling the lower lip) or in action (e.g., stomping
around). Each adult then mirrors the child’s expression of the emotion, receiving feed-
back from the child. When all emotions have been covered, the exercise begins in ear-
nest. The child throws a ball to someone in the room and calls out an emotion. The
catcher must reproduce the emotion to the child’s satisfaction before throwing the ball
to the next person, who must reproduce another emotion that is called out, and so
forth. At each turn, the child must judge that the emotional expression is adequate be-
fore the ball can be passed on. The exercise can be repeated for any or all other family
members’ expressions of the emotions. The exercise can be fun for the family and also
provides an opportunity for each family member to be more attentive to others’ emo-
tions as well as differences among them in the way they express various emotions.
The Trading Places Game

In this exercise (Fearon et al. 2006), parents imagine how their child might think and feel
in various situations chosen by the child (e.g., taking a test at school, going to bed, doing
chores). The parent then takes the role of the child, expressing thoughts and feelings as-
sociated with being in the situation. The child acts as a coach, letting the parent know the
extent to which he or she is getting it right (“colder” or “warmer”). The child can help
guide the parent as to what to think, say, and feel. In addition to helping parents recognize
what they do and do not know about how their child thinks and feels, the exercise pro-
vides the child with an opportunity to be in a position of authority about his or her mental
states; moreover, it provides children with the experience of their parents learning new
things about them.
Mentalizing in Parents With Personality Disorder

and Their Children
The success of the family program has stimulated interest in parents and carers who
themselves have mentalizing problems and the effect that these difficulties may have on
their children. Several programs have been developed that focus on the parents’ capac-
ity to mentalize during their interactions with their children. Psychoeducational exer-
cises are commonly used in the initial stages of treatment. Information about
mentalizing is provided at the beginning of the exercises with an emphasis on attach-
ment and development. Parents are often fascinated by ideas about child development,
particularly the idea that the child’s mind develops through the mind of the mother—
that how she sees and thinks and feels about the child has an influence on how the child
actually feels.
The aim of programs for parents with personality disorder and their children is to
enhance the attachment relationship and to improve life-course outcomes for both par-
ents and children within vulnerable young families. Families and parents at risk, such as
those with poor social support, trauma histories, and a history of childhood neglect, are
Brief Treatment 181
TABLE 7–3. Mentalizing family members: structure of the “compare perspectives”

exercise
Mother or female Father or male Sibling or

Me parental figure parental figure siblings
How do I feel about
myself?
How do I feel about
this hospitalization?
What makes me
happy?
What makes me
unhappy?
What problems do
I have with other
family members?
What aspirations do
I have for myself?
What fears or
struggles do I have?
What regrets do I
have?
What is it that I can’t
say out loud?
targeted because research suggests that parents and children with markedly disrupted
attachment relationships are most at risk over the long term.
Mothers with borderline personality disorder, for whom mother and infant pro-
grams have been developed in the United Kingdom, may have limited capacities to un-
derstand the mental processes of their children and tend to experience the child as
creating states in them “deliberately.” They may misconstrue the child’s motivation,
basing it on their own experience rather than focusing on the child’s experience: “He
just tries to upset me”; “He is a bad sort, making sure I don’t have any time for myself”;
“He’s just like his father—wants you to feel guilty.” Exemplary exercises involve under-
standing distress, understanding different emotional states of the infant, describing
quality of attachment, and examining attunement to the child’s emotional states.
Understanding Distress
Mothers are asked to imagine their young infant and think about when he or she gets
upset and cries. First, they are asked to think about what their infant looks like when
upset; for example, arms and legs waving, screaming, red-faced, getting hotter, unable
to keep still. Second, the mothers are asked to consider not so much what is wrong with
the infant but what is the best thing to do at this point. Do they ask themselves if the in-
fant wants contact with them? Is it correct that the sooner the response, the quicker the
infant is soothed, and if so, why? How do we know when an infant is soothed? The pa-
tients are asked to describe detailed features of their infant when contented, including
vocal and visual indicators. A soothed infant often lies still, gazing calmly at the care-
giver. How is this gaze returned by the mother? The therapist may discuss the idea that
the way the gaze is returned helps the infant learn about what soothing feels like;
mother and infant have a nice feeling between them, begin to feel “happier,” and smile
together.
The patients are then asked to discuss their own feelings when their infant is dis-
tressed and what happens to those feelings when the infant is calm. This allows mothers
to consider their own emotional states, to value them, and to take them into account as
part of the information to use when trying to understand what might be causing distress
in the infant.
Understanding Different Emotional States of the Infant

The mothers are asked to discuss further what happens if their infant is not soothed by
their interaction: Is there is anything they can do? Discussion usually centers around
how a distressed infant, left to cry, will become increasingly upset. This can become un-
bearable for the mother. Some mothers may describe how the infant becomes quiet if
ignored. The reasons for this are discussed: Is it possible that the infant gives up, re-
signed to a nonresponsive caregiver? Is the infant learning independence? Is a quiet in-
fant a content infant? The patients discuss the infant’s possible states of mind. The aim
is to highlight that the same state—in this case, quietness—might mean many different
things about the emotional state and experience of the infant.
Finally, the patients discuss their own feelings about the crying infant who be-
comes quiet without intervention. The group leader asks them to try to identify and to
label their feelings and to describe them in detail, perhaps describing other times when
they have had a similar feeling.
Quality of Attachment Task

This task is not simply about what attachment relationships are but about the quality of
attachment relationships. Mothers are asked to describe the quality of their relation-
ship with their child. The group leader often has to outline what is meant by this: Is the
relationship gentle and loving? Is it more distant and functional? Is it warm or cold? Is
the child independent, clingy, fractious, and so on? How does the mother manage these
aspects of the relationship? Participants are asked to describe a recent interaction to il-
lustrate their description. This can then be discussed from the perspective of the child
and the mother. It is important that the group does not come to believe that one type of
Brief Treatment 183
relationship is better than another; they should realize that the interaction between
mother and infant is important and that both mother and infant influence this process.
Many mothers naturally wish to ensure that their child experiences a better quality of
attachment relationship than they themselves believe they experienced. How this wish
can be realized is explored, and the therapist establishes a discussion about the impor-
tance of both the emotional and the physical needs of the child. An ever-increasing sup-
ply of material comforts and playthings is not the primary way of improving the
attachment relationship. This is realized more through the emotional reciprocity be-
tween the mother and the infant and the mother’s focus on the infant’s mental pro-
cesses.
Emotion Regulation and Attunement Task

The group discusses what is meant by attunement. The therapist begins by talking
about the reciprocity of emotional interaction between mother and infant. The sim-
plest focus is discussing how the mothers manage a physical state such as tiredness. The
participants are asked to describe how they know their child is tired: How did you help
your child manage his or her tiredness? Parents differentiate between their own fatigue
and the infant’s. The group discussion can move to differentiating more complex emo-
tions. The parent has to be in tune with the child’s needs and should not assume that the
feelings the parent has are those of the child.
Developing a Problem Formulation

Many psychiatric patients who come for intensive or extended treatment (e.g., specialty
inpatient programs, residential treatment, and partial hospitalization services) have had
extensive previous treatment, including years of psychotherapy, brief hospitalizations,
and innumerable medication trials. They decide to undertake more comprehensive
treatment because they have had problems making or sustaining progress with these
previous treatments. Often, they feel “stuck.” Yet they do not necessarily approach this
new treatment opportunity eagerly. They feel confused and demoralized, and they are
often resentful at having to face the confines and restrictions of treatment, which they
may have been coerced into accepting by clinicians and family members. To make use
of this opportunity, patients must be helped to engage in a mentalizing process that fa-
cilitates collaborative exploration of problems that have impeded successful treatment.
In part, this mentalizing process is directed toward a narrative problem formulation,
and this formulation, always a work in progress (see Table 7–4), becomes a central part
of the mentalizing process.
Plakun (2006) included the development of a formulation as one of the common
factors across psychotherapies. A comprehensive formulation is a significant compo-
nent of long-term MBT. Bateman and Fonagy (2006a) recommended that the individ-
ual therapist develop a written formulation in collaboration with the patient and the
treatment team. This formulation is provided to the patient for comment and refine-
ment. The formulation models the mentalizing approach and organizes thinking for
the patient and therapist while also providing a focus on clearly stated goals. The for-
mulation also makes explicit links to aspects of treatment that will help the patient
reach the goals. It addresses beliefs about the self and their relation to internal states
and construes the patient’s current concerns in relational terms. It also makes reference
to historical factors that place current concerns in a developmental context. It includes
commentary on both strengths and weaknesses in mentalizing and anticipates problems
that might arise in individual and group treatment. Periodic reviews of treatment
progress (e.g., every 3 months) include reformulations as a basis for ongoing treatment.
(For examples of comprehensive mentalizing formulations, see Allen et al. 2008, pp. 172–
175; Bateman and Fonagy 2006a, pp. 50–52.)
Lemma et al. (2011) are developing a form of brief (16-session) individual psycho-
therapy, Dynamic Interpersonal Therapy (DIT), which integrates a mentalizing focus
with aspects of attachment theory, object relations theory, and interpersonal psycho-
analysis. Central to DIT is the identification of an interpersonal-affective focus that guides
the therapy throughout. This interpersonal-affective focus encapsulates one dominant,
unconscious interpersonal pattern organized around a self-representation, object rep-
resentation, and characteristic affect. In the collaborative spirit of mentalizing, the for-
mulation must be meaningful to the patient in relation to current concerns. It is
mutually negotiated in the initial phase of treatment, with the patient participating ac-
tively in the process. Also in the spirit of mentalizing, the formulation remains a work-
ing hypothesis, which will be revised in accordance with an evolving understanding.
For example, after the first three sessions, the therapist might sum up his or her ob-
servations as follows:
The patient seems preoccupied by how others—including the therapist—see her (e.g., as
boring). In the face of this preoccupation, she loses her capacity to think and becomes
panicky; moreover, her preoccupation and panic are fueled by a running internal con-
versation in which she feels continually berated and unable to stand up to her own self-
berating.
This formulation illustrates how a symptom—anxiety or panic—can be placed in an in-

terpersonal context that is played out in attachment relationships, including the trans-
ference. This interpersonal conflict also has an intrapsychic parallel in the internal
conversation. Childhood origins are explored to clarify and illuminate the core prob-
lem, but the primary focus remains on current enactments. At the end of DIT, the ther-
apist provides the patient with a one-page “good-bye letter,” which includes the last
iteration of the interpersonal-affective focus, the problems encountered, the progress
made, and the problems outstanding.
Therapists have innumerable ways to develop and explicate a more or less elabo-
rate focus for treatment. All of these will test the mentalizing capacity of both therapist
Brief Treatment 185
TABLE 7–4. A mentalizing formulation
• Should be developed collaboratively between patient and therapist

• Is considered as a work in progress rather than a final document
• Models the mentalizing approach
• Organizes thinking for the patient and therapist
• Provides a focus on clearly stated goals
• Makes explicit links to components of treatment
• Addresses beliefs the patient has about himself or herself
• Construes the patient’s current concerns in relational terms
• Places current concerns in a developmental context
• Highlights strengths and weaknesses in mentalizing
• Anticipates problems that might arise in individual and group treatment
and patient. The spirit is more important than any particular protocol, and we are con-
tinually experimenting with ways of engaging patients in developing a useful problem
formulation in both group and individual therapies.
Working Toward Formulations in Group Contexts

Mentalizing and Core Issues
As a prompt to formulating a problem focus in group contexts, we use the group exer-
cise “Mentalizing and Core Issues.” Patients are asked first to list the reasons for their
admission—that is, their presenting complaints. Then they produce a statement about
how previous attempts at treatment have led to their feeling “stuck.” Finally, patients
are asked to speculate about “core issues”—that is, those processes or problems that
have made progress in treatment difficult. In short, what has gotten in the way?
Ms. N, who reported feeling depressed and hopeless, acknowledged that she tended to ig-
nore or resist others’ attempts to help her. After some reflection, Ms. N reported that al-
though her dark depression was “awful,” depression was a “comfortable,” familiar
experience. In contrast, she feared that if she worked to find a path to greater happiness, she
might get her hopes up only to have them dashed, and the prospect of such disappointment
seemed much worse than remaining depressed.
The group leaders then asked Ms. N and other group members what a treatment
plan for this dilemma might involve. After some discussion, Ms. N agreed with the group
that finding a way to take very small risks would be a place to start. In the course of this
discussion, Ms. N and the group were able to redefine her problem from one of “resisting
treatment” (a pejorative and blaming position) to a more specific problem related to her
fear of disappointment, which led to a pathway for approaching that problem area con-
structively.
Mr. C’s experience also illustrates the process of identifying core issues:
Mr. C, a young male patient with a history of depression, anxiety, and explosive anger, re-
ported that his relationship with his father was strongly affected by his father’s aggressive
and abusive nature. Mr. C acknowledged that he had mixed feelings about becoming less
aggressive because he thought that his aggression protected him from being victimized
by others. Mr. C had previously avoided real engagement in treatment because he feared
that he would be forced to experience and express feelings that would render him vul-
nerable and weak. He had recently come to understand that he had pushed people away
by being a bully, and he no longer wanted to be isolated. Group members pointed out
how much fun Mr. C was to be around when he wasn’t being intimidating. They also
questioned his assumptions about how others would react to a more emotionally sensi-
tive presentation. Mr. C talked about how hard it was to move forward without a model
for a strong, sensitive man in his past to show him the way. Some of the group members
empathized with the experience of missing affectionate parents and its effects on them,
including the behavior patterns they developed toward others as a result of lacking pos-
itive parental models.
Ms. O’s report about a visit to her mother further illustrates how a mentalizing
group can assist with problem formulation:
As usual, Ms. O had been very attentive to her mother’s needs, yet despite her efforts, she
felt dismissed by her mother. Ms. O used a mentalizing stance and was careful to not
overreact emotionally; nonetheless, she felt that the situation was hopeless because she
could never get things right with her mother. Ms. O reported that she had always felt
careful around her mother, but her cautiousness increased considerably after the acci-
dental death of Ms. O’s older brother some years ago. The group advocated that Ms. O
think more about her own needs, but she ignored this suggestion, and a group leader
made note of her doing so. Ms. O then explained that she tended to care for others a lot
while feeling shortchanged and resentful in doing so. The group took up this issue and
imagined what might maintain such behavior. Some ideas included wanting to feel use-
ful, wanting to be in control, and questions about the possible advantages of feeling re-
jected. One group member wondered what it would be like for Ms. O to value her own
life and desires in the context of her brother’s death. Ms. O connected this inquiry to her
survivor guilt along with her sense that her mother begrudged Ms. O’s being alive. This
was a very painful moment for all group members. The leaders drew Ms. O’s attention
back to her response to the group’s suggestion that she needed to give greater consider-
ation to her own needs. Ms. O responded that she did not generally think about what she
needed, although she often felt overwhelmed and sometimes felt desperate to receive
caring treatment from others. Other group members related to Ms. O’s experience, and
there was general agreement that desperate states tended to drive others away, so that
persons in desperation rarely found the support they were seeking. Ms. O and others
Brief Treatment 187
thought that being more attentive to one’s needs and expressing them sooner rather than
later was likely to be more effective in meeting the needs.
Mentalizing: Progress on Core Issues

Another group exercise, “Mentalizing: Progress on Core Issues,” requires patients to
begin by completing a worksheet on which they list a few core problems that they are
working on in their current stage of treatment. Then they answer several questions
about each problem: What am I actually doing to make progress on this problem?
Where do I need to be with this problem by the time I leave the treatment program?
Whom do I talk with about this core problem? What important problems am I not ad-
dressing? In completing this worksheet, patients are explicitly encouraged to consider
how they are making use of various aspects of treatment, including individual and
group therapy, meetings with members of their treatment team, and more informal
contacts with their peers.
Ms. Y, a young woman, identified herself as a “preacher’s kid.” She presented with a his-
tory of depression (associated with low self-esteem), anxiety, and substance abuse. In
completing this exercise, Ms. Y recognized that she blamed herself severely for past mis-
takes and that she tended to ruminate about these errors of judgment. She worried in-
cessantly about things over which she had no control, and she felt that she had failed to
live up to the standards of her parents and their church congregation. Ms. Y recognized
experiences in her past that she had never been able to discuss. Without prying into the
details of these experiences, the group members engaged Ms. Y in a discussion about
what prevented her from addressing these matters from her past. Trusting that the group
was striving to mentalize with her, she acknowledged that shame and humiliation played
a large part in her struggles to think about and communicate with others about her past
experiences. She connected her reluctance to work on these problems with her fear of
disappointing her religious parents. The group process then focused on separating the
assumptions she made about her parents’ expectations from others’ potentially more ac-
cepting views.
Developing Formulations in
Individual Psychotherapy
The development of a useful formulation depends on establishing a relationship cli-
mate conducive to mentalizing. Therapists require patients’ help in arriving at a for-
mulation. Questions and clarifications serve not only to provide information but also to
create an atmosphere of thinking together, elucidating ideas for consideration, and
evaluating them together as a team. The therapist’s transparency is crucial to this col-
laboration, as the use of silence illustrates. It is not uncommon for a therapist to sit in si-
lence and wait for the patient to produce something for discussion. The therapist
passively communicates such an expectation by simply remaining silent. Often, patients
experience this behavior quite negatively. They may see the silence as withholding on
the therapist’s part, or they may feel pressure to produce and become anxious lest they
fail to come up with anything significant. Interpreting the basis of the patient’s reac-
tions is liable to impede the process, at worst creating an atmosphere of a judge (the
therapist) and a defendant (the patient). An alternative approach might be as follows:
Perhaps it is an early session in the course of treatment, and, striving to focus the treat-
ment, the therapist has been asking questions and clarifying issues. Then the therapist is
silent. The therapist senses the patient’s discomfort, which the patient confirms. The
therapist then offers to explain his or her reasons for sometimes remaining silent. “Some-
times I, myself, may not think of anything to say. But usually I want to make sure that we
are discussing issues that are relevant to you. So, I take a break from talking to allow you
to gather your own thoughts and raise whatever else might be on your mind—perhaps
something I hadn’t thought of that may be important to our understanding of what is go-
ing on with you.”
Promoting an open dialogue about what is on each participant’s mind is conducive

to developing the sense of trust that will enable patients to address core concerns and
ambivalence about change that keep them stuck.
Ms. E was a patient with a history of severe depression and unrelenting nonsuicidal self-
injury (i.e., self-cutting). She had been interpersonally isolated and alone. She was also
intensely self-deprecating, often blaming herself for others’ troubles, especially those of
her parents. Ms. E was dismissive of the potential value of psychotherapy but attended
her sessions faithfully. She proclaimed that therapy would not stop her from cutting. The
therapist engaged her by stating his position: he, like any other therapist, would like to
help her refrain from injuring herself. He acknowledged that she had not felt helped by
psychotherapy. He stated that he would simply ask her to talk with him and express her
thoughts and feelings as authentically as she could.
Ms. E began to tell the therapist about the emotional and physical abuse she suffered
at the hands of her mother when she was a little girl. She reported that several years ago,
her mother stopped being abusive for some unknown reason and had since become more
caring and friendly. The therapist asked for Ms. E’s help in understanding how her self-
cutting might be connected to her relationship with her mother. Ms. E allowed the ther-
apist to help her sort this out, and they discovered that Ms. E harbored deep resentment
about the early abuse and also resented her father for failing to intervene. Yet she was ter-
rified to express any of these feelings to her parents for fear that her mother might re-
taliate and return to being abusive. Ms. E finally acknowledged that whenever she was
angry at anyone, she blamed herself for the trouble and engaged in cutting to punish her-
self. This formulation enabled Ms. E to grapple with the dilemma that she faced: the di-
lemma of wanting a “real” relationship with her mother while simultaneously feeling
afraid to express her all-too-real feelings of resentment. Over time, Ms. E and her
mother were able to discuss Ms. E’s resentment openly, and her self-cutting diminished.
Brief Treatment 189
When a mentalizing climate conducive to collaboration has been established, work

on the patient’s core problems may nevertheless not always go in the direction the ther-
apist intends. Mentalizing in psychotherapy is a reciprocal process; hence the therapist
also must be open to the patient’s influence. For example:
Mr. F, a young man in his mid-20s, was admitted to the hospital with problems of de-
pression, low self-esteem, social anxiety, withdrawal, isolation, and suicidal behavior. He
informed the therapist that he was sexually abused by an elderly female relative when he
was 3 years old. His father committed suicide when he was 12. Mr. F could not remember
anything from the intervening years. He was tortured by feelings that he had been
stained by the early sexual abuse; in addition, Mr. F had concluded that he had not been
able to provide his father with a reason to continue living because he was such a disap-
pointment to him.
Fairly late in Mr. F’s 8-week course of treatment, the therapist asked him if his mother
had any photographs of Mr. F and his father together. The therapist thought that viewing
such photographs together might evoke helpful memories and also serve as evidence of his
father’s affection. Accordingly, the therapist suggested that Mr. F ask his mother to bring
her photographs on her next visit. To the therapist’s surprise, Mr. F was not warm to the
idea. He had learned to bring his own ideas to the table, and he responded, “Why do you
think I have never looked at those photographs? I don’t want to open up a wound that I
won’t have time to close.” Mr. F elaborated that he did not want to see his father’s love de-
picted in a photograph and then have to grieve the loss of him in the short amount of time
remaining to work with the therapist. This encounter led to more exploration of the losses
in Mr. F’s life, including the one to come with the therapist.
As we noted in the group context, the process of arriving at a conjoint formulation

can be structured by inviting the patient to do some writing, a process that also can be
incorporated into individual psychotherapy. The senior author (J.G.A.), for example,
asks patients to provide brief answers to a few questions, with the following guidelines:
I find that we can accomplish more in the relatively brief time frame for individual psy-
chotherapy if we can agree on a central focus for therapy—that is, a written formulation
of the main problems we are working on. I also find that coming up with a focus and for-
mulation of the main problems is not necessarily easy. This is an example of a task that re-
quires “mentalizing,” by which we mean being aware of your own thoughts and feelings
as well as the thoughts and feelings of others. Because the problems that typically bring
people to treatment include not only difficulties within the individual but also conflicts in
key relationships, we rely on mentalizing of both self and others to clarify these problems
and to work on them. As a starting point for our work in finding a focus, I would appre-
ciate your answering several questions on the back of this sheet. After we have had a
chance to go over this and work together, I will write up a draft of a formulation that we
can continue to refine together over the course of the psychotherapy.
The questions then asked are as follows:
• What are the main problems that you would like help with?
• What would you like to change about yourself?
• What has kept you stuck or prevented you from making progress?
• Is there some problem or conflict you have not been facing or dealing with?
• If you achieved your goals in therapy, what would you be doing differently?
• What gives you hope?
The intent of this exercise is not to identify the correct formulation but rather to
engage the patient in reflection and collaborative dialogue. The therapist incorporates
the patient’s thoughts into the formulation and then asks for the patient’s help in refin-
ing and revising the formulation. For example:
Ms. H presented a relatively clear problem in the first two sessions of therapy. A highly
competitive physician, she had worked in her father’s medical practice for more than two
decades, counting on taking over the practice when he retired. She was convinced that a
major reorganization was needed and felt frustrated and resentful that her aging father
would not relinquish control. Moreover, she longed for her father’s esteem and instead
felt belittled and devalued by her father’s continual scrutiny of the care she was providing
for her patients. Ms. H’s main concern related to her awareness that she took out her
frustration with her father on her husband and children: as her father did to her, she tried
to “manage” her family by being obsessively critical and controlling. Her husband had
begun to contemplate divorce, in part for the children’s sake.
Ms. H brought her answers to the worksheet to the third session. Given her prom-
inent relationship problems, the therapist was surprised by her response to the first ques-
tion (“What are the main problems that you would like help with?”): “to be at peace with
myself.” This prompted the therapist to address with Ms. H the extent to which her frus-
tration with her father was painful in part because Ms. H felt like a failure in relation to
her own expectations and standards. This enabled Ms. H to focus on something over
which she would have more influence (i.e., her own expectations as contrasted with her
father’s actions).
A Note on Process and Content

We have emphasized that we prioritize mentalizing process over any particular mental
content. We have argued that the effectiveness of any psychotherapeutic treatment
hinges on a conjoint mentalizing stance. Yet brief treatments also place a premium on
a specific focus in relation to a formulation of a core problem that has kept the patient
stuck. Thus, we cannot give short shrift to content. To some degree, patient and ther-
apist must “get it right” for the therapy to be beneficial. Mentalizing is an art (Allen et
al. 2008), and developing a useful formulation requires mentalizing talent. Although
some structure might be imposed on the process, no algorithm is available for finding
Brief Treatment 191
the proper focus. Our focus on mentalizing is intended merely to increase the odds of
the patient and therapist conjointly getting it right.
Mentalizing Challenges for Clinicians

Like their patients, clinicians can be vulnerable to compromised mentalizing, which
then derails their central task: helping patients to make sense of their minds when they
are having trouble doing so.
Therapists might hope to be more resilient and more able to cope flexibly com-
pared with their patients. However, even if this were true, therapists are not immune to
attacks on their own mental functioning, which occur most prominently through the
experience of intense anxiety. One way in which therapists might seek to protect them-
selves is by relying on technical knowledge and treatment structure—sometimes at the
expense of the primary task, which is to keep mind in mind whatever the setting, modal-
ity, or agenda: group or individual, exploratory or psychoeducational, formal or infor-
mal. The ability to mentalize is continually tested, and the sources of anxiety are many:
anxiety about being able to inspire patients to join in the task of the therapy, anxiety
about applying the model according to manualized instructions, and anxiety about be-
ing seen to do well in the eyes of colleagues and supervisors. Moreover, patients’ ex-
pressions of intense affects associated with their conflicts with therapists and with one
another in groups are liable to derail mentalizing when therapists most need it.
In this section, we give some examples of group leaders’ mentalizing going awry.
We begin with the paradox of placing the “not-knowing” therapist in the expert role as
group leader and then discuss the need to keep multiple perspectives in mind as well as
challenges to maintaining the not-knowing stance. We conclude with the implied the-
sis of this section: namely, that patients and therapists are in the same boat, insofar as
both need to mentalize in the face of challenges.
Dealing With the Expert/Student Paradox

A mentalizing therapeutic process is predicated on keeping the therapist out of the “ex-
pert” mind reader role and developing a collaboration in which the therapist and the
patient conjointly explore mental states with an open-minded attitude. Yet most con-
spicuously in psychoeducational groups, the therapist is cast in the expert teacher role.
Maintaining the mentalizing stance in the context of this role can be a challenge, po-
tentially complicated by the fact that leaders can feel anxious about their level of ex-
pertise. As always, individual differences loom large: clinicians interpret treatment
manuals in their own way and will extract different things from various training work-
shops, so a new psychoeducational group or service will bear the individual stamp of the
leader. Introducing the treatment approach to patients can be done in various formats,
ranging from face-to-face discussion to PowerPoint presentations to the handing out
of written materials. Regardless of format, such presentations will convey the under-
standing of mentalizing and describe the aims, objectives, and rules of the group or
treatment programs. Any such teaching aids to pass on information to the participants
are useful as a means of engaging thinking, yet they all put the leader in the expert role.
To reiterate, staff members and patients are vulnerable to losing mentalizing in the
face of anxiety. Yet anxiety is inevitable, and clinicians can cope with their anxiety in
ways that undermine mentalizing in the group. For example, patients might criticize
something about the leaders (e.g., their age, gender, or training) or complain about the
group (e.g., that patients are being labeled and categorized). Such criticism might cause
the leader to feel attacked and become defensive. The leader might go wrong in two
general directions. On the one hand, the leader might overdo the structure, becoming
rigidly attached to the agenda and failing to convey anything except perhaps a deter-
mination to convince the patient of the correctness of the leader’s point of view. On the
other hand, the leader might let the group take over and lose the structure altogether.
In either case, the group loses the sense of a containing and safe environment within
which to explore thinking and feeling. Either situation may leave the patients feeling
abandoned and liable to become overwhelmed with the feeling of having done some-
thing wrong—just as the staff also might feel. At worst, patients can become defensive
and antagonistic, and staff members may become depressed and demoralized about
their ability to cope and to do something useful.
Ideally, when confronted by patients, the leader will use the criticism as an oppor-
tunity to mentalize and weave the comment into the structured agenda. For example, if
a patient protests, “This is just common sense, and I can’t see anything special to it!” the
leader might reply that the patient seems to be understanding perfectly and that they
might call this “commonsense therapy,” perhaps quipping that achieving common
sense is a high aspiration in the mental health field. This comment also could lead into
a discussion of how mentalizing is promoted in development by the common sense (and
intuition) reflected in good parenting, as we discussed in the mentalizing education
curriculum. In this context, we make the further developmental point that good ther-
apists aspire to do what good parents do naturally. If a group member questions the
leader’s training or experience, this challenge can be explicated as an occasion for men-
talizing—namely, exploring the patient’s assumptions and anxieties about the leader
and the leader’s experience of being challenged. Admittedly, to use old-fashioned lan-
guage, such exploration takes ego strength on the part of the leader.
Holding Multiple Perspectives in Mind

In a session devoted to introducing the program to a group of patients, a brief Power-
Point presentation might be followed by an exercise. For example, the leaders might
ask the group members to imagine what being in the group would feel like. Group
members may do this task individually by writing their thoughts down, or they might
work in pairs or small groups before reporting back to the whole group. When a group
Brief Treatment 193
is struggling with the exercise, staff members might facilitate exploration by disclosing
something about their own thoughts and feelings about being in the group (e.g., their
wish to get things right and their fear of getting them wrong). We try to help several pa-
tients articulate their views to the group, with the hope that a range of different per-
spectives will emerge. As with all group exercises discussed earlier in this chapter, the
group leaders strive to maintain a group spirit that is nonjudgmental and accepting of
different points of view as well as curious about the reasons for such differences.
The following example of starting a group in a new service illustrates how the men-
talizing agenda can go awry:
The psychoeducational group was settling in and had just received news that another
group of new patients would be joining their group in a few weeks’ time. The group was
asked to look at a photograph and to imagine what the person in the photograph was
thinking (a photograph of Tony Blair was shown). A patient launched into a complaint
about Mr. Blair, contending that he allowed too many asylum seekers into the United
Kingdom, when safety and closing ranks would have been a better option. One of the
group leaders feared that the patient’s view might be experienced as an attack on ethnic
minority patients in the group, and the leader questioned the patient’s view. The patient
immediately felt exposed and denied any racist intentions.
A dynamic understanding of the patient who criticized Blair’s policies might in-
clude some understanding of the threat that the patient experienced in relation to the
potential intrusion of new members into the group, coupled with a wish to settle com-
fortably into the group and put up a metaphorical “Do not disturb” sign. A therapist
working within the mentalizing stance would not interpret this potentially unconscious
meaning but rather would keep this possibility in mind in a way that might help to con-
tain the conflicts that present themselves in the group.
In the face of such a challenge, the task is to continue with the agenda. Other pa-
tients are invited to share their own thoughts about the photograph. Differences
among patients are highlighted with the understanding that each person’s view has its
own validity and meaning. Further exploration of the variety of perspectives will po-
tentially uncover rich material related to each patient’s experience in the here and now
and in the past. Group leaders may or may not connect patients’ responses to the pros-
pect of newcomers joining the group in the future. Ideally, the group members them-
selves might make these links as the group facilitates elaboration of thinking.
Maintaining the Not-Knowing Stance in the

Face of Misunderstandings
A central facet of mentalizing is understanding misunderstandings. Yet misunderstand-
ings are liable to lead instead to defensive maneuvers on the part of patients and staff
members alike. As emotions become heated and opinions polarized, mentalizing can col-
lapse, and the group’s functioning can deteriorate. For example:
At the beginning of one group, the well-meaning therapist invited group members to
identify their problems so that the group could work with them. One group member, Ms.
T, responded by citing her difficulties coping with a range of stressors: her children’s de-
mands, her unforgiving partner’s relentless criticism, and having to participate in this de-
manding treatment program to boot. Another patient, Ms. M, turned her chair around,
exposing her back to Ms. T. Ms. T noticed Ms. M’s withdrawal and asked Ms. M sarcas-
tically, “Am I boring you?” A staff member intervened abruptly by asking Ms. M to turn
her chair back to face the group, without giving Ms. M a chance to respond to Ms. T’s
question. Then another patient, Ms. L, attacked the leader who intervened because of
the harsh way she felt he had treated Ms. M. Tempers flared, and Ms. M threw a chair be-
fore storming out of the session.
In a supervision group, the therapist was helped to mentalize in hindsight. He real-
ized that he had moved too quickly to try to control a situation that he thought might be-
come fraught, no doubt because Ms. T had challenged Ms. M quite vigorously. Under
such pressure, it is difficult to think and to know what is helpful to do. Rather than asking
Ms. M immediately to turn back toward the group, the therapist might have expressed
curiosity about Ms. M’s having turned away from the group without making any assump-
tions, as Ms. T had done. He might acknowledge that such a move could be interpreted
as a rejection, yet he would emphasize that he could not know for sure what the move was
about. This exploration would provide Ms. M with an opportunity to verbalize her rea-
sons for moving (it became clear later in the group that Ms. M was responding on the ba-
sis of her problems with her own children).
In this case, however, the therapist was too quick to intervene and was criticized by a
member of the group, Ms. L. The mentalizing therapist needs to consider the criticism
carefully. Did he treat Ms. M badly (i.e., in a nonmentalizing fashion)? In the supervision
group, the therapist was surprised at his response to Ms. M, which was unusually control-
ling for him. He had feared that he would lose control of the group, and in the heat of the
moment, he had acted uncharacteristically. Exploring the event in the supervision group
allowed other staff members to reflect on their own failures in mentalizing under pressure.
Other group leaders came to realize that they could not, on their own, always maintain the
group as a working group. They concluded that the patients in the group needed to know
that the staff members wanted them to take some responsibility for maintaining the group
climate as a safe place for thinking freely. They thought that the exploration could have
taken place in the psychoeducational group itself. The therapist now felt confident that he
could discuss his response, and similar responses in the future, within the group. In a sub-
sequent psychoeducational group session, he acknowledged his failure to maintain men-
talizing and openly acknowledged the help he had received from his colleagues to think
about what had happened. He also expressed his appreciation to Ms. L for her criticism be-
cause it had allowed him to reflect on his behavior toward Ms. M.
Being in the Same Boat

The mentalizing stance requires humility on the therapist’s part about his or her own
mentalizing capacity. Patients are mentalizing when they are helped to realize that the
therapists also are limited in their ability to sustain mentalizing. Patients are likely to
Brief Treatment 195
feel less anxious if they know that staff members follow their own prescriptions by seek-
ing help for themselves in consultation and supervision as well as in accepting help
from coleaders—and patients—in the group. Witnessing staff members’ efforts to
maintain mentalizing (and their failures!) will, in time, inspire patients to wonder about
their own responses and start asking questions of themselves and others, such as “Why
did I do that?” or “Why did she say that?” These are mentalizing questions, which need
to be asked within a therapeutic climate. We use the slang “excrementalizing” (Allen et
al. 2008) for distorted mentalizing—in effect, mentalizing but doing a “crappy” job of
it. For example, a group leader, in referring back to an erroneous assumption, is free to
say, “I was ‘excrementalizing’ a while ago,” and he or she will likely have ample oppor-
tunities to say this.
Hence clinicians need to keep in mind that working with fearful and confused
minds is likely to have an adverse effect on their own mentalizing—they will lose and
regain it. Teamwork and supervision serve to anchor therapists and patients. Insofar as
therapists share vulnerabilities associated with attachment history and associated prob-
lems with emotion regulation—not to mention psychological problems and psychiatric
disorders—with their patients, therapists are in the same boat. To state the obvious, we
are all human, and this point should be made from time to time in mentalizing groups.
Nevertheless, a crucial difference exists between therapists and patients, which is asso-
ciated with therapists’ professional role: they are obligated to make continuous efforts
to mentalize, and it is no small effort. Patients are not similarly obligated, although
therapists hope to inspire them to be motivated to mentalize and to develop more skill
in doing so, so that mentalizing will ultimately become self-reinforcing and even more
natural.
Summary
• Regardless of the length of the treatment, the particular modality, or the clinician’s
theoretical orientation, an effective psychotherapeutic process requires that the
therapist engage the patient in mentalizing by cultivating an attitude of nonjudg-
mental curiosity about mental states. In this respect, psychotherapy mirrors devel-
opment: mentalizing begets mentalizing. Mentalizing is the job of patient and
therapist alike.
• Mentalizing-focused treatment puts a premium on process over content—for ex-
ample, placing more value on the capacity for reflection than on arriving at partic-
ular insights. Yet we should not give short shrift to content. Progress in brief
treatments depends on maintaining a focus throughout; this focus requires a clear
formulation of the patient’s core problems, taking into account ambivalence about
change that has impeded progress. Developing a useful formulation immediately
puts the therapist’s and patient’s capacity for collaborative mentalizing to the test.
• Structuring the brief treatment process has the potential to facilitate mentalizing on
the part of the therapist and the patient, particularly in the midst of clinical crises.
Illustratively, conjoint mentalizing is crucial to ameliorating the sense of alienation
central to suicidal states; yet clinicians’ mentalizing can be undermined by the anx-
iety inherent in working with suicidal patients. Structured clinical interviews, de-
signed to elucidate various facets of the suicidal state of mind, can be used to
promote mentalizing in therapists and patients. Such interviews enable the patient
to feel that the therapist has the patient’s suicidal state of mind in mind, and this em-
pathic connection constitutes the bedrock of interventions for suicide.
• Brief psychoeducational approaches have the potential to promote treatment en-
gagement, in effect, by jump-starting treatment. These approaches dovetail declar-
ative and procedural knowledge. On the one hand, patients are educated explicitly
about the concept of mentalizing and its development and relation to psychiatric
disorders, and they are helped to understand the ways in which various treatment
modalities are designed to facilitate mentalizing. On the other hand, patients are
engaged in a variety of structured group exercises that provide practice in mental-
izing. Yet although the psychoeducational groups are intended to help patients
“catch on” to mentalizing, we construe treatment as a whole as a practice ground for
mentalizing.
Suggested Readings
Bateman A, Fonagy P: Mentalization Based Treatment for Borderline Personality Disorder: A
Practical Guide. New York, Oxford University Press, 2006
Fonagy P, Gergely G, Jurist EL, et al: Affect Regulation, Mentalization, and the Development
of the Self. New York, Other Press, 2002
CHAPTER 8
Partial Hospitalization
Settings
Dawn Bales, M.Sc.
The original randomized controlled trial of mentalization-based treatment in a par-

tial hospitalization setting (MBT-PH) showed that effects were discernible 5 years af-
ter treatment was completed (Bateman and Fonagy 1999, 2001, 2003, 2008b). In 2004,
the De Viersprong Center of Psychotherapy in the Netherlands decided to try to rep-
licate the partial hospitalization program developed in the United Kingdom to deter-
mine whether the favorable outcomes could be repeated by an independent institution
in a naturalistic setting outside the United Kingdom. In an initial cohort study, we
showed that this was possible (Bales et al., in press). By 2010, we had developed a well-
structured mentalization-based treatment (MBT) unit, staying as close as possible to
the original programs and offering MBT-PH and MBT as an intensive outpatient pro-
gram. After successfully implementing MBT in our service, staff have begun offering
training to other units and assisting them in implementing MBT. In this phase, we have
found that attention to certain organizational aspects of developing MBT programs
197
can be helpful. In this chapter, we consider some of these issues and describe how treat-
ment can be organized to create the optimal context within which interventions en-
hancing mentalization can be delivered.
Patient Population
Borderline personality disorder (BPD) is a heterogeneous condition with large varia-
tions in comorbidity, social function, and severity. The De Viersprong Center of Psy-
chotherapy is an institution offering specialized outpatient, partial hospitalization, and
inpatient treatment for patients with personality pathology. Currently, the Viersprong
Institute for Studies on Personality Disorders has 10 different treatment programs for
patients with BPD, varying in treatment orientation, intensity, and duration. Within
the center, the most severely affected patients with BPD are referred for MBT. For re-
search purposes, DSM-IV-TR (American Psychiatric Association 2000) diagnoses are
obtained via structured interview ratings (Structured Clinical Interview for DSM-IV
Axis I Disorders [SCID-I; First et al. 1997b], Structured Clinical Interview for DSM-
IV Axis II Personality Disorders [SCID-II; First et al. 1997a], or Structured Interview
for DSM-IV Personality [SIDP-IV; Pfohl et al. 1997]), combined with expert opinion.
The most complex patients with BPD as a primary diagnosis are included. In these pa-
tients, 80% have more than one Axis I diagnosis, with anxiety, mood, eating, and sub-
stance abuse disorders being most common; 70% have more than one full Axis II
disorder beyond their BPD diagnosis, with paranoid, avoidant, dependent, and antiso-
cial personality disorders being the most common; and 70% have substance abuse and
dependency problems, further indicating the severity of the condition in the popula-
tion. Patients with severe self-destructive and acute and chronic suicidal behavior are
included and are often a danger to themselves or others during the initial phase of treat-
ment. All patients have a history of several failed treatment experiences and hospital ad-
missions. According to Kernberg’s criteria (Kernberg et al. 2002), the patients have a
low-level borderline or psychotic personality organization. BPD patients with a mid-
to high-level borderline personality organization, less acting-out behavior, and no drug
dependency issues are referred to other programs (mainly schema-focused therapy).
Principles of Service Development

Several principles should be considered when developing MBT-PH programs
within mental health services. In reviewing the literature, Bateman (2000) concluded
that effective treatments share several common features. These are summarized in
Table 8–1. Many of these features are included in guidelines for treatment of BPD
(National Institute for Health and Clinical Excellence 2009b; Oldham et al. 2001) and
overlap with features associated with well-organized research programs.
Partial Hospitalization Settings 199
TABLE 8–1. Common features of effective treatments for borderline personality

disorder
• Well structured
• Devote considerable effort to enhancing compliance
• Focus sharply on specific problem behaviors such as self-harm or problematic interpersonal
relationship patterns
• Offer a coherent conceptual framework that patients and therapists
can share
• Encourage a supportive attachment relationship between therapist and patient, consistent
with the therapist’s adopting a relatively active rather than a passive stance
• Relatively long in duration
• Well integrated with other services available to the patient
Source. Reprinted from Allen JG, Fonagy P, Bateman AW: Mentalizing in Clinical Practice, p. 284. Wash-
ington, D.C., American Psychiatric Publishing, 2008. Copyright © American Psychiatric Association.
Used with permission.
We now describe some of the essential features of a well-organized partial hospital

treatment program, which acts as a framework for the application of more specific
MBT interventions.
Treatment Goals and Treatment Plans

The central thesis of MBT is that the phenomenology of BPD is the consequence of
several factors. These are outlined in Table 8–2. The developmental model on which
MBT is based suggests that environmental adversities and neurobiological vulnerabil-
ities are intertwined. This is consistent with the complex etiology and symptomatology
of BPD. Within this conceptual framework for BPD, precarious mentalizing is seen as
the core problem; thus, in MBT, interventions are considered effective if they enhance
a mentalizing process. The overall aim of MBT is to develop a therapeutic process in
which the mind of the patient becomes the focus of treatment. The objective is for the
patient to find out more about how he or she thinks and feels about him- or herself and
others, how that dictates responses to others, and how “errors” in understanding self
and others lead to actions in an attempt to retain stability and to make sense of incom-
prehensible feelings. The therapist has to ensure that the patient is aware of these
objectives, that the therapy process itself is not mysterious, and that the patient under-
stands the underlying focus of treatment.
By enhancing mentalizing capacity about self, others, and relationships, all patients
work on five general treatment goals. These are summarized in Table 8–3. Each of
these goals is incorporated into the patient’s treatment plan along with a mentalizing
TABLE 8–2. Symptoms of borderline personality disorder
Borderline personality disorder symptoms are related to:

• Attachment-related inhibition of mentalizing
• Reemergence of modes of experiencing internal reality that antedate the
developmental emergence of mentalizing
• Continual pressure for projective identification
• Reexternalization of the self-destructive alien self
formulation that is developed in the individual sessions. In the treatment plan, goals are
personalized by summarizing the joint understanding developed between patient and
therapist of the underlying causes of the patient’s problems in terms of mentalizing,
their development, and their function at present. The goals are linked to the compo-
nents of the program within which the patient and the therapist think most of the work
will be done to achieve them. All team members treating the patient need to understand
the treatment plan and its implications for their work with the patient. In the treatment
reviews with each patient, the patient is asked to report his or her views on the issues de-
scribed in the treatment plan and current progress toward goals. In the reviews, differ-
ent views are integrated into a coherent set of ideas together with the patient. The
reviews in themselves stimulate the mentalizing process of patient and staff, helping the
patient to develop a coherent interpersonal and developmental narrative.
Structure of Mentalization-Based Treatment

in the Partial Hospitalization Setting
Structure refers to the way the program is put together from different components, how
these are implemented on a daily basis, and how the program is organized over the
longer term. The organization of the program in the Netherlands falls into three parts:
1. Pretreatment: pretreatment group introducing MBT; course-explicit mentalizing

(CEM) on addiction; CEM for caregivers
2. Treatment: day hospital treatment (partial hospitalization); outpatient treatment
MBT caregiver program
3. Posttreatment: stepped-down part of partial hospitalization treatment; individual
therapy
Each component requires a different approach from the therapist and the team.
TABLE 8–3. Five general treatment goals of mentalization-based treatment

in a partial hospitalization setting
1. Engagement in therapy
2. Reduction of psychiatric symptoms, particularly depression and anxiety
3. Reduction of self-damaging, threatening, or suicidal behavior
4. Improved social and interpersonal functioning
5. Stimulation of appropriate use of general or mental health services (including prevention
of reliance on prolonged hospital stays)
Pretreatment Program
Inevitably, many patients will be referred rapidly from mental health services while a
service is being developed, leading to a waiting list. The general rule is that the first
50 patients are those whose other treatments have failed and who have demoralized the
referrers. Because our MBT-PH program was the only program for BPD in the Neth-
erlands with few exclusion criteria, a waiting list for patients developed rapidly. To en-
sure that the patients began engaging in treatment immediately, a pretreatment
program was developed (Table 8–4). All patients referred for MBT, either for partial
hospitalization or for the intensive outpatient program, enter the pretreatment pro-
gram until a place becomes available in one of the MBT programs. It has been reported
that some patients experience increasing distress when they start treatment and that
this might drive them to seek alternative treatment elsewhere. In our experience, this
can be avoided by use of a pretreatment program in which the main focus is engaging
the patient in treatment.
Lack of motivation and failure to develop commitment are exclusion criteria for
many psychotherapies. Only motivated patients are taken into treatment. MBT, on the
contrary, was developed to treat a less motivated population. In the De Viersprong pro-
gram, most patients showed variable motivation for treatment, which is unsurprising
given their fragmented and unstable sense of self. Ambivalence about change is central
to the borderline structure, leading to oscillations between demands for help and sud-
den rejections of it. Progressively engaging the patient in a constructive relationship is
a core aspect of successful treatment. Even when patients seem motivated, their com-
mitment can rapidly change, sometimes within the course of a day, and this makes it
very important to maintain a focus not only on engaging them but also on keeping
them in treatment.
To understand shifts in motivation and further reduce the dropout risk, patients are
offered individual sessions in the pretreatment phase, in which time is spent searching
for dominant relationship themes and tentatively linking them to therapy and the treat-
TABLE 8–4. Components of pretreatment program of mentalization-based

treatment in the partial hospitalization setting
• One day per week, introduction to mentalization-based treatment, writing therapy

• Individual session
• Telephone accessibility
• Home visits if necessary
• Psychoeducation
• Crisis plan
• Stabilization of social and behavioral problems (e.g., drug or alcohol misuse)
• Medication review
ment process (transference tracers). Time and effort are spent on outreach work: tele-
phone calls, house calls, and active pursuit of the patient to build up the therapeutic
alliance and to repair ruptures. Another task of the individual sessions is to make sure
the patient understands the focus of treatment and how it will help him or her. Specific
information includes explaining and discussing the diagnosis, providing psychoeduca-
tion about mentalizing and personality disorder, starting the mentalizing formulation
and identifying the treatment plan with a hierarchy of therapeutic aims, reviewing
medication, and defining a crisis pathway with the aim of agreeing on a 24-hour crisis
plan (see Figure 8–1 for an outline). Social and behavior problems that are most likely
to interfere with effective treatment, such as drug abuse and unstable social conditions
(financial problems, homelessness), are targeted early.
Implementation
The pretreatment program consists of an individual session, an introductory MBT
group, and a writing therapy or mentalizing cognitive therapy (MCT) group organized
around themes related to social and behavior problems. In addition, patients can sign
up to see the psychiatrist individually during a psychiatric medication consultation
hour (described in the Medication Hour subsection later in this chapter). On other
days, patients may call the unit. Staff members have a group reflection at the end of the
day to discuss adherence to the model. Every week, the staff members discuss the pa-
tient’s treatment plans.
Telephone accessibility. At the beginning of treatment, patients are given the unit
telephone numbers and informed that a staff member will be available by telephone for
urgent matters. The unit telephones have an answering machine, and if messages are
left outside office hours, a team member will return the call by 11:00 A.M. the next work-
ing day. Telephone discussions are kept short, are not therapy, and should not be used
Partial Hospitalization Settings
MBT PROGRAM NL TRAJECTORY PROCESS
Pretreatment Initial phase

⇒ Assessment of mentalization
⇒ Diagnosis
⇒ Individual
⇒ Psychoeducation—explain
⇒ i-MBT, CEM-a, CEM-c
Engagement in treatment model
⇒ 1-day program
⇒ Stabilization—social
⇒ Medication review
Treatment Middle phase ⇒ Treatment plan and dynamic
formulation
⇒ Crisis planning
⇒ Day hospital MBT ⇒ Maintain therapeutic alliance
⇒ IOP MBT ⇒ Repair alliance ruptures
⇒ IOP MBT-C ⇒ Manage countertransference
⇒ OP MBT-ASP ⇒ Individual and group therapists ⇒ Maintain team morale
⇒ MBFT integrate their views ⇒ Interpersonal work
⇒ Individual + group therapy
⇒ Specific techniques
Interpretive mentalizing
Follow-up treatment Final phase
Mentalizing the transference
Conclusion of acute treatment

⇒ Individualized care ⇒ Separation responses
⇒ Stepped-down ⇒ Contingency planning
Follow-up
⇒ Group therapy and MCT Maintain mentalizing
⇒ Individual therapy Stimulate rehabilitative changes ⇒ Prevention of relapse
FIGURE 8–1. Structure of the mentalization-based treatment hospitalization unit in the Netherlands.
CEM=course-explicit mentalizing (a=addiction; c=caregivers); MBT=mentalization-based treatment (A=adolescent; C=caregivers; i-MBT=intro-
ductory MBT group; IOP=intensive outpatient; OP=outpatient); MBFT=Mentalization-Based Family Therapy; MCT=mentalizing cognitive
203
therapy; NL=Netherlands.
in this way by either the patient or the therapist. The aim in any telephone discussion
remains to rekindle mentalizing if it has been lost. Accessibility is seen as an important
supportive aspect of treatment throughout the whole treatment trajectory, however.
For some patients, the confirmation that staff continue to “have them in mind” through
a telephone call can help stabilize them; outside office hours, the answering machine
can serve as a reminder that they continue to be held in mind.
Outreach work. Therapists contact and may visit the patient as a part of the engage-
ment process or to enhance or repair the therapeutic alliance. Initially, telephone con-
tact or a letter may be enough to help a patient reengage, but at times a visit to the
patient’s home may be necessary. Generally (but depending on treatment phase and on
what the staff think), therapists call the patient when he or she has missed several con-
secutive sessions. The number of missed sessions before contact is made depends on
the assessment of the patient’s crisis or dropout risk. If contacting the patient fails and
the staff still have not been able to reach a patient after 2 weeks, the therapists write a
letter explicitly stating their concern and inviting the patient to an individual session,
stating that they want to try to understand the rupture in alliance. If the patient still
does not attend, then a therapist goes to the patient’s home.
Introductory MBT group. In the individual session, information is given about men-
talizing and MBT, the program itself is discussed, and patient and staff responsibilities
and rules are outlined. Further details of the initial individual session are given in the
following subsection. The introductory MBT group is a slow open group that uses the
principles described by Allen and colleagues in Chapter 7 of this volume. It is an explicit
mentalizing group that introduces mentalizing and MBT. It educates the patient as part
of the preparation for the partial hospitalization or outpatient psychotherapy, but is not
“educational” in the sense of telling the patient what he or she needs to know or how to
deal with problems. It is instructive insofar as it stimulates the patient to consider the
overall process of mentalizing, its relation to his or her difficulties, and its contribution
to his or her success or failure in managing emotional interactions, which are the pri-
mary aims of the group. The group follows a structured 12-week program, with each
session lasting 90 minutes.
Individual therapy session. At the beginning of therapy, it is important to extensively

explore the patient’s relationships, (self-) destructive behaviors, and previous treat-
ments. Recognizing mental states and patterns will help the therapist know which types
of interventions need to be used and indicate the form of the relationship that is likely
to develop between the patient, the therapist, and the treatment staff. Once these pat-
terns have been identified, they are discussed with the patient and incorporated into the
mentalizing formulation and treatment plan. They offer an important opportunity to
use transference tracers with the tentative suggestion that some of the relationship pat-
terns may be repeated within the treatment itself.
Crisis plan. Nearly all patients will experience a crisis at some point during treat-
ment. Often self-destructive acts in crisis are a result of overwhelming feelings and
panic. Failure by mental health professionals to understand the role of self-harm in
coping with unmanageable emotional states may lead to inappropriate use of medica-
tion and unnecessary hospital admissions. Both responses remove responsibility from
the patient for addressing painful affects and are potentially iatrogenic.
Agreeing on and documenting what to do in the event of a crisis is one of the very
first issues discussed in the individual session during the pretreatment phase. Such a crisis
plan has two parts: the individualized (process) part and the practical part (as written up in
Bateman and Fonagy 2006a). From a mentalizing perspective, it is not fitting to give the
patient a plan, telling him or her what is best at what time. It is more in keeping with the
model to stimulate the patient to think about what situations and accompanying mental
states could lead to a crisis and what might be helpful to restabilize him or her.
In the crisis plan, ways of managing difficult emotional states related to self-
destructive acts that interfere with therapy or endanger life are identified. The first part
of the crisis plan, the mentalizing functional analysis (see Mentalizing Functional Anal-
ysis section of Kjolbe and Bateman, Chapter 9 in this volume), is collaboratively devel-
oped between patient and therapist by stimulating discussion about different stages of
mental states that precede the crisis. Each of the following stages is defined:
• 0=feeling in control
• 1 and 2=patients defining themselves
• 3=in crisis or out of control
Patients try to identify their mental states and behaviors in each of the separate stages.
The therapist uses clarification and affect elaboration techniques, frequently coaxing the
patient to rewind mental processes to points prior to the loss of control, thereby helping
the patient to identify feelings and to place them in a context. Overwhelming, undiffer-
entiated feeling states are microsliced into smaller, more specific mental states by using
moment-to-moment exploration of the episode leading up to self-harm. The emphasis is
on examining feeling states and on identifying possible misunderstandings or oversen-
sitivity. The patient is helped to identify when he or she could have reestablished self-
control and what could have prevented the patient from moving on to the next stage to-
ward a crisis. Strategies that have been helpful in managing emotional crises in the past
are identified, suxch as leaving a provocative situation, telephoning someone if trapped in
a feeling of loneliness, or distracting the mind by engaging in a behavioral task such as
cooking. The therapist also tries to stimulate the patient to reflect on how others might
observe each stage (signals for others) and what others could do or should not do that
might be helpful. Significant others are invited to sessions to collaboratively work out this
part of the crisis plan.
In the beginning of treatment, this part of the crisis plan is tentative. Patients often
have no idea about their different mental states and about the behaviors that result from
a failure of mentalization, only stating, “It happens at once, and there’s nothing I can
do.” The plan is a work in progress, and each time certain aspects become clearer, they
are added to the plan. The therapist is required to revisit the crisis plan whenever a cri-
sis occurs. When the actions already identified in the plan fail to work, it can be helpful
to stimulate the patient to think about what is missing in the plan, what mental state
might not be described, what did not help, and why it did not help. In this way, the ther-
apist is continuously pointing out the patient’s own responsibility for dealing with pain-
ful and possibly overwhelming affects. At the same time, it helps to reduce the patient’s
perplexity about his or her emotional states, and continual clarification reduces the
likelihood that feelings will need to be managed through self-harm or other such ac-
tions.
In addition to such patient-specific plans, in the second part of the plan, the ther-
apist outlines the emergency system that is available to the patient. During working
hours, the patient can contact the unit but only if other ways of managing the emotional
states have failed or have been deployed with limited effect. The use of emergency ser-
vices outside working hours is also discussed, emphasizing that emergency teams will
have access to the crisis plan and will attempt to help the patient manage an acute sit-
uation until he or she is able to discuss the problem in therapy on the next working day.
Stabilization of social and behavior problems. Social and behavior problems that
are most likely to interfere with treatment are identified, and ways of addressing them
are organized during the pretreatment period. The stabilization is not, however, a con-
dition of entering treatment; it is more a focus of the pretreatment period and may
overlap with treatment itself.
Patients start MBT as soon as an appropriate treatment program has availability,
regardless of what has been accomplished at that moment in the pretreatment phase.
The staff members take over aspects of care described earlier. In our unit, patients have
several possibilities: the MBT-PH program, the MBT as an intensive outpatient pro-
gram, the pilot intensive outpatient treatment program for caregivers, and the pilot
outpatient treatment program for antisocial personality disorder. In this chapter, we
describe only the partial hospitalization program.
Treatment Program
Most patients starting MBT-PH have nearly completed their initial phase and are start-
ing on the middle phase of treatment. By this point, they usually have fewer crises, less
fluctuating motivation, and greater engagement in treatment. The initial phase is often
the hardest work for the therapists, whereas the middle phase tends to be the most dif-
ficult for the patient. During the middle sessions, the aim of all the active therapeutic
work is to enhance mentalizing capacities.
The De Viersprong Center of Psychotherapy was the first to offer a formal MBT-
PH day program in the Netherlands. Treatment consists of a maximum of 18 months of
partial hospitalization (average of 15 months) followed by follow-up treatment in an in-

dividualized, stepped-down mentalizing maintenance program. The highly structured
5-day program combines individual and group psychotherapy, focusing on implicit
mentalizing processes with expressive therapies (art therapy, writing therapy, MCT)
and promoting skills in explicit mentalizing (see Figure 8–1).
In implementing MBT-PH in the Netherlands, the first author (D.B.) drew on her
experience of training in the United Kingdom at the Halliwick Day Unit, St. Ann’s
Hospital, London, where the original research was carried out, which enabled her to
learn the structure and method of each component of the complex program. Even
though the specificity of the therapeutic activities is variable, a description of each com-
ponent gives a focus for others attempting to implement MBT-PH.
MBT-PH consists of small and large groups. Each small group has eight or nine
patients with two therapists. The large group is formed by joining the two small
groups. The patients of two small groups running in parallel share certain rooms (e.g.,
living room, computer room, kitchen) and interact in between therapy sessions. The
large group allows the patients to focus on mental states of self and others in the im-
mediacy of the contacts they have all week. Furthermore, both small groups may be
struggling with similar problems, and these can be shared within the large group.
MBT-PH groups are led by two therapists. Clearly, this is more costly but often
necessary with this patient population. Many of the patients can be very aggressive,
particularly in the initial part of the middle phase of treatment, in reaction to perceived
threats to the stability of the self. In these phases of treatment, they are often very an-
gry, feeling victimized, rejected, and distrustful. Their aggression may be verbal but can
also become physical and can be easily provoked. The therapists’ task is to keep the
arousal at an optimum level, not allowing sessions to become uncontrolled. To do this,
therapists must continually monitor the mental states of the other group members and
tailor their interventions appropriately. When a patient shows aggression directly to-
ward one of the therapists, it can be very difficult for that therapist to keep mentalizing.
In such situations, the second therapist can take over, giving the other therapist time to
recover his or her own mind. If several patients are highly emotionally aroused and
functioning in the psychic equivalence mode, the therapists may have their hands full
controlling the session, and it can be very helpful for them to split their roles, ensuring
that different patients receive enough support and empathy to lower their arousal and
help reinstate mentalization.
Combined or Conjoint Model for MBT-PH?

We use a combined model of group and individual psychotherapy with the group ther-
apists offering the individual therapy. When starting the program, we had no choice
simply because of staffing levels. At a later stage, with more patients, groups, and staff,
we could have changed the arrangement to a conjoint model as used in the United
Kingdom. However, we found that the use of a combined model had advantages. First,
working individually with group patients allows therapists to limit the number of pa-
tients they must keep in mind. Most of our therapists work in not only the MBT-PH
program but also the pretreatment program (introductory MBT group) or the follow-
up program. Second, consistency of treatment is ensured, although a patient could re-
ceive consistently poor treatment from only one therapist. However, this is addressed
through a system of supervision and case discussion. Third, the potential advantage for
patients of being able to discuss a problem with one therapist or with another in a con-
joint model is also, on reflection, a possible disadvantage to the extent that the oppor-
tunity for mentalizing the transference can be lost. When problems arise, assistance
from the other group therapist or group members may be more useful than a discussion
with another individual therapist. Fourth, not offering conjoint treatment builds con-
stancy and continuity. What happens in the group can be discussed easily in the indi-
vidual psychotherapy. Finally, because the individual therapist is the same person as the
group therapist, splitting of transference becomes less likely, and the risk of idealizing
one aspect of treatment and denigrating the other is minimized.
Intensity
Attending a program on a daily basis presents problems for people with personality dis-
order because it requires commitment and personal organization. It is important to en-
sure that the intensity of interpersonal interaction is moderated and that patients have
adequate time between sessions to reflect, to rest, and to distract themselves, if they are
to manage the emotional stimulation. The intensity is moderated by allowing time in
between treatment components; we choose to have 1–2 hours of time in between the
morning and the afternoon program. This has several advantages for severe borderline
patients who often get aroused in situations that require high levels of interpersonal in-
teraction. Many patients tend to become overinvolved, whereas others feel more
trapped in their isolation within the group. Because of their unstable sense of self, they
often seem to need this time between program components to restabilize.
Description of Therapy Components

The main aim of MBT is to enhance patients’ mentalizing capacity. Even though par-
tial hospitalization has different therapy components, they all share this aim, which can
be specified further into the following shared components:
• To promote mentalizing about oneself

• To promote mentalizing about others
• To promote mentalizing of or about relationships
Throughout the whole program, this aim is accomplished by
• Identifying and working within the patient’s mentalizing capacities

• Focusing on internal states in the therapist and the patient
• Representing these internal states to the patient

• Sustaining this focus in the face of continual emotional challenges by
the patient
All program components are highly structured (in time, content, method, thera-
pists) and thus predictable for the patients. An essential element within MBT-PH is the
link between all components. The themes within the small group partially determine
the topics used within the expressive therapies, and overlapping issues from the small
mentalizing groups form the focus of the large group therapy. The task of the therapists
is to establish continuity between sessions, to link different aspects of the program, and
to help the patient recognize and mentalize about any discontinuity. This integration is
essential in stimulating the formation of a coherent sense of self.
Mentalizing group psychotherapy. Mentalizing group psychotherapy is one of the

most important components of the partial hospitalization program. It is a powerful
context in which patients can focus on their own mental states and those of others in the
immediacy of peer interaction. Group therapy stimulates highly complex emotional in-
teractions, which all patients can use to explore their own understanding of the motives
of others. Patients have to describe what is in their mind while reflecting on their own
motives and attempting to understand those of others. For many patients, this feature
of the program is one of the most difficult aspects of treatment in that they have the task
of monitoring and responding to eight or nine minds rather than being able to focus on
only two, as in individual therapy.
The daily mentalizing group therapy lasts 1 hour and is led by two therapists. The
group starts with a therapist or patient informing the group about absences or other
relevant issues related to the group (e.g., messages from other patients, introduction of
a new patient or therapist). After this, the patients are responsible for deciding what
issues will be discussed. It is important that patients are not left in silence for long
because unhelpful anxiety will result. Therapists must be prepared to stimulate
mentalization within or about the silence, to bring up issues from previous sessions
(e.g., actively bringing up a conflict between group members that has not been fully
considered in other sessions), or to focus on current problems or positive aspects of the
overall program.
The therapist’s task is to stimulate mentalizing and constructive interaction be-
tween as many patients as possible. In doing this, the most difficult task is maintaining
an optimal arousal level. If arousal is too low, the session may become meaningless, fur-
ther stimulating pretend mode. If arousal is too high, patients’ attachment systems will
become overstimulated because of anxiety, and rigid schematic representations of oth-
ers will be mobilized, leading to action rather than reflection. These possible iatrogenic
effects must be minimized.
For further discussion of group therapy intervention, see Karterud and Bateman,
Chapter 4 in this volume.
Mentalizing cognitive therapy. MCT is an explicit mentalizing group focusing on a

wide range of mentalizing processes. In MCT, cognitions, but also other aspects of
mental states, are explored in a structured way. Cognitions are a key element of working
within MBT, as in all psychosocial treatments. MCT uses some aspects of the structure
and strategies of cognitive-behavioral therapy (CBT). The structured form of the
MCT session is very similar to cognitive therapy, but there are some essential differ-
ences. CBT has its roots in social learning theory, and its model of behavior does not in-
clude dynamic determinants. Thus, it is less process- and more content-oriented. The
MBT therapist is encouraged to think dynamically about the patient’s experience. It
thus becomes more process- and less content-oriented. This allows consideration of
pre- or unconscious thoughts, feelings, wishes, and desires and patients’ struggles with
these complex mental experiences in the context of the interpersonal pressures of their
lives, particularly attachment relationships. The cognitive therapist focuses on chang-
ing maladaptive cognitions; the MBT therapist is less interested in restructuring the
content of the cognitions and more interested in changing the process by reinstating
mentalization.
MCT, unlike many forms of CBT, involves no specific use of problem-solving
skills or teaching of fundamental communication skills; no attempt to delineate cogni-
tive distortions outside the current patient-therapist relationship or to focus on behav-
ior itself; no explicit work on schema identification; and no homework.
MCT consists of a small group that meets for 75 minutes once a week. A patient
describes a situation in which he or she experienced (or is currently experiencing) over-
whelming emotion or engaged in (self-) destructive behavior. The situation is repre-
sented on a whiteboard. The patient’s mental state (but also the possible mental states
of others if involved) and behavior are explored, and components of the event and the
associated feelings are written down. The therapist focuses on exploring the mental
states broadly rather than using precise and detailed identification of thoughts, feel-
ings, or wishes. The main focus of the session is the mentalizing process, with much less
focus on the end product or content of the events and interaction. If the patient wants
to explore his or her (self-) destructive behavior, the therapist’s main focus is to help the
patient “tidy up the behavior” that has resulted from a failure of mentalization, tracing
action back to feeling, and thus stimulating mentalizing about the (recent) past. The
therapist helps the patient take his or her mind back to the problematic experience,
from the safety of emotional distance. In the case of overwhelming emotion, the ther-
apist tries to help bridge the gap between the primary affective experience and its sym-
bolic representation by helping the patient understand and label the emotional state
and place it within the current context, sometimes further exploring linking narrative
to the recent and remote past.
When the events and interactions have been clarified, the therapist and group help
the patient by bringing in alternative perspectives. The difference from CBT is that
here the alternative perspectives are not a result of a Socratic dialogue or of disputing
“irrational or maladaptive” cognitions but are just alternative perspectives brought up
by other patients. This helps patients question their assumptions. Sometimes problem-
atic interactions within the group are identified and explored in a structured way with
the mental states of several group members highlighted, focusing on different perspec-
tives about a turbulent issue in the group.
Creative/art therapy. The aim of art therapy in MBT-PH is to offer an alternative

way of promoting mentalization—sometimes conceived of as external mentalizing
(Allen et al. 2003). The use of art allows the internal to be expressed externally, through
an alternative medium and from a different perspective. Experience and feeling are
placed outside of the mind and into the world to facilitate explicit mentalizing. Under
these circumstances, mentalizing becomes conscious, verbal, deliberate, and reflective.
Patients produce something that is part of them yet separate. In this way, the therapy
creates transitional objects, and the therapists have to work at developing a transitional
space within the group in which the created objects can be used to facilitate expression
while maintaining stability of the self.
Creative therapy differs from other program components because the patient makes
a concrete “product.” The product gives the opportunity for the group and patient to fo-
cus specifically on a certain area of reflection. For some patients, expressive therapies are
less anxiety-provoking than directly reflecting about themselves in relation to others.
With their product made, an aspect of the self is outside and is therefore rendered less
dangerous, less controlling, and less overwhelming. Feelings become manageable, and
the understanding of oneself and others is more tolerable because of the distance created.
Other patients, particularly those who function predominantly in psychic equivalence
mode, can be more anxious during creative therapy. The product they make, now also vis-
ible on the outside and to others, makes that aspect of themselves too “real,” and they be-
come overwhelmed. Therefore, the art therapist must tailor her or his work individually
with different patients at different phases of their therapy.
Art therapy is done in a small group twice weekly for 75 minutes. The form varies
from working individually on personal goals in the group, to working individually on a
group theme, to making a group project. At the start of each session, patients are helped
to focus on how they are feeling at the moment and what they would like to work on.
Sometimes a prominent issue in the group is brought in by the therapist or the patients.
Once the form of the session (e.g., theme, individual vs. group work) is decided, the pa-
tients choose where in the room they want to work on their project for 30 minutes.
After completing their work, the patients gather again for group discussion of one
another’s work. In this discussion, as in all program components, the therapist’s task is to
promote mentalizing by focusing on the expression of affects, their identification, and
their personal and interpersonal contexts. The therapist also should ensure that patients
consider the meaning of the expressive efforts of others and can help patients recognize
that others may see their work in a different way from the way they see it, helping create
alternative perspectives. The standard of the art is not important; the process of expres-
sion and discussion of the work is significant.
Therapists must continually bring the discussion back to the agreed focus rather
than follow other avenues of exploration as they might in a mentalizing group or indi-
vidual therapy. This technique is necessary to increase the patients’ ability to attend to
a task without being diverted by other themes to increase effortful control.
Writing group. Writing down one’s experiences, feelings, and emotions helps to
bridge the gap between primary experience and representation and its symbolic repre-
sentation, which allows the reflective process to develop and strengthens the secondary
representational system. Through writing, implicit mentalizing becomes explicit men-
talizing. Writing allows for reflection without the interference of other minds and with
distance in time if the patient has written about an earlier event, so less arousal occurs.
Writing therapy takes place in a small group once a week for 90 minutes. To begin,
all the patients and the therapists write on a piece of paper a theme that they feel is a
prominent issue in the group or on the unit. All the papers are placed in a box. One of
the patients picks out a paper at random, and all the patients write down the chosen
theme. They then have 30 minutes to write about the theme, especially its personal
meaning. Next, each patient reads out loud what he or she has written, and together, led
by the therapists, they explore the similarities and differences between their essays.
Again, the therapists aim to promote mentalizing by helping the patients to create al-
ternative perspectives on what they have written. As in art therapy, what is written on
paper is less important than the process of developing the theme, writing about it, and
discussing the personal essays.
Unit meeting. When groups of people are together in a unit, consideration of others
is important. Arguments can occur about the use of the kitchen, failures to wash up, the
disappearance of items of cutlery, the seating area being left untidy, and so on. A brief
meeting occurs weekly to deal with these practical problems. The meeting is run by the
staff. Individual or interpersonal issues are not addressed in this meeting; if they are
brought up by the patients, staff members suggest that they take the problem to their
group or individual therapy.
All patients from the unit and one or two staff members meet once a week for a
maximum of 30 minutes. The time frame depends on the number of issues to discuss;
often, this meeting may take as little as 10 minutes. Patients can bring up any unit
housekeeping issues, such as the use of the kitchen, broken utensils, groceries, or an ac-
tivity they want to plan (e.g., a Christmas lunch).
Social hour. Patients often experience crises during the weekend, when contact with
the unit is not possible. It is important not to end the week with a component that
might induce too much arousal, leaving patients to go home in nonmentalizing states.
For this reason, the weekly program ends with a social hour—a relaxed, low-arousal in-
teraction between patients and staff. Patients and two staff members choose and play
games together.
Medication hour. In MBT, medication is viewed as an adjunct to psychotherapy. It

enhances the effectiveness of psychotherapy, improves symptoms, stabilizes mood, and
may help patients attend sessions. Prescription of medication needs to take transfer-
ence and countertransference phenomena into account and therefore needs to be in-
tegrated into the program itself.
Before the start of treatment, the unit’s psychiatrist carefully identifies the patient’s
psychiatric symptoms, current medication, and history of medication. Two medication
hours are available each week, during which all patients from the MBT unit can sign in
for an appointment. Therapists can advise patients to see the psychiatrist, but it is each
patient’s own responsibility to go or not. During treatment, the patient is responsible
for his or her own medication. Changes of medication are discussed with the treatment
team before being prescribed to ensure that possible transference or countertransfer-
ence aspects are considered. Medication should rarely be prescribed during a crisis and
never to help manage staff anxiety.
Mentalization-Based Family Therapy module. Recently, our unit implemented

Mentalization-Based Family Therapy (MBFT; see Asen and Fonagy, Chapter 5 in this
volume) as a module that patients from the different MBT programs can be referred to
with their families. MBFT addresses mentalizing processes within the family context
rather than focusing on specific symptoms. Its aim is to provide the family members
with the tools that will enable them to initiate a self-healing process. Improved under-
standing within a family will improve the quality and supportiveness of family attach-
ment relationships and strengthen the family’s capacity to control and manage
problems. This can facilitate the patient’s further progress in treatment.
Final phase. The final phase of treatment in the MBT-PH program commences at
12 months. It is very important for the therapist to be mindful of time because a lot of
work still must be done in the final phase to ensure consolidation of therapeutic gains.
In this last phase of active treatment, the patient’s responsibility to develop indepen-
dent functioning is increased as earlier work is integrated and consolidated. The focus
of the last 6 months is the patient’s feelings about the loss of an intensive treatment and
about reintegrating into society. Collaborative development of a follow-up treatment
plan individually tailored to the patient’s needs is an essential task in this final phase of
treatment.
Posttreatment Program
After 18 months of treatment, it is unlikely that patients with severe personality disorders,
who often have histories of failed treatments, multiple hospital admissions, and inadequate
social and relational stability, will be able to adapt and reintegrate to their new lives without
further support. This is usually the case, no matter how successful the treatment has been.
Individual, tailored follow-up treatment with stepped-down care is therefore offered.
Goals in follow-up treatment are summarized in Table 8–5. Two programs are or-
ganized. The first is a 1-day-per-week program with intermittent follow-up appoint-
ments. The second is continuation of individual sessions but with the frequency
reduced over time, the trajectory of which is negotiated toward the end of MBT-PH.
Some patients leaving MBT-PH will choose the 1-day follow-up treatment program
combined with intermittent individual follow-up appointments. Others prefer to have
only individual follow-up sessions with their individual therapist, with the frequency
gradually reducing.
The 1-day follow-up treatment program consists of group therapy and a writing
group. In the follow-up groups, the emphasis is on topics related to reintegration with
society.
During individual follow-up appointments, the therapist continues to use mental-
izing techniques to explore the patient’s underlying mental states and to discuss how
understanding oneself and others leads to resolution of problems, helping to manage
both problematic areas of interpersonal or intimate relationships and the process of re-
turning to education or employment.
In the follow-up trajectory, the time between appointments is increased over a
6- to 12-month period to encourage greater patient responsibility. The therapist and
patient decide together how long the patient will continue to be seen in this way. The
intensity and frequency of appointments in the follow-up contract are flexible, and the
patient can request an additional appointment if he or she has an emotional problem
that is difficult to manage. We find that it is very helpful to offer patients this possibil-
ity; some come back after many months or even years when they feel they are relapsing,
and often only a few sessions are necessary to reinstate mentalization and help them re-
stabilize. This continual follow-up with permission for self-referral means that patients
experience continuity over a prolonged period. Some patients choose to be discharged
after MBT-PH knowing that they may call to request an appointment at any time in the
future. Others plan only a few appointments but set them far ahead with a 6-month in-
terval; this assurance that we continue to have them in mind seems to give them greater
confidence and self-reliance about their ability to reintegrate.
Mentalizing Environment
An important factor within the MBT-PH program structure in daily practice is how
well staff function, how predictable they are, how consistently they implement treat-
ment, and how clear boundaries are in terms of roles and responsibilities. Inconsis-
tency, lack of coordination, incoherence of response, unreliability, and arbitrariness are
all antithetical to structure. We discuss some of these issues.
Important nonspecific aspects, such as the interrelations of the different aspects of
the MBT program, the therapists and their working relationship, the continuity of
themes among the groups, and the consistency and coherence with which the treat-
TABLE 8–5. Goals of follow-up mentalization-based treatment

in the partial hospitalization setting
1. To prevent relapse
2. To maintain (and further enhance) gains made in mentalizing capacity
3. To stimulate further rehabilitative changes and reintegration
ment is applied over time are likely to be key factors in effective treatment of severe
personality disorders. Within MBT, this essential integration is achieved through a fo-
cus on mentalizing. How, then, does one create a framework in which mentalizing be-
comes and remains the focus?
Creating a Mentalizing Environment

The partial hospital treatment program requires patients to attend over a long time and
involves considerable interaction between patients. The atmosphere created, the char-
acter of the building, and the staff and their functioning all need to be conducive to the
orientation and focus of the treatment. This is the therapeutic milieu, which Janzing
and Kerstens (1997, p. 246) defined as “an organized treatment unit, in which a situa-
tion is created in which a patient is offered relationships with a group of patients and
staff. These relationships offer the patient the opportunity, within his capacities (and
deficits), to work on a solution to his problems.” Within MBT-PH programs, the mi-
lieu is not a treatment method in its own right as it might be in therapeutic communi-
ties. However, establishing the best possible environment for MBT is a very important
consideration when treatment is being organized. Material aspects of the milieu in-
clude the building, the location, the entrance, the style of written information, and the
available therapy rooms, whereas the nonmaterial aspects include the staff, the quality
of their working relationship, their attitude toward patients and one another, the con-
sistency and coherence of the approach, and the management support of the program.
In creating an optimal treatment milieu, treatment orientation and focus are the
primary considerations. Within MBT, the milieu should stimulate mentalizing about
self, others, and their interactions; that is, a mentalizing environment. An open, re-
sponsive, mentalizing atmosphere is not only needed for patients but also essential for
the staff. A well-functioning team will create a secure atmosphere within the treatment
milieu. This allows disagreements between therapists and patients to be used construc-
tively; facilitates an inquisitive, curious, and open-minded culture; and encourages at-
tempts to understand differences, generating and accepting alternative perspectives. A
mentalizing milieu encourages thought over action: every action beyond protocol is
first checked out with other staff members to identify possible underlying transference
and countertransference processes. In our experience, 75% of such intended actions
are unnecessary and possibly even antitherapeutic.
To offer a safe and supportive environment, strong feelings engendered in staff

need to be contained without either using excessive protection or overstepping (ther-
apeutic) boundaries and becoming overly permissive. When staff are able to keep men-
talizing in the midst of strong emotions and confusion and can do what is necessary to
reinstate mentalization in patients and groups, patients will experience their own emo-
tions as less frightening and dangerous. This will ensure that patients are less likely to
become overwhelmed and destabilized. Predictable and consistent staff members who
are thoughtful and patient in their approach will add further stability to the system.
Last, but certainly not least, setting clear boundaries in a respectful way without re-
moving patients’ own responsibility is essential to contain strong emotions and thus is
a vital part of a mentalizing milieu.
Rules or Recommendations?
Rules are part of the boundaries of the mentalizing environment. In explaining the rules,
it is important to maintain a mentalizing stance. First, the rules need to be stated and ex-
plained in a straightforward manner, making sure they are as clear and comprehensible to
the patient as they are to the therapist. The reasons for the rules should be explained, and
the patient’s responses should be explored. In our view, the approach in giving the rules
should be one of discussing recommendations rather than directly giving rules. This does
not mean that if a recommendation or rule is not followed by a patient, the therapist will
not take action. For example, a therapist will end a session if the patient is under the in-
fluence of drugs. We recommend that patients do not attend the unit under the influence
of drugs or alcohol because they cannot participate effectively in treatment. If they do
take drugs, they are asked to leave and not to attend until their mind has cleared to discuss
what made them engage in a self-destructive and therapy-destructive behavior (see sub-
section Drugs and Alcohol later in this chapter).
MBT-PH includes only rules that are necessary to secure a safe environment. Too
many rules may lead to an ultraprotective and controlling environment, which is antithet-
ical to mentalizing. Furthermore, abiding by many rules is very difficult for most patients;
they are unable to enter into binding contracts because they cannot predict their future be-
havior. Introducing extra rules or individualized contracts about attendance, self-harm, and
suicide, for example, would be asking the patient to control the very behavior for which he
or she is seeking treatment. We see it as essential to treatment that disorganized and de-
structive behavior outside treatment is explored within treatment, so that actions can be
traced to feelings by rewinding the events. Patients then can give meaning to the behavior
that has resulted from a failure of mentalization. Behaviors that are inherently threatening
to patient or therapist safety and block mentalizing are seen as antitherapeutic and thus pos-
sibly interfering with treatment of all parties involved. Violence, drugs and alcohol, and sex-
ual relationships are such behaviors. The three essential rules concerning these behaviors
are discussed in the following subsections.
Violence
It has to be very clear that neither physical nor verbal violence to others in the unit will
be tolerated. Threats to people outside the unit are a different matter (although the in-
dividual who makes them is considered responsible for them) and may become a focus
of therapy rather than a reason for discharge. Depending on the severity of physical vi-
olence or the recurrence of it in the unit, the person responsible may be discharged and
the police involved. In other cases, the person may be given a time-out, the length of
which is decided by a minimum of two members of the staff team (a mentalizing per-
spective on violence is discussed in Bateman and Fonagy 2008a, and an outline can be
found in their Chapter 12 in this volume). Patients often describe high levels of arousal
with problems understanding the intentions of the other person or describe feeling
threatened by collapse of their own state of mind—“I just lost it.” Threatened, actual,
or perceived humiliation and disrespect can then lead to a threat to the stability of the
self. Aggression becomes an attempt to restabilize the self.
Individual therapy is often continued during time-out from the rest of the MBT-
PH program, in order to try to reinstate mentalization. Before the patient can continue
in treatment, the patient (and staff) must explore the incident fully, gaining some un-
derstanding of the processes that led to the violence; the patient must have better con-
trol over impulsivity; and the staff must feel safe. Only then may the patient return to
the MBT-PH program. The patient group members are kept informed about what is
happening. During the patient’s time-out, the therapists actively bring the aggression
or violence issue to the group therapies to ensure that participants throughout the
whole system of treatment consider what has happened.
Drugs and Alcohol

In a population of patients with severe personality disorder, approximately 70% have
drug or alcohol abuse problems. Drugs and alcohol alter mental states and interfere
with the exploration of mental states, negating the overall aim of treatment. Thus, the
rule is that patients under the influence of drugs or alcohol are not allowed to remain in
a group or an individual session. When asked to leave, some patients may challenge the
therapists and may demand proof (i.e., by testing of their blood or urine samples). We
do not test blood or urine. At the beginning of treatment, patients are told that if two
members of staff believe that a patient appears to be under the influence of drugs or al-
cohol, they are empowered to ask the patient to leave and to return only when his or her
mind is not altered by drugs or alcohol. We are very transparent about our motivation
to work this way and are clear that patients will not necessarily be excluded from ther-
apy because of their addictive problems. Furthermore, in our experience, because of
the open discussion and enhanced mentalization about drug and alcohol issues during
group therapies, other patients who are often more quickly aware than the therapists
that someone is under the influence of drugs will ask that patient to leave and to return
only when not under the influence of drugs.
Sexual Relationships
It is impossible to prevent patients from meeting during the evening and on weekends. It is
understandable that they do meet outside of the day-hospital treatment, which is such an
important and, for a time, such an extensive part of their lives. Some may meet by chance
because they live locally, whereas many feel isolated and lonely and so seek out contact,
viewing other members of the group as kindred spirits. The dangers of regular outside con-
tact are discussed at the start of treatment. Contact between patients outside treatment in-
terferes with the treatment of the individual and influences the whole group. Patients are
encouraged not to keep their meetings a secret but to discuss them within the group and in-
dividual sessions. Sexual relationships between patients are strongly discouraged. Sexual re-
lationships (and friendships to some extent) involve “pairing” of minds, which alienates
others within the group. Patients frequently underestimate the effect of these dangers.
A Consistent and Coherent Approach

Patients with BPD are very sensitive to inconsistency. Inconsistent responses from an in-
dividual or from different members of a team confuse them, making them suspicious and
anxious. Fear and anxiety lead to instability in their representational system and under-
mine their mentalizing capacity, leading to destabilization of their sense of self. Thus, it is
very important that all therapists on a team are consistent in their interventions; for ex-
ample, they should be consistent in the way they deal with absences, in their reaction to
aggressive behavior, in their management of crises, in their responses to patient demands
(for more, longer, or extra sessions, for instance), and in the discussion of verbal insults.
For therapists to be consistent, they all need to understand the theoretical basis of MBT
and integrate this understanding in their interventions. Only then will they be able to
think quickly and effectively during treatment and tailor interventions, within a coherent
framework, to the uniqueness of each and every clinical situation.
Therapists have to work together to ensure that they all understand the process of
treatment, the reasons for interventions, and how to implement them. A lot of empha-
sis is placed on developing a secure, open, and cohesive team (see subsection Team
Functioning later in this chapter) and making sure every team member is communicat-
ing in the same way, remaining consistent in his or her approach, and thus adhering to
the MBT model.
Training, Adherence to the Model, and

Team Supervision
All team members at the MBT unit work only with MBT to ensure that no confusion
arises in the theoretical framework being used and that their interventions remain
focused on mentalizing. Reading the MBT manual and practical guide alone is not
enough to grasp the concept of mentalization and its translation into clinical interven-
tions that enhance mentalization; training and supervision are necessary. All staff mem-
bers are trained (minimum of the basic course, advanced course, specialist course,
individual supervision, and team supervision) in MBT, but basic training is not enough
to ensure adherence to the model in practice. Staff group reflection and team supervi-
sion are integrated into the program to enhance adherence. Both aim to ensure that
therapists keep to the MBT model and apply it appropriately and with fidelity. In both
the group reflection and the team supervision, the therapist should feel free to discuss
the major evolving transference themes along with his or her countertransference re-
sponses to the patient.
On a daily basis, after working with a treatment group, the therapists have a post-
group reflection to discuss which interventions stimulated mentalization and which in-
terventions were not effective. Once a week, the therapists discuss their adherence by
completing adapted scales currently in development. Two to three times a year, the
group and individual therapists are supervised by senior team members who complete
and discuss the adherence scale. These discussions can become quite critical of certain
styles of interventions, but when the group manages to maintain a mentalizing stance,
the discussion can be fruitful about what makes the therapist move off model.
Once every 2 weeks, the whole staff participates in team supervision. One (alternat-
ing) member of the staff group prepares this session by selecting literature on a topic re-
lated to MBT (often a “hot” topic in the unit, for example, on dealing with crises,
aggression, pretend mode) and preparing a patient-therapist role-play. In the team su-
pervision, 15 minutes is spent discussing the theory, and an hour is spent role-playing.
Staff Selection and Team Functioning

MBT-PH involves a fully integrated team in which all aspects of treatment—psychiat-
ric, psychological, social, and expressive—are integrated into a coherent whole. The
team thus includes mental health professionals with different skills, including psychia-
trists, psychologists, nurses, and art therapists. One of the many advantages of a fully
integrated team is that transferences are split between members of the same team
rather than between independent practitioners. In a well-functioning, cohesive, and
coherent team, split transferences will arise and be discussed, understood, and inte-
grated within the team before beginning to discuss them with the patient. Powerful
countertransference feelings also can be contained and understood in an open and
secure team, often preventing the all-too-common situation of an independent
professional being pushed into inappropriate enactments. Staff selection, training,
group reflection and supervision, intervision, and team support all contribute to a well-
functioning, cohesive MBT team.
Staff Selection
Increasing evidence indicates that who treats the patient in psychotherapy is important.
Some state that a therapist’s qualities may be as important as the characteristics of the
treatment itself in determining good outcomes. Not all therapists are able to treat
BPD. Bateman and Fonagy (2006a, p. 126) suggest:
[Therapists treating BPD patients] need a high degree of personal resilience and quali-
ties that enable them to maintain boundaries whilst offering flexibility, survive hostility
without retaliating, and manage internal and external conflict without becoming over-
involved. They must be effective “team players” and comfortable with working in a
multi-disciplinary group without insisting on strict, professionally determined demarca-
tion of tasks. The rigid, narcissistic, self-protective, defensive professional is positively
harmful to a team approach. The flexible, reflective, communicative, considerate indi-
vidual who is clear about personal and interpersonal boundaries and who can tolerate and
withstand the emotional impact personality disordered patients have on himself and a
team is a bonus.
According to Gunderson (2008), therapists who do well (with borderline patients)

are usually reliable, somewhat adventurous, action oriented, and good-humored. This
translates into being active and responsive. We agree with Gunderson’s description and
would explicitly add that the therapist should be neither too anxious nor too avoidant,
should be able to maintain mentalizing when arousal is high, and should not withdraw
when patients are becoming verbally aggressive but instead should dare to stay active
and responsive, setting clear limits when necessary.
In implementing MBT in several already functioning teams, we have encountered
problems when some members of staff were reactive instead of proactive, slightly
avoidant rather than personally engaging, and more passive than active and expressive.
When patients experience overwhelming affect, such staff members avoid grasping the
patients’ strong feeling states and fail to help patients understand and label the experi-
ence. The patients are left anxious, overwhelmed, and confused. This engenders severe
acting out and boundary violations. The staff members then become more anxious and
feel helpless and incapable, further losing control in the group, with obvious negative
effects on patients and staff. Management of these harmful effects needs effective lead-
ership.
Leadership
The team leader or manager plays a crucial role in developing, implementing, and de-
livering a coherent and consistent MBT-PH program and in managing a group of ther-
apists treating this complex group of patients. Therefore, a team leader must have
excellent communication and leadership skills, the capacity to select employees with
proven affinity with the target population, and the competence to build teams and to
manage staff openness and psychological safety effectively.
Because of the complexity of patients with severe personality disorder, MBT pro-
grams need to be well embedded in the organizational structure of the psychiatric ser-
vices. It is important that the team leader maintain a constructive alliance and sufficient
political influence within higher levels of the organization. At the highest levels, if the
institution’s board members are to facilitate MBT teams, they need to recognize the
risks concerning patient security, such as the dangers of suicide and aggression to oth-
ers. The team leader needs to have a thorough understanding of the theoretical basis of
MBT and to keep a mentalizing stance in leading the team. It is essential that the leader
maintain an overview of the unit and its place within the organization, being able to
mentalize about parallel processes in the patient group, the staff, and possibly the or-
ganization as a whole. He or she needs to keep a distance from transferential processes
in the team and have enough leadership qualities to be able to help reinstate mentaliz-
ing in the staff when necessary and to develop a “critical, self-reflective culture,” for ex-
ample, to prevent staff from acting in reaction to a teleological demand from patients.
Alongside the team leader, at least one other leading staff member is needed, often
the most experienced and senior professional who is naturally respected by all staff, to
help maintain the structure of the treatment program, to support the staff, and to su-
pervise on an everyday basis.
Team Size
How many staff members are needed to create a well-functioning, stable team? (This
issue is also addressed by Kjolbe and Bateman in Chapter 9 in this volume.) In our ex-
perience, a minimum of two partial hospital patient groups consisting of 8 or 9 patients,
each working in parallel, or one partial hospital group combined with one introductory
MBT group is necessary for the unit to be feasible in terms of staff numbers and cost-
effectiveness. It is generally believed that the minimal critical mass for establishing a
functioning team is about 6 people. However, a team of this size is probably too small;
problems will arise with vacations, sick leave, or maternity leave. It would be impossible
to maintain a program in which MBT is applied consistently and coherently with a
team of this size. A team of 8–12 members is probably a better size. This number also
depends on the amount of full-time and part-time employees. The United Kingdom
MBT-PH program initially was run by only full-time therapists, which has many ad-
vantages in that continuity and consistency are easier to maintain. In the Netherlands,
it is nearly impossible to recruit only full-time staff, so the staff complement has to be
larger, and more effort is necessary to keep all the program components linked.
The size of the team also depends on the stage of development of the MBT unit
and the number of patients being seen in different MBT programs. Early in develop-
ment of a unit, a small group of staff makes training easier and facilitates the develop-
ment of a coherent mentalizing culture. When the team is mature, it can be larger. It
becomes increasingly difficult to coordinate care and to share information safely with
more than 12 therapists, and the risks of inconsistency increase.
Another important aspect is staff support to ensure that a relatively stable team
feels confident to provide an open, secure, and supportive culture for patients. Fre-
quent staff changes are unsettling for all patients and for some staff members. Border-
line patients, by definition, are very sensitive to abandonment. Staff changes can lead to
ruptures in a therapeutic alliance, a breakdown in trust, and possibly even a decision to
drop out of treatment.
Team Functioning
Developing a secure, cohesive team is essential for effective teamwork and a well-
functioning MBT unit. Keeping a healthy morale in treating severe personality disor-
ders can be challenging for several reasons. First, borderline patients are emotionally
challenging, at times picking on staff members, finding their weak spots, and under-
mining their therapeutic zeal. Second, change in personality disorder is slow. Third,
splits within the team, whether arising from problems within the patient or in the team
itself, commonly manifest themselves as disagreements that may become polarized,
making it hard for individuals not to blame one another for management or treatment
difficulties. Fourth, the fluctuating nature of the problems of the borderline patient and
the intermittent crises can lead to an onerous workload and constant anxiety about risk.
Finally, a patient’s suicide has a profound effect on not only the individual caring for the
patient but also the whole team.
Sustaining and maintaining a secure, cohesive team with a healthy, enthusiastic
morale can be achieved through a mixture of intervision, team supervision, and group
reflections and the development of a secure atmosphere within the mentalizing milieu.
Intervision
The team’s cohesiveness can be enhanced through staff mentalizing about themselves
and one another—“practicing what they preach.” This is known as intervision in main-
land Europe and among staff groups in the United Kingdom. Once every 2 weeks (al-
ternating with team supervision), the treatment staff have “intervision,” in which a
broad range of team issues can be discussed. These issues are often more personal than
in the team supervision, which is more theoretically and practically oriented. For the
team to be able to work together effectively, it is very important that all members feel
secure enough to talk openly with one another about their own personal emotional re-
sponses in working together and in treating the patients. This can be more important
when disagreement occurs in the team, which is a danger to effective treatment because
it will cause inconsistencies and undermine patients’ (and therapists’) mentalizing ca-
pacity.
Disagreements in the team, often conceived of as “splitting,” can have several causes.
When they occur, the most important point is to try to establish their meaning. Possible
causes include the internal processes of the patient, poor team communication ending in
fragmentation, team members’ own personally unresolved transferences, and difficulties

experienced by the staff. Sometimes they have little to do with the patient. Often, it is a
mixture of factors. Parallel processes become transparent, needing to be dealt with in in-
tervision. Parallel processes are elements of longer-lasting processes found in the patient
group that at the same time are found in the staff and sometimes simultaneously in the or-
ganization. It is often unclear where the process first originated, within the patient group
or within the staff. Reinstating mentalizing about these processes and establishing mean-
ing help to (re)integrate the team and enable the team to offer consistency in treatment.
Different causes of splitting need different interventions. Splitting arising in the
context of unresolved transferences or because of poor communication needs team-
work (intervision) rather than patient work, but splitting caused by projections of the
patient may need clinical discussion within the team (team supervision) followed by di-
alogue with the patient.
During a period when three members of staff were on maternity leave, a member of staff was
on long-term sick leave, and new staff members joined the team because of service develop-
ment, many changes occurred in the unit. The longer-employed remaining staff members
had a lot of extra work covering for the staff absences and training new staff members. They
felt overworked, frustrated that the therapists had all become pregnant around the same time,
and tired. They started to isolate themselves and to describe themselves as “trying to survive,”
to ask for more time off, and to demand to take courses. This led to fragmentation and split-
ting in the team—the “committed” therapists and the “noncommitted” therapists–and less
consistency and coherence in treatment. At the same time, patient attendance dropped dra-
matically, requiring more outreach work. The die-hard patients started forming a group
aligned against the nonattenders, demanding that staff do something and set stricter rules
around attendance.
In team supervision, the theme was the teleological mode. Staff practiced interventions
with role-plays of patients demanding staff action—for example, discharging those patients
who were not attending regularly. The team focused on these problems for several intervi-
sion sessions by discussing the frustrations, the splitting phenomena, and the parallel pro-
cesses with the patient group.
It became apparent that the splitting and the parallel processes arose within the context
of unresolved transferences and because of poor communication. Tracing these processes and
discussing possible interventions reinvigorated the team and reinstated a more thoughtful ap-
proach to the problems in the unit and to managing the patient demands; a mentalizing team
was restored.
Research
Implementing Research and Monitoring System
We find it important to study the effects of our different MBT programs continuously
for research purposes but also to monitor individual patients’ therapeutic progress. All
patients are asked to participate by filling out questionnaires every 6 months until
3 years after starting treatment. Once a month, time is reserved between morning and
afternoon sessions in their therapy program for this purpose. Patients receive an annual
report with personal feedback on the outcome of their measurements. The results from
research lead to new developments.
Research Findings on
in a Partial Hospitalization Setting
Data have been collected on the program described in this chapter. In a naturalistic co-
hort study, 40 Dutch patients with severe BPD and a high degree of comorbid Axis I
and Axis II disorders were assessed every 6 months during a maximum of 18 months of
treatment (Bales et al., in press).
As we have described earlier in this chapter, the De Viersprong Center of Psycho-
therapy was the first to offer MBT-PH in the Netherlands. The MBT-PH program
in the United Kingdom was replicated. The maximum duration of treatment was
18 months of partial hospitalization followed by a maximum of 18 months of mainte-
nance mentalizing (group) therapy. Adherence to the MBT model was monitored by
daily reflections within the staff, use of the adherence scale as described by Bateman
(2004), and weekly team supervision. The team was trained by the developers of MBT,
and in the first year, adherence was rated by Bateman’s observation of group sessions.
Summary of Findings
This prospective cohort study (Bales et al., in press) was the first to show that MBT can
be effectively disseminated outside the laboratory setting. Our findings were of con-
siderable interest because they 1) were obtained by an independent institute, 2) were
reported in a naturalistic setting outside the United Kingdom, and 3) did not involve
exclusion criteria other than schizophrenia or intellectual impairment. The study pop-
ulation consisted of patients with severe BPD and a high level of psychiatric comor-
bidity (including paranoid and antisocial personality disorders, substance abuse and
dependency, and bipolar disorders).
All treatment goals were achieved. First, because only 12.5% of the patients pre-
maturely left treatment because of dropout or “pushout,” it is fair to conclude that the
vast majority of patients were effectively engaged in treatment. Second, self-reported
quality of life, depression, general symptom distress, and borderline symptomatology
all improved significantly within 18 months. Third, we observed a significant decrease
in interpersonal problems and a significant improvement in interpersonal relationships
and social role and personality functioning, all within 18 months of treatment. Fourth,
all patients showed a decrease in self-harm and suicidal acts. Finally, we observed a sig-
nificant decrease in the frequency of additional treatment needed, and no psychiatric

hospitalizations were required.
Future Directions
Future research should address treatment processes and identification of the effective
components of treatment. Although it has been suggested that the focus on stimulating
attachment to the therapist while asking patients to maintain mentalizing capacity is
the key element in effective treatments of BPD, no direct empirical support in favor of
this theoretical claim has been found. Other potential key elements in effective treat-
ments of BPD include the substantial amount of outreach work, the consistent appli-
cation of a coherent approach, and the intensity and duration of treatment (Bateman
and Fonagy 2000; Fonagy and Bateman 2007; Verheul and Herbrink 2007). The search
for patient and therapist characteristics that influence treatment outcome, mechanisms
of change, and key elements of effective treatments all may help to tailor treatments to
individual patients and may thereby lead to more effective and cost-effective treatment.
Conclusion
This Dutch study (Bales et al., in press) showed that MBT can be applied effectively in
other settings and countries and yields strong support for the clinical effectiveness of
MBT-PH in patients with severe BPD and a high degree of psychiatric comorbidity.
Our findings might stimulate clinicians and researchers to stretch the boundaries of
psychotherapy even further, by including patients with severe comorbidities such as
substance use disorders, bipolar disorder, and paranoid and antisocial personality dis-
orders.
Suggested Readings
American Psychiatric Association: American Psychiatric Association Practice Guideline for the
Treatment of Patients With Borderline Personality Disorder. Washington, DC, American
Psychiatric Association, 2001
Bateman AW, Fonagy P: Psychotherapy for Borderline Personality Disorder: Mentalization
Based Treatment. Oxford, UK, Oxford University Press, 2004
Bateman AW, Fonagy P: Mentalization Based Treatment for Borderline Personality Disorder:
A Practical Guide. Oxford, UK, Oxford University Press, 2006
Fonagy P, Gergely G, Jurist E, et al: Affect Regulation, Mentalization and the Development of
the Self. New York, Other Press, 2002
Gabbard GO: Psychodynamic Psychiatry in Clinical Practice. Washington, DC, American Psy-
chiatric Publishing, 2005
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atry Series, Vol 19, No 3; Oldham JM, Riba MB, series eds). Washington, DC, American
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Jørgensen CR, Kjølbye M, Freund C, et al: Level of functioning in patients with borderline per-
sonality disorder: the Risskov-I study. Nordic Psychology 61:42–60, 2009
Jørgensen CR, Kjølbye M, Freund C, et al: Outcome of mentalization-based and supportive psy-
chotherapy in patients with borderline personality disorder: preliminary data from a ran-
domized trial (submitted for publication)
Livesley JG: Practical Management of Personality Disorder. New York, Guilford, 2003
CHAPTER 9
Outpatient Settings
Morten Kjolbe, M.D.
Patients with borderline personality disorder (BPD) make considerable demands on

mental health services and on mental health practitioners. Although many patients re-
ceive treatment for BPD by practitioners working alone, this is probably true only for
those patients who have higher levels of social and interpersonal functioning and who
present with relatively low risk. Patients who are frequent users of emergency services,
persistently attend general practitioner surgeries, and require urgent hospital admis-
sion are likely to be managed and treated within outpatient, day hospital, and inpatient
mental health services. In this chapter, we consider the treatment of severe BPD in an
outpatient setting. Treatment within inpatient facilities and day hospital settings is dis-
cussed elsewhere (see Bales and Bateman, Chapter 8, and Vermote et al., Chapter 10,
in this volume).
227
Principles of Outpatient
Service Development
Evidence is accumulating that some features associated with well-organized research
programs also might be important for engaging patients with BPD in treatment and
keeping them involved over a long time. All research treatments for BPD have a clear
theoretical rationale and treatment structure, are implemented consistently, are rela-
tively long term, and are delivered by staff who work with a coherent theory but who
are not controlling or inflexible.
Mentalization-based treatment (MBT) fulfills all these basic requirements. It was
developed with research as a core element and was organized clinically with psychody-
namic practitioners in mind. It resonates with many principles followed by this group
of therapists (Table 9–1). In addition, MBT uses a commonsense psychology, which ap-
peals to therapists from other schools, incorporating generic ideas that are frequently
used in all psychotherapies and focusing on outcomes of interventions rather than
highly specific techniques. This plurality allows therapists to modify their practice
rather than learn a new therapy. Consequently, more experienced practitioners will re-
quire only minimal training and supervision.
Consistency
As Bales and Bateman discussed in Chapter 8, patients with BPD are sensitive to in-
consistency. Inconsistent responses from an individual or from different members of a
team muddle them and make them anxious. Fear and anxiety undermine their mental-
izing capacity; in turn, they desperately try to explain their own feelings and other peo-
ple’s motivations by becoming increasingly rigid. As mentalizing is lost, rigid object
relations models or schemas of the type that have been clearly identified by dynamic
therapy practitioners or schema-focused therapists, respectively, become operational.
Staff and therapists are stereotyped by the patient. From a mentalizing perspective, the
pathological problem lies with the loss of mentalizing rather than with the application
of the schemas, which are themselves not specific to BPD. However, it is important to
be aware that inconsistent responses from staff members can produce and maintain
rigid and often problematic behavior in patients with BPD. Consistency in the treat-
ment is therefore paramount.
Length of Treatment
Research literature suggests that any treatment for BPD needs to be relatively long
term and should be delivered in a stable environment. The length of time for which pa-
tients need treatment remains unclear. Certainly, short-term treatment for a few
Outpatient Settings 229
TABLE 9–1. Principles of outpatient service development
• Flexible and open-minded staff

• Agreed theoretical base
• Consistent application of treatment model
• Longer-term treatment
• Liaison with acute inpatient facilities when patient admitted
• Responsiveness to emergency departments
• Development of crisis interventions
• Organized supervision
months has no empirical support. Some authors suggest a brief stabilization phase for
acute symptoms, such as suicide attempts and self-harm, followed by a longer-term
program for some of the more stubborn difficulties, such as those related to social func-
tion. Longer-term treatment is considered necessary because chronic symptoms such
as depression, anxiety, aggression, and paranoid ideation are not reduced in short-term
treatments and require a considerable period of time to change. Moreover, patients
with BPD show marked impairment in social and interpersonal functioning, and cur-
rent evidence suggests that these features change slowly, even with treatment. Over
many years, patients struggle with long-term problems in relationships and difficulties
in social interactions.
Acute Inpatient Care

No evidence indicates that acute psychiatric inpatient treatment is effective for BPD.
In fact, the literature indicates the contrary (Gunderson 2008). However, brief inpa-
tient treatment might be useful to stabilize chaotic behavior that is bringing the patient
into contact with the criminal justice system or to manage acute suicide risk related to
comorbid depression.
Understanding BPD from a mentalizing perspective usefully informs treatment in
acute psychiatric settings (Table 9–2). Continual interaction between patients and be-
tween patients and staff over 24 hours is profoundly stimulating and highly likely to
overwhelm the emotional processing ability of borderline patients. As we have men-
tioned repeatedly, the subsequent anxiety reduces mentalizing, leading to the emer-
gence of psychic equivalence and loss of secondary representational process. Inevitably,
the borderline patient struggles to cope and gradually defaults to behavioral responses
that are themselves provocative to staff, setting up a cycle of interactional abuse. Staff
members must learn to withdraw from provocation rather than challenging the patient
and to remain calm when they feel they are losing control, especially when they are
likely acting reflexively to attempt to assert themselves through actions, as in the fol-
lowing examples:
Ms. W, a young woman with BPD, was admitted to the hospital because of suicidal be-
havior, with the aim of reducing her suicidal tendencies and protecting her. The staff in-
tervened by limiting her freedom to go out. Whenever Ms. W was suicidal or self-
destructive, she was either physically restricted or observed through continuous personal
contact with the staff. These attempts to control Ms. W inevitably led to anxiety in the
patient, activating her attachment system and producing overwhelming emotions that
had the potential to trigger new suicidal and self-destructive behavior. As is typical in
such cases, Ms. W and staff were caught in an increasingly destructive interaction in
which Ms. W’s behavior generated aggression in the staff. In this instance, this pattern
culminated in the following incident.
One warm summer day, Ms. W expressed a desire to sit in the garden. She was de-
nied this request because of the shortage of staff in the department on that particular day.
They believed that she could not be alone in the garden because of her suicidal behavior.
Ms. W then pointed out that a staff member was already in the garden. But she was in-
formed that the staff member was from another department and told that if she did not
comply, she would be restricted to her room, by force if necessary. Ms. W reacted by at-
tempting to jump out of the window. This triggered a violent interaction in which one of
the staff members was kicked. From a mentalizing perspective, neither Ms. W nor the
staff members were able to mentalize, and as a consequence, the interaction became fixed
in the teleological and psychic equivalence modes, with aggressive behavior as the result.
Ms. V, another patient, was found to have barricaded herself in a day room on the inpa-
tient ward. Staff asked her to remove the barricades, but she refused. They then tried to
force the door but had no success. Eventually, the police were called and asked to break
down the door. They did so, and Ms. V was forcibly removed from the room and sedated.
When the incident was reviewed with Ms. V, it became apparent that she felt she had to
shut herself in the day room on her own because this was the only way in her view to get
some “peace.” Continual interaction with others was exhausting. Because she was as-
sessed as a suicide risk, she was observed regularly by staff and not allowed off the ward,
so she had no chance to be on her own. Unable to express her feelings to the staff, Ms. V
managed the situation in the only way she knew how.
The care of patients with personality disorder in nonspecialist psychiatric services

is universally of limited value. Recurrent admissions, frequent attendances in crisis, and
excessive demands are common. It is useful to identify those patients with BPD who are
admitted to the hospital and identify their pathway of care over time. Prolonged hos-
pital admission with unwarranted detention based on concerns about suicide risk is
common.
Practitioners also should be aware that suicide risk is increased at hospital dis-
charge, not necessarily as a result of the discharge itself but more because a coherent
discharge plan is not developed. Discharge that takes place as a result of a failed con-
tract (e.g., breaking an agreement about not bringing drugs onto the ward) increases
TABLE 9–2. Risks of inpatient care for borderline patients
• Excessive stimulation as a result of the ward context

• Overzealous nursing related to anxieties about suicidality
• Lack of differentiation between acute and chronic risk
• Management via action in response to psychic equivalence
• Motivations of patient understood by staff according to teleological principles
risk. Patients are often discharged with immediate effect in these circumstances, with-
out careful exploration of their actions. No mentalizing of the events takes place in the
mind of the treatment team. Inevitably, nonmentalizing in the staff begets nonmental-
izing in the patient, so the action of ejecting a patient from an acute care ward is matched
with a reciprocal action from the patient.
Crisis Interventions and When to Admit

Patients With Borderline Personality Disorder
It is important to have a close collaboration with the emergency department because
patients with BPD are high consumers of acute services. BPD patients with chronically
suicidal behavior are at increased risk for receiving acute psychiatric interventions, of-
ten with adverse effect. It is an important task for the casualty staff to be able to differ-
entiate between acute and chronic suicidal behavior in patients with BPD. Acute
suicidal ideation often involves an experience of loss. The patient often reacts with the
development of depressive symptoms and an increased risk of suicide. Because the task
is to prevent suicide, admission needs to be considered. To reduce the risk of an unpro-
ductive and long admission, it is vital to make a plan for the duration and purpose of the
admission and for the follow-up after admission.
In the case of chronic suicidal ideation, it is important to view the patient’s behavior
as part of a pathological object relation and a breakdown of mentalization. As we have
pointed out, the main task of the staff in such cases is to remain calm and to avoid acute
interventions, which often only serve to make matters much worse. Here the task is to
help the patient regain the capacity to mentalize by intervening according to MBT in-
tervention procedures, described later in this chapter.
Access to Treatment
Pathways to treatment are an important consideration. BPD patients are poor mental-
izers under stress, and this can create problems in both routine and crisis situations.
Many BPD patients have difficulty attending treatment, and these problems greatly in-
crease when the path to treatment is complicated or long. Accordingly, it is our expe-
rience that patients who live a long way from the treatment facilities or who have a
complex journey to attend treatment have an increased risk of dropping out. Many pa-
tients cannot cope with the prospect of a long journey or with having to change trans-
port several times to reach the outpatient or day hospital facilities. This is an important
consideration when planning the strategy for the treatment of BPD patients in a larger
region. Solutions to this problem are either to have several specialized clinics with short
and easy pathways to treatment or to create a transport system that will make it easy to
arrive at the central specialized treatment unit.
Staff Selection and Team Function

Not all therapists are well suited to working with patients with BPD. Finding the most
appropriate staff can be difficult simply because we have limited information about the
characteristics of therapists necessary for successful treatment (Table 9–3). According
to Gunderson (2008, p. 241), “[T]herapists who do well (with borderline patients) are
usually reliable, somewhat adventurous, action-oriented, and good-humored. This
translates into being active and responsive.” Although these features are not specific to
any professional group, nurses are often better trained to manage crises and to react
calmly to provocation in comparison with other mental health professionals. The ini-
tial research trial of MBT in a day hospital setting showed convincingly that MBT can
be executed by trained nurses under supervision.
Several areas of additional expertise also may be important: ability to appraise and
to develop treatment, capacity to deliver treatment itself, interest in development of a
team culture, and knowledge of research. Team members must have the skills among
them to make a consistent diagnosis and to manage complex patients with comorbid
disorders if they are to have the capacity to deliver a comprehensive treatment pro-
gram. Some comorbid disorders, such as drug misuse, depression, impulse-control
problems, and binge-eating disorder, must be managed within the treatment program
for BPD, whereas others, such as schizophrenia, bipolar disorder, other psychotic dis-
orders, and drug addiction not in remission, are likely to be managed and treated within
a joint care arrangement.
Another important question is how many staff members are needed to create a sta-
ble team. Teams can be too small or too large. It is generally believed that the minimal
critical mass for establishing a functioning team is about 6 people, but a team of this size
will be very vulnerable to sick, maternity, and paternity leaves, so a better number is
probably around 8 people. Once a team grows to more than around 10 people, it be-
comes increasingly difficult to coordinate care and to share information safely, so the
risks of inconsistency become greater.
Defining a caseload for members of a team is an area fraught with difficulty. Borderline
patients are notorious for not coming to treatment sessions or attending at inappropri-
ate hours. Time needs to be allowed for acute consultations, crisis intervention, and be-
tween-session contacts. From a mentalizing perspective, contact with the patient who
TABLE 9–3. Some factors important for staff and teams working with patients with
borderline personality disorder
• Reliable, adventurous, flexible, and good-humored staff

• Balance of skills across the team
• Ability to manage anxiety of suicide threats and other crisis situations
• Interest in delivering treatment within a team
• Size of team not too small or too large
attends erratically is very important, particularly during the initial phase of treatment,
because the patient often will take noncontact from the therapist as proof that he or she
is indifferent; failure of the therapist to make contact with the patient who fails to at-
tend equates to “The therapist didn’t notice that I was not there” in the mind of the pa-
tient (who is operating in psychic equivalence mode).
Teamwork
The argument that it is beneficial to work with borderline patients in a team setting is
supported by the literature (National Institute for Health and Clinical Excellence
2009b). Some of the advantages are that it is easier to meet treatment demands in a
team setting, powerful countertransference feelings and reactions are diluted when the
patient has several therapists, and the team structure reduces the burden on an individ-
ual therapist. The team can provide a supportive culture for both patients and thera-
pists, which is essential to the treatment of BPD. This requires a relatively stable team.
Frequent staff changes are unsettling for all patients; at best, they lead to uncertainty in
a patient about whether to continue treatment, and at worst, they trigger a rapid end to
a therapeutic alliance and a breakdown of trust. This is particularly so for patients with
BPD who, by definition, are “sensitive to abandonment.”
Countertransference and Supervision

It is well known that working with borderline patients can lead to powerful emotional
responses in therapists. Supervision integrated into the working pattern of staff is an
absolute necessity. We think that it is not possible or desirable to treat borderline pa-
tients without supervision. Unless a constant focus is maintained on the emotional
states of the staff or the way the therapist acts with the patient in the treatment, the risk
that the individual treatment and the treatment setting in general will become frag-
mented and fail to maintain therapeutic boundaries is increased. Supervision must be
within the theoretical frame of reference and include all the staff members. Fragmen-
tation of the treatment team may lead to differences in approach and lack of coherence,
which will destabilize patients with BPD.
At one point, half of the staff members of the Clinic for Personality Disorder, Aarhus
University Hospital, Denmark, were trained group analysts and were the primary ther-
apists in the group therapies. They had separate supervision by a group analyst outside
the clinic. This led to the team being divided into an individual and a group section,
which resulted in a fragmented treatment program. In particular, problems occurred
when the patients in individual therapy were supposed to begin group therapy after
3 months of preparatory individual work. Patients would not start in group therapy, and
the individual therapists were not consistent enough in their arguments about group
therapy and were reluctant to insist that patients start group therapy. The individual
therapists became the patients’ defenders against the thought of group therapy. This ex-
perience led us to change our procedure regarding who was doing group therapy. We
went from having single group therapists to cotherapists for each group, which meant
that most staff members participated as group therapists and that all staff, whether par-
ticipating as cotherapists or not, participated in supervision of the group therapies. This
structural change integrated individual and group therapy in our minds and significantly
reduced the problems of patients starting in group therapy.
This is just one illustration of the need to constantly consider whether difficulties
with patients or with the therapy point to a problem with the therapist or with the treat-
ment system. This viewpoint is in accordance with the MBT model.
Developing a Mentalizing Culture in Groups

Starting a new group for patients with BPD is hard work for both patients and thera-
pists. Patients with BPD have difficulties representing other people’s minds and thus
are likely to become confused in a group. Anxious and uncertain patients become agi-
tated, and therapists need to anticipate sudden mental changes while maintaining a
calm and thoughtful atmosphere in the group. The therapist therefore has to work hard
at motivating the patient to participate in group therapy and be aware that overstimu-
lation is likely to lead to dropout.
The literature suggests that the number of dropouts in the start-up phase of group
therapy is high in patients with BPD (Marziali and Monroe-Blum 1995). There are two
ways to solve this problem. First, the therapist should carefully select the most stable
patients on the waiting list when starting a new group for people with BPD and avoid
patients who are chaotic or unstable because of housing problems or small children. Al-
though this is often not feasible for clinical services, it can be important to consider how
to create a stable group that can contain the most unstable patients with BPD.
Second, the therapist should establish slow open groups. Slow open groups have an
intrinsically supportive system; new patients can benefit from the experience of pa-
tients who have been in the group for some time. These experienced members can tell
the new arrivals about how they experienced the group at the beginning of their treat-
ment and what they have learned from the group during their treatment.
Form of Treatment
MBT as a research intervention in an outpatient context is practiced as a combination
of individual and group psychotherapy. Some other therapies for BPD also offer a com-
bination of group and individual treatment (e.g., dialectical behavior therapy), but oth-
ers offer individual psychotherapy only (e.g., transference-focused psychotherapy and
schema-focused psychotherapy) or group psychotherapy alone (e.g., interpersonal
group psychotherapy for BPD). Group therapy alone has not been sufficiently studied,
and an empirical question remains about whether this format can be effective on its
own (see Karterud and Bateman, Chapter 4 in this volume, for further discussion). Cer-
tainly, from a mentalizing perspective, it is often easier for patients to mentalize com-
munications from peer members than those from the therapists. Communications
from the therapist produce more emotions and may evoke more powerful transference
issues. As a stimulus for further research in this area, the first author (M.K.) developed
a research program embedded within a clinical service comparing two different inten-
sities and combinations of treatment in a randomized controlled design. We describe
this clinical research program, which remains in the spirit of MBT, aiming primarily to
increase mentalizing of patients with BPD.
An Experimental Outpatient Program

for Borderline Personality Disorder
Assessment Process
After referral, the patient is first seen by either a psychiatrist or a psychologist for two
or more assessment interviews. The patient’s desire for help can be molded into a pos-
itive therapeutic alliance. Although patients with BPD are reported as often presenting
in states of panic, anxiety, and anger, this refers primarily to crisis presentation. More
commonly, patients present for assessment as compliant but a little desperate, fearful
that they will be rejected and prevented from receiving the treatment they desire. The
therapist who openly expresses interest in their underlying mental states, the key to the
mentalizing process, will be rewarded with the rapid development of a positive thera-
peutic alliance.
In the first interview, the way in which the patient presents himself or herself and any
problems is explored, together with the way the patient interacts with others and with the
interviewer. A psychodynamic problem formulation is then made jointly with the patient.
In the second interview, the main focus is on the assessment of personality disorders and co-
morbid Axis I disorders through the application of the appropriate structural interviews. To
ensure reliability in diagnostic practice, the doctors and psychologists perform a sample of
Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II) inter-
views together. Following this extended assessment, the patient is given a comprehensive
psychoeducational report, in which the formulation and diagnosis are discussed. The pa-
tient does not need to be in complete agreement with the evaluation, but he or she must at
least understand why the team reached their conclusions.
If the patient fulfills the DSM-IV-TR (American Psychiatric Association 2000) diag-
nostic criteria for BPD, he or she is informed about the treatment program, group therapy,
and the research design and asked to participate in the randomized controlled trial (see Fig-
ure 9–1). If the patient agrees, then he or she is randomly assigned to either weekly group
treatment or weekly combined individual and group therapy. In both treatment programs,
the need for medication is assessed, and the patient is offered participation in a psychoed-
ucational program about BPD after starting therapy. All participants can attend this pro-
gram several times during their treatment in the clinic.
Pamphlets describing the research project and the treatment program and a small
booklet on BPD are provided.
Start of Treatment
On starting the treatment, the patient is invited to an introductory session with the team. In
this session, the patient is introduced to the team members and to the future therapists.
During the session, the interviewer, who is either the primary interviewer from the assess-
ment or the first author, evaluates whether the patient’s symptoms or life situations have
changed since the assessment interview. The patient is informed about how the team mem-
bers work together, and the following areas are discussed with the patient: 1) all members of
the team discuss the patient’s treatment; 2) the individual and group therapists discuss the
respective sessions with each other; among other things, this promotes mentalizing of one-
self in other contexts; and 3) the group therapist is cautioned not to mention information he
or she has learned from the individual therapist in the group unless the patient has volun-
teered it in the group.
Special attention is paid to how the patient is able to attend the treatment program and
to potential factors that might interfere with this and increase his or her risk of dropout. In
our experience, several factors are significant. First, as we have already mentioned, not only
the distance but also the complexity of the transportation to the clinic is important. How
long does it take to get to the clinic? How many changes of bus or train are necessary? Does
it fit in with work or other commitments? Second, the patient’s close partner or family
members need to understand treatment and even be offered help themselves so that they
can support the patient’s attendance. Too often relatives and family members are forgotten,
leaving their concerns and difficulties unaddressed. Finally, the patient’s motivation for
treatment and possible misuse of alcohol or drugs must be discussed because these also may
increase the risk and likelihood of dropout.
Referral Medication following APA standardsa
PE PE
Assessment IS Group therapy, 2 years Follow-up, 1½ years
PE PE
IS Individual therapy, 1½ years All sessions are videotaped.
Group therapy, 1½ years Follow-up, 1½ years
FIGURE 9–1. Patient pathway in research trial.

IS=introductory session; PE=psychoeducation.
a
Oldham J, Phillip KA, Gabbard G, et al.: Practice guideline for the treatment of patients with bor-
derline personality disorder. American Psychiatric Association. Am J Psychiatry 158:1–52, 2001.
Treatment Processes
The treatment of BPD has evolved considerably since the discussion in the 1980s of
whether to use solely supportive or explorative interventions. From a psychoanalytic point
of view, Gabbard (2000) has argued that the therapist in general must use interventions
along an expressive-supportive continuum. From the perspective of treating BPD in par-
ticular, both Gunderson et al. (2005) and Livesley (2003) stressed the importance of a
phase-specific model. The idea of phase specificity is also inherent in the MBT model, in
which the course of therapy is divided into an initial, a middle, and an end phase. Within
these phases, the interventions are given in accordance with the intervention spectrum as il-
lustrated in Figure 9–2.
Figure 9–2 shows the progress of one borderline patient from the first author’s clinic,
illustrated by the change in Hopkins Symptom Checklist–90 (SCL-90; Derogatis 1983)
global severity index. It is notable that the patient’s condition worsens shortly after starting
treatment and that a reduction in symptoms occurs after only 6–9 months. After therapy
termination, this patient showed a persistent decline in the intensity of symptoms.
Problematic
2.5 behavior and
affect regulation
2
Global Severity Index
Consolidation
of mentalization
1.5
Treatment
1 alliance and
supportive
interventions Problematic
0.5
relationships
0
0 2 4 6 8 12 16 20 24 6 (30) 12 18
Assessment Termination (36) (42)
Time (months)
FIGURE 9–2. Phase-specific model of treatment of borderline personality disorder.
Treatment Alliance
In accordance with the MBT model, the initial aim is to establish a treatment alliance.
This is done by informing and teaching the patient about the problems of BPD. The
main intervention strategies are psychoeducational and supportive. The patient is also
told to be prepared for the risk that his or her condition may deteriorate in the early
stages of treatment, both as a result of the attachment exposure and because starting to
discuss one’s life problems is bound to create distress and discomfort. The therapist also
must be prepared to work actively to reestablish the therapeutic alliance whenever it
ruptures during the course of treatment. These ruptures are especially likely at the be-
ginning of treatment and after crises either in the patient’s life or in therapy itself.
Mentalization-Based Treatment Interventions

The principles for therapists to follow are very simple and are illustrated in Figure
9–3. Interventions are deliberately illustrated from surface to depth, with support and
empathy at the surface. When patients’ emotions are high, their mentalizing capacity is
low, and therefore the therapists’ interventions should stay on the surface (i.e., support-
ive and empathic). When the capacity to mentalize improves, as a consequence of ei-
ther less emotional arousal or therapeutic work increasing the ability to manage
emotional states, interventions can move toward deeper levels with the proviso that a
Support and empathy

+
+ Emotional intensity –
Clarification and elaboration

Mentalizing
Basic mentalizing
Interpretive mentalizing
–
Mentalizing of transference
Attention to the transference/countertransference
FIGURE 9–3. Principles of mentalization-based treatment interventions for therapists

to follow.
focus on mentalizing of the transference is emphasized only later in therapy or when

the mentalizing capacity of the patient increases.
It is important to evaluate the patient’s mentalizing capacities constantly and tailor
interventions accordingly. The following clinical example illustrates the implications of
a failure in this capacity in the therapist and shows how it can be remedied through the
use of the MBT principles:
Ms. Z, a patient with BPD, came to her individual session and began by expressing her
anger with the therapist. The therapist responded at the level of clarification by saying,
“That sounds important. Could you tell me more about that?” Ms. Z then reported that
she was angry about something that had happened in the last 5 minutes of the previous
session. As she described the situation in more detail, the therapist began to recollect the
episode in his mind and in doing so made a comment about a discrepancy between her
experience and his memory of the same events. Ms. Z reacted by exploding in anger, ac-
cusing the therapist of being extremely narcissistic and self-centered. At first, the thera-
pist felt wounded and reacted defensively, which further enraged Ms. Z and resulted in a
further violent verbal attack on the therapist. The therapist recognized that his comment
had provoked Ms. Z’s wrath, and her mentalizing was decreasing rather than recovering.
He correctly realized that, in terms of mentalizing, the only option was to focus on his
own contribution to her state. His actual experience was that acknowledging his own
contribution was a submission rather than simply a way to reduce the tension of the ses-
sion. Piecing this together in his mind (i.e., continuing his own mentalizing), the thera-
pist then thought that this was a concordant countertransference (this is discussed
further in the Countertransference section of Chapter 3), in which he was a little child,
the self part, that was terrified of a monstrous aggressive father, the object part, and the
only way of surviving was by submission. Suggesting this to Ms. Z would present the pa-
tient with the therapist’s understanding. This is a nonmentalizing intervention and is
therefore contraindicated in MBT not only because it does not support the mentalizing
capacity of the patient at that moment but also because the therapist is taking over the
mentalizing process from the patient at the very point when he should be trying to re-
kindle it. However, the therapist also realized that the power and anxiety contained
within his experience suggested that Ms. Z was in a concrete and teleological mode; ex-
pressing different views of minds at these moments is contraindicated in MBT.
This understanding helped put the therapist back on track (i.e., realizing that Ms. Z
was in a nonmentalizing mode meant that she could not tolerate differences of opinion).
Therefore, the therapist intervened according to the model by being supportive and em-
pathic rather than making a transference interpretation. “I can understand that you are
angry with me because I wasn’t able to understand you. Could we just take a small break
here and try to understand what happened when I misunderstood you?”
The crisis was resolved, and later in the therapy this interaction became quite im-
portant and was very helpful to Ms. Z in understanding and working through her prob-
lems. Revisiting the incident on several occasions allowed Ms. Z to understand the
effect she could have on others when she found herself determined to make them sub-
mit to her view and how she could also feel that people were trying to convince her to
believe things that she thought were incorrect.
Interventions Over the Course of Treatment

Not only the type of intervention but also the focus of the intervention changes during
treatment, as illustrated in Figures 9–2 and 9–3. Initially, supportive interventions are at the
forefront of treatment, but as problematic relationships are considered, more detailed in-
terpretive mentalizing takes place with the use of transference tracers. These are indicators
that the relationship with the therapist is relevant to understanding the relationships that
the patient has in his or her current life. Consolidation of mentalizing requires a reasonably
robust mentalizing capacity, and then mentalizing the transference can be effective.
After the therapeutic alliance is established, the main focus is on problematic behav-
iors, such as self-destructive or suicidal behavior. The MBT principle of working from sur-
face to depth interventions is applied, and concrete episodes are explored by applying the
mentalizing functional analysis, which is described later in this section.
Both our data and our therapeutic experience suggest that patients have the most dif-
ficult time in therapy when they recognize that what they are doing is destructive but are
unable to change. Changing behavior takes time, and only after repeatedly working
through the mentalizing functional analysis will patients be able to make some changes in
their life. When this occurs, it marks another shift in the therapeutic focus, from behav-
iors to relationships. Of course, relationships have been part of the therapeutic focus all
along because this is very much in the MBT model, but now the focus is more on the way
the relationships function and the changing of relationships. The patient often begins to
have a different experience of self and other and of the way he or she interacts with others.
This paves the way for changes in internal object relations and behavior in relation to
other people. Quite frequently, the patient changes not only his or her self-concept but
also his or her concepts of partners and friends.
In the last part of therapy, therapists emphasize consolidation of the capacity to men-
talize. At the beginning of therapy, the patient cannot mentalize in the face of emotions.
Later, the patient can begin to mentalize with the help of the therapist, but often gener-
alization is limited, and the patient fails to mentalize in many circumstances outside the
therapy sessions. Toward the end of therapy, the hope is that the patient will be able to
mentalize both in and outside the treatment setting. However, only careful follow-up of
patients will determine whether this aim is achieved. Clinical data suggest that it is
achieved to some extent:
One patient said in the last group session: “My life started two years ago when I began
therapy. Before, I was confused and did not know who I was or what I felt. Now I know
who I am, and I am in contact with my feelings.”
Another patient said that one day as she was going for a walk, after she had ended
therapy, she noticed that she had a shadow and realized for the first time in her life that
she was a person and not just a sexual object that men could use or misuse.
A third patient e-mailed, “Thank you for giving me back my life,” and asked for the
slides from the psychoeducational program because she wanted to give a lecture on bor-
derline conditions and their treatment at her school.
The Mentalizing Functional Analysis

The mentalizing functional analysis follows the principles of the basic mentalizing level
in the MBT intervention model. It is a structured and easily manageable intervention ap-
proach, used either to help the patient and therapist work through emotional storms in
the heat of the therapy session or to address destructive behaviors that are reported by the
patient. Hence it is commonly used early in treatment when behavioral disturbance is of-
ten more apparent.
Patients with BPD become addicted to their self-destructive behaviors and are ter-
rified that their struggle to control and reduce those behaviors may result in chaos and
more self-destructive behavior. It is important for the therapist not to try to control the
behavior because he or she will not be able to do so. Instead, the therapist needs to regard
the act as an attempt to restabilize mental function once stability has been lost. From a dy-
namic and mentalizing perspective, the destructive act suggests that a collapse in men-
talization has occurred. This collapse in mentalization is often precipitated by a relational
event or another emotionally provoking situation. The therapist therefore goes through
several steps (Figure 9–4).
The first step for the therapist is to help the patient explore the content of this
event with the stop, stand, and rewind technique. The therapist must focus on the event
even if the patient does not want to talk about it. Of course, if focusing causes too much
anxiety for the patient, the therapist needs to allow the patient to talk about other
things before sensitively returning to the topic. Second, the therapist must probe by
asking what was going on in the patient’s mind before the event took place. This is as
important as finding out about the external context. The mentalizing functional anal-
ysis is concerned with the patient’s state of mind and its interaction with external cir-
cumstances. Often, the patient is not able to remember what triggered the reaction;
after all, the main function of the reaction is to elude the participating event and the
emotions that it creates. The therapist’s task is therefore to go back to “neutral terri-
tory,” through a stop, rewind, and explore, and then begin to progress in time. With
this method, the triggering process is explicated and can be further explored in rela-
tional terms when appropriate.
Throughout the process, the therapist and patient focus on the breakdown in men-
talization and explore what kind of nonmentalization the patient used. Exploring and
understanding the emotions that the breakdown in mentalization produces form the
core of the mentalizing functional analysis.
Then the therapist and patient explore the motivation and function of the action
and finally explore the often negative consequences of the reaction.
Ms. Y, a borderline patient, reacted to her boyfriend’s announcement that he and his
friends were off to a football match by cutting herself. Her experience of being alone pro-
duced an unbearable stress that led to a breakdown in mentalization. Ms. Y began to expe-
rience her boyfriend’s absence in psychic equivalence mode. Her concrete understanding
interpreted the boyfriend’s absence as proof that he did not love her. Further development
of this idea led her to more rigid schematic thinking in which she “knew” that he was really
out on a date with somebody else (i.e., misuse of mentalization). This inevitably produced
more intolerable feelings that Ms. Y could not manage. Her only option, or rather the only
possibility she could think of, was to cut herself. This self-destructive act made her relax,
but unfortunately it also produced shame. When her boyfriend returned, he became angry
on noticing her bandaged wrist. This perpetuated her cycle of self-criticism.
By working through these patterns of rapidly changing mental states in a wide

range of circumstances, the patient gradually learns that feelings are not something that
spontaneously arise; rather, they are created by interactions with others and interpre-
tations of those interactions. Understanding the process as it is happening allows men-
talizing to be maintained.
Research
Our research efforts are integrated into our daily clinical practice. In our first project
(Risskov I), patients were randomly assigned to either combined mentalization-based
Content? Affect? Motivation? Function?
Precipitating
factor Emotions
Internal and Interpretations Reaction
external
Breakdown in mentalization
Pseudo- Concrete Misuse of Consequence
mentalizing understanding mentalizing
FIGURE 9–4. Mentalizing functional analysis: therapist’s steps to address breakdown

in mentalization.
psychotherapy or supportive psychotherapy in an outpatient setting. Two-thirds of the

referred borderline patients were offered the combined treatment consisting of weekly
individual psychotherapy for 18 months, supplemented after 3 months with weekly
group psychotherapy for 18–20 months, whereas the remaining one-third were offered
supportive therapy consisting of group therapy every 2 weeks. Both treatment groups
were offered group-based psychoeducation once a month for 6 months (patients were
allowed to participate several times in the psychoeducational program) and medical
treatment in accordance with the recommendations of the American Psychiatric Asso-
ciation (Oldham et al. 2001). Treatment duration was 2 years.
Our current and ongoing study has 108 patients. The demographic and clinical
characteristics are as follows: an overwhelming majority (95%) of our patients are fe-
male, the mean age is 29.2 years (SD=6.2 years), and most of the patients are either liv-
ing alone (46%) or alternating among several partners (24%), moving constantly from
one partner to another. On average, the patients met 6.7 of the 9 DSM-IV-TR diag-
nostic criteria for BPD (SD=1.2) and met diagnostic criteria for an average of 2.2 co-
morbid Axis I disorders. The most common Axis I diagnoses are past recurrent or
current major depressive disorder (n=80; 74%), anxiety disorder (n=37; 34%), and eat-
ing disorder (n=51; 47%). At the time of assessment, 18 patients (17%) received a di-
agnosis of alcohol abuse, and 14 (13%) received a diagnosis of substance abuse. The
most common comorbid Axis II conditions were dependent personality disorder
(n=35; 32%) and avoidant personality disorder (n=14; 13%).
Of the patient sample, 25% reported being sexually abused in childhood or being
raped in adolescence or adulthood. More than three-quarters (81%) reported self-
destructive behavior, more than one-quarter (27%) within the last 3 months, and more
than two-thirds (68%) reported making at least one suicide attempt at some point in
their lives.
The average level of education is low compared with the general population in
Denmark. Almost half of the patients (43%) have completed only primary and second-
ary school or the equivalent to this (less than 10 years of education). Only 2 of 108 pa-
tients have an academic degree; 17% are students. Not surprisingly, a remarkable
proportion of the patients (75%) are either unemployed or receiving social security
(70%) or permanent pensions (5%). Only 7% are employed. Almost two-thirds of the
patients in our study (64%) were taking antidepressant drugs at the time of assessment,
and 31% were not taking medication.
Overall, this group of patients represents a typical clinical sample with few exclu-
sion criteria, and outcome data will be published in due course.
Conclusion
Patients with BPD make considerable demands on mental health services, unfortu-
nately often with negative responses and consequences. However, research has clearly
shown that outpatient treatment programs with a coherent theory and clear structure,
when applied consistently over a relatively long term, can lead to a significant improve-
ment for patients. MBT fulfills all these requirements (see Table 9–4). Long-term
treatment is important to reduce chronic symptoms such as depression, anxiety, aggres-
sion, paranoid ideation, and impairment in social and interpersonal functioning.
In constructing a treatment program for patients with BPD, it is also important not
to overstimulate the attachment system because this inevitably will lead to failures in
mentalizing capacity. This is often the problem when borderline patients are admitted
with suicidal behavior. In these circumstances, it is not uncommon for both the pa-
tients’ and the staff’s mentalizing systems to be undermined, which further undermines
the patients’ mentalizing capacity and results in increased suicidal behavior. It is there-
fore important to remember that when staff members fail to mentalize, patients’ fragile
capacity to mentalize will be further undermined. Supervision is therefore paramount
in any treatment program for borderline patients. It is likewise important to be alert to
the possibility that problems in the therapy can derive from problems in the treatment
system. In summary, mentalization offers a consistent theory and MBT a simple and
commonsense-based treatment.
TABLE 9–4. Five key clinical points of mentalization-based treatment in

outpatient settings
1. Patients with borderline personality disorder have a right to receive evidence-based

treatment.
2. The treatment program must have a coherent theory, have a clear structure, be long term,
and be applied consistently.
3. Patients with borderline personality disorder cannot mentalize under stress and have
difficulty with regulating their emotions. Mentalization-based treatment addresses
these problems.
4. The clinician must be careful not to overstimulate the attachment system, which can
undermine the patient’s capacity to mentalize.
5. Staff supervision is necessary for the treatment program to be effective.
Suggested Readings
Bateman A, Fonagy P: Psychotherapy for Borderline Personality Disorder. New York, Oxford
Bateman A, Fonagy P: Mentalization-Based Treatment for Borderline Personality Disorder.
New York, Oxford University Press, 2006
Choi-Kain LW, Gunderson JG: Mentalization: ontogeny, assessment, and application in the
treatment of borderline personality disorder. Am J Psychiatry 165:1127–1135, 2008
CHAPTER 10
Psychodynamically
Oriented
Therapeutic Settings
Mentalization-based treatment (MBT) is increasingly being offered to people with

borderline personality disorder (BPD) and is successfully applied in a wide range of
treatment settings around the world (e.g., Fonagy and Bateman 2006a). Originally de-
veloped in a day hospital context, MBT is now offered to patients in outpatient services
and in inpatient settings. However, many services, particularly inpatient and day patient
247
services, currently offer psychodynamic treatment rather than MBT itself, and the staff
are trained primarily in dynamic therapy. Many of these groups want to integrate MBT
into the existing therapeutic culture. This requires a different approach from starting
MBT anew. In this chapter, we discuss whether it is possible to integrate MBT with ex-
isting psychodynamically oriented treatment programs delivered in inpatient and day
patient settings, without either treatment losing its distinct characteristics. The service
discussed in this chapter offers treatment to a heterogeneous group of people with per-
sonality disorder rather than only patients with BPD.
A central assumption of this chapter is that MBT and dynamically oriented ap-
proaches are distinct but overlapping treatments and that it might be possible to orga-
nize a treatment program that integrates both models while offering MBT or dynamic
therapy according to the patient’s needs. When possible, the choice between modalities
would be based on pretreatment variables and the phase of the treatment to ensure that
patients receive the most effective interventions at the appropriate time in treatment.
However, the two approaches are not neutral techniques. Each entails a specific mind-
set of the therapist, and each has a distinct view about the mechanisms of mental
change. Therefore, bringing the two models together in one setting necessarily evokes
several complex staff and organizational dynamics, which we discuss in this chapter.
First, we describe the existing psychoanalytic treatment setting and the empirical
background on which we based our decision to integrate MBT with a psychoanalytic
treatment approach. In the second part of the chapter, we discuss clinical applications
and illustrate in more detail how MBT is implemented in family and couples therapy
and in supervision with the nursing staff. We believe, congruent with MBT principles,
that an essential part of treatment of patients with personality disorders entails a rela-
tionship focus, particularly given the roots of the capacity for mentalizing in attach-
ment experiences. Therefore, family and couples therapy implemented in the
treatment setting give an in vivo opportunity to foster mentalization in the context of
real attachment figures. Similarly, in supervision with nursing staff, the capacities for
mentalizing of patients and nurses in interaction are explored in an open atmosphere,
which is seen as in vivo training and a necessary support and guarantee of the setting’s
mentalizing culture.
Clinical Setting
The service for clinical psychotherapy at the University Psychiatric Hospital of Lou-
vain’s Kortenberg campus (known as KLIPP) has existed for more than 35 years. The
service offers psychoanalytic therapy in six groups of patients with mixed inpatients
(n=32) and day hospital patients (n=16), so that a shift from full-time into day treat-
ment is facilitated. All patients have personality disorders, according to DSM-IV-TR
Axis II disorder criteria (American Psychiatric Association 2000), or a borderline per-
sonality organization (BPO), according to Kernberg’s (1996) conceptualization.
Psychodynamically Oriented Therapeutic Settings 249
Conceptualizing a Psychoanalytic Process

in Patients With Personality Disorder
Understanding the process of psychic change in a heterogeneous group of patients with
personality disorders is difficult when the classic concept of the psychoanalytic process
is used. This classic psychoanalytic process consists of repetition of the past, content in-
terpretation, and working through (Vaughan and Roose 1995). In our opinion, such a
conceptualization represents only a small aspect of the functioning and treatment in
patients with a borderline personality organization. We therefore conceptualized the
underlying basic psychoanalytic process in patients with personality disorder as occur-
ring along three dimensions (Vermote 2005; Vermote and Vansina 1998):
1. A background dimension, consisting of an inner feeling of safety, as described in the

work of Balint, Winnicott, Sandler, and Sroufe, similar to the concept of a secure
base originally described by Bowlby
2. An object relations dimension, essentially based on the work of Kernberg (e.g., Clarkin
et al. 1999b)
3. A mentalization dimension, as elaborated by Bion and by Bateman and Fonagy
This conceptualization leads to a more differentiated view of the nature of person-

ality pathology and the ensuing therapeutic process in patients with personality disor-
ders compared with patients with higher-level neurotic functioning. In particular, in
our view (see Figure 10–1), in patients with a high-level borderline personality organi-
zation, the splitting in self- and object relations is relatively mild. Patients have a mod-
erately strong capacity for mentalization, and their feeling of inner safety may be frail,
but they nevertheless have some sense of inner safety.
In patients with a low level of BPO functioning, severe impairments in each of the di-
mensions are present, and the three dimensions are not distinct, particularly during high
emotional arousal. In these circumstances, object relations disintegrate and representa-
tions become diffuse and lack distinction; the ability to process experiences mentally is
limited; and a predominance of psychic equivalence mode with profound feelings of in-
security is seen (Table 10–1). This state of mental collapse in the psychic functioning of
patients with a borderline personality organization has to be addressed in the treatment
of BPD. This means dealing with poorly formed representations of self and other, en-
hancing mental processing of emotions, and understanding one’s own and others’ behav-
ior from the point of view of mental states.
In the psychoanalytic process of BPD, the so-called basic layer (Vermote 2005) con-
sists of changes at this level. This contrasts in many ways with the more classic psycho-
analytic process that is aimed at clarifying and interpreting relatively intact object
relations, repression, and psychic conflicts by repetition, content interpretation, and
working through.
1. Feeling of safety 2. Mentalization 3. Object relations

Working alliance Symbolization Whole objects Classic
Differentiation
Pretend mode As-if transference psychoanalytic

process:
repetition,
regression,
working
Total situation Part-objects through of inner
Feeling of safety through Acting out, evacuation Projective identification
therapeutic frame and
conflicts
therapeutic relationship Psychic equivalence
in the here and now mode
Merging of the three dimensions with part-object relating in a total situation:

Basic psychoanalytic process: growing feeling of safety, decrease of
splitting and part-object relating, and increase of mentalization
FIGURE 10–1. Three-dimensional model of the psychoanalytic process in patients

with personality disorders.
Source. Vermote 2005.
Treatment Program
Congruent with our views of the nature of personality pathology, our treatment pro-
gram is organized around the three dimensions of a feeling of safety, mentalization, and
object relations. The feeling of safety is enhanced by the offer of 24-hour support, the
empathic attitude of the staff, patient-staff meetings, informative meetings to increase
predictability, and protective measures such as rules and agreements to deal with self-
destructive impulses. The dimension of self-object relations manifests itself in the
groups and during interaction on the wards, which are conceptualized in terms of a
“theater” of the internal objects. This material is used in the psychotherapy sessions.
The focus of psychoanalytic therapy in our treatment program is on the psycho-
analytic process of the patients in a multifaceted program consisting of 1) verbal ther-
apies (i.e., group psychotherapy) and 2) nonverbal therapies (i.e., art therapy,
psychomotor psychotherapy, and music therapy, each twice a week). Verbal and non-
verbal therapies are seen as equally important because they both provide windows
through which the psychoanalytic process can be seen from different perspectives. The
psychoanalytic process in patients with borderline personality organization is initiated
in the nonverbal therapies during which patients can express and experience their inner
world in an emotionally expressive way, gradually finding a form in art or music, for ex-
ample, to communicate undifferentiated and painful feelings. For instance, the mental
process of a patient can be inferred from drawings made during art therapy, experi-
TABLE 10–1. Characteristics of severe personality disorder
• Diffuse and indistinct representations

• Inability to process mental experience
• Failure of mentalization
• Predominance of psychic equivalence mode
• Fears for survival
• Loss of inner safety
enced during the improvisations developed in music therapy, and observed in the phys-
ical expression during psychomotor therapy as well as understood from the associative
material of the group therapy. Each therapist makes interventions in the language of his
or her medium and takes care not to make pseudopsychoanalytic interventions.
In the weekly staff meetings, the patient’s unique pattern of inner change is clari-
fied, and a working hypothesis is formulated. This is not easy because such a process is
a rather ineffable phenomenon, which often can be described only in indirect ways such
as through metaphors.
Challenges and Problems

Over the years it became clear that, even when we integrated aspects of the focus on men-
talizing, many challenges and problems in treating personality pathology remained. For
instance, an intensive focus on the psychoanalytic process of patients with personality dis-
order in an inpatient setting always brings with it the danger of malignant regression
(Meissner 1996). To counter this potential for regression we made two amendments to
common practice. First, we decided not to use seclusion rooms, which had been in com-
mon use in the past. Seclusion and restraint offer satisfaction to some patients with per-
sonality disorder (e.g., those who wish to challenge authority or need to satisfy
obstructive inner objects). Second, we created “ateliers” as a further means of countering
malignant regression. These ateliers (literally, artists’ studios) offer some respite from the
focus on the analytic process and explicitly take place outside of the psychotherapeutic
program and frame. Patients are free to subscribe to them for a limited and fixed number
of sessions. Ateliers are available on different topics: poetry, mindfulness, philosophy,
music, dancing, and running. They are meant to address healthy parts of the personality
in a nonregressive way. Finally, all staff continually monitor patients and groups for signs
of malignant regression and discuss these in a weekly patient-staff meeting that focuses
on the therapeutic culture in the treatment setting.
The findings of a 12-month naturalistic follow-up study, which was conducted
to evaluate the psychodynamic hospitalization-based treatment described, led us to
reconsider some of the assumptions on which our treatment setting was based. Al-
though intent-to-treat analyses in a sample of 70 patients with personality disorders
supported the effectiveness of the treatment program, indicating a large effect size
(Cohen’s d=1.08) (Vermote et al. 2009), which was sustained at 5-year follow-up (Ver-
mote et al., manuscript in preparation, 2011) using trajectory analyses, two groups of
patients with moderate levels of symptoms at intake were identified. One group
showed sustained improvement in symptoms during treatment and follow-up, but the
second group of patients had no improvement (Vermote et al. 2009). Further analyses
suggested that the first trajectory consisted mainly of patients with so-called introjec-
tive personality styles (i.e., patients who primarily presented with issues regarding au-
tonomy and self-definition), whereas the second trajectory consisted mainly of patients
with anaclitic personality styles (i.e., patients who presented with issues of dependency
and neediness; see, e.g., Blatt et al. 2007).
Although the treatment program was associated with sustained changes, even at
5-year follow-up, the identification of this subgroup of patients whose symptoms did
not respond as well as those of the other group of patients led us to reconsider some of
our basic assumptions.
Adaptation of Treatment Model to

Patients’ Needs and Introduction of
We attempted to adapt the treatment to the needs of the group of low-level anaclitic bor-
derline personality organization patients whose symptoms had failed to respond to the
classic psychoanalytic approach while maintaining the structure of the setting. The MBT
approach (e.g., Bateman and Fonagy 2006a) was originally conceived for this group of pa-
tients, and outcome studies showed that MBT is an efficacious treatment for this group.
However, we were aware that adapting the treatment program to patients’ needs could af-
fect the program’s coherence, which might have a negative effect on treatment outcome.
Indeed, it has been argued that structure and consistency are core features of effective
treatment programs for personality disorder (Bateman and Fonagy 2006a).
When we tried to implement MBT for this group, some differences between MBT
and psychoanalytic therapy became manifest on all three of our treatment dimensions.
On the object relations dimension, MBT focuses less on transference or at least cautions
against the use of the transference early in therapy (Fonagy and Luyten 2009). The feel-
ing of security as a nonspecific therapeutic factor is also important in MBT at the be-
ginning of treatment, when supportive and empathic interventions are recommended in
the context of a clear focus on the patient’s perspective. The greatest difference between
the two approaches is on the mentalization dimension, which we describe next.
Two Models of Mentalization

In the hospital setting, MBT was introduced alongside the psychoanalytic therapy ap-
proach, which had been offered as a treatment program for more than 30 years. In psy-
choanalytic therapy, the emphasis on mentalization was largely based on Bion’s theory
of the unconscious and conscious psychic processing of emotions, which differs in im-
portant respects from the current model of mentalization. It is impossible to sketch the
difference between the two models without caricaturing them. Let it suffice to say that
Bion’s model is based on Melanie Klein’s theory of unconscious functioning; Freud’s
ideas on the origin of thinking; Hume’s theory of mental activity; and several models
from mathematics, geometry, and physics. In particular, Bion distinguished different
steps or categories in the process of thinking. An important aspect of his theory is the
interpersonal origin of the thinking process, in which the infant communicates emo-
tions to the mother by projective identification. Later, Bion realized that he was miss-
ing an important part of psychic change and began to study changes at the level of
psychic functioning before representation (Bion 1967; Vermote 2005).
The model of mentalization discussed throughout this book is a complex, expand-
ing, and integrative model that is rooted in attachment theory. The ensuing research
was groundbreaking and finally led to a model of psychic functioning integrating neu-
roscience, genetics, attachment research, social psychology, and major psychoanalytic
works by Freud, Bion, Winnicott, and Sandler. The model focuses on the “I,” not only
as a representation and subjective experience but also as an agent. The capacity to in-
terpret one’s own and others’ thoughts and feelings is a vital aspect of the experience of
agency.
Although the approaches have many similarities, they also have some important
differences. These became clear when we implemented MBT in our setting. In the
Bion-inspired approach that we used for more than 30 years, therapists focused on try-
ing to help patients contain their emotions by being open to these feelings and by work-
ing with their own countertransference to give meaning to what the patients were
experiencing. Especially at the beginning of treatment, the patient was helped to be
more aware of his or her psychic reality and to rely less on managing psychic pain by ac-
tion (e.g., through excessive exercise, promiscuity, use of drugs, or self-harm). The pa-
tient was helped to tolerate undifferentiated feelings. The attitude of the therapist in
dealing with such acting out was characterized by a faith in the internal process of the
patient (Bion 1970), in which gradually a psychic dimension opens up so to speak. This
process cannot be forced on the patient. It takes place when the setting and the attitude
of the therapist are good enough—that is, when the therapist is nonjudgmental, re-
spectful, and able to trust in the primacy of mental processes rather than be reactive to
behaviors.
All therapies in the program are seen as equal contributors to this creative process,
and the patient is made aware of this process. Some patients discover an inner psychic
functioning that was previously unknown to them, whereas for others this inner auto-
matic creative psychic elaboration may be something that is initiated by the therapies.
Disruptive symptoms most often diminish when this happens (Vermote 2005), but de-
pressive feelings and anxiety can become more pronounced when patients get in touch
with and can tolerate their psychic reality. This increase in symptoms can be seen as a
therapeutic regression.
In MBT, the focus is less on this spontaneous, automatic psychic elaboration of
emotions and more on an active stance in helping the patients to think about their own
and others’ minds. The affect level is carefully titrated during all interpersonal inter-
actions, and transference is taken into account only gradually. Patients gain a greater
feeling of control, and their feelings of alienation and incoherence, which are consid-
ered as the main triggers of destructive behavior, are gradually diminished. Hence,
both approaches do differ in important ways, and it remains a challenge to integrate
both. However, we have also found that they are complementary in many respects and
give rise to an interesting dynamic.
Dynamics Between Mentalization-Based

Treatment and the Existing Psychoanalytic Model
As noted, we introduced MBT because of our finding that patients with a lower-level
borderline personality organization and an anaclitic personality style did less well in
psychoanalytic therapy and could perhaps benefit more from an MBT approach, par-
ticularly at the beginning of treatment and in crises and affect storms, with a gradual in-
tegration of psychoanalytic therapy and MBT during the treatment process. For
patients with a high-level borderline personality organization, a more “pure” psycho-
analytic therapy approach seems to be indicated from the beginning.
MBT and psychoanalytic therapy are both strong models with comprehensive but
different perspectives on the treatment of personality disorders. As soon as MBT was
implemented, a dynamic interaction between both approaches became discernible
when applying the two models in tailoring the therapy to the needs of the patient. This
was manifest at the levels of patients’ psychic functioning, therapists’ mind-set, and the
organization of the setting. We learned that for individual patients, when two models
are applied in a single treatment setting, they may interact either synergistically or an-
tagonistically. For example:
Ms. A, a patient who had endured abuse, was overwhelmed by strong emotions when she
had contact with other abused patients on the ward. She decided to start legal proceed-
ings against her abuser, which at the time was a self-destructive course of action. In her
state of emotional turmoil, use of MBT principles to engage her in a discussion about her
decision helped her to reduce her panic, which prevented dramatic developments and es-
calation of suicide threats. When Ms. A was feeling calmer, she drew figures in the art
therapy that expressed her internal objects. In this way, she unlocked contact with her in-
ternal world. It helped the staff, and Ms. A, to see the vulnerable and frail person within
who had been hidden by her disruptive behavior. Gradually getting in touch with her
creativity gave her some solace.
The example of Ms. A illustrates how MBT helped a patient deal with her acting out,
after which a psychoanalytic therapy process and treatment became possible.
Another example of the two approaches working synergistically might be a case in
which psychoanalytic therapy is being used as a defense against psychic change, and an
MBT approach can resolve the impasse:
Mr. B, a patient with low-level borderline personality organization, was talking in the
psychoanalytic group therapy about the internal representation of his father and produc-
ing a wealth of sophisticated fantasies about it. He got stuck in a kind of malignant re-
gression, enjoying the fantasies and using them as a way to avoid his current reality.
From an MBT point of view, this case can be seen as hypermentalization related to
functioning in pretend mode. This needed to be made clear by switching perspectives
and focusing on the affect of the patient. Indeed, Mr. B started to make progress only
when he was invited in the group therapy to reflect about what his attitude really meant
to his wife and family and when he tried to see what could happen in their minds. It was
clear that for this patient, in this phase of his treatment, applying only the psychoana-
lytic model was antitherapeutic and possibly iatrogenic, and an MBT approach helped
him progress.
However, MBT may block psychoanalytic therapy. A talented, somewhat remote,
and closed person whose personality organization might be characterized as a high-
level narcissistic borderline personality organization can develop better contacts with
other people and feel increasingly in control of him- or herself when an MBT approach
is used. Although effective in this sense and during this phase of treatment, continuing
exclusive use of the MBT model with this type of patient is not the best option because
it would further close the patient’s inner world. An explorative psychoanalytic approach
appears more appropriate at this moment. The patient may discover a new, creative ca-
pacity after first going through a phase of resistance.
Interaction Between Mentalization-Based

Treatment and Psychoanalytic Therapy in
the Mind-Set of Therapists
For the staff members, it is very difficult to make use of both models and to find the
“right zone” for a particular patient at a particular phase in therapy. Although both
models are built on a basic attitude of not-knowing, psychoanalytic therapy involves
being sensitive to the psychoanalytic process in a mental state of free-floating atten-
tiveness and reverie. MBT starts from the same mental stance of not-knowing but
makes use of this information differently—namely, in an active focus on understanding
and misunderstanding of self and others. Taking both stances at the same time is diffi-
cult for most therapists. Often, this difficulty is exteriorized, with frequent discussions
about psychoanalytic schools and models, when in fact the difference reflects two dif-
ferent functions of the mind.
Interaction Between Mentalization-Based

Treatment and Psychoanalytic Therapy in
the Organization of the Setting
We can also see the dynamics between the two models of treatment at work when set-
ting the rules of the treatment concerning self-harm, transgressions of agreed bound-
aries, and substance abuse. In our setting, a verbal contract is made with the patient
before the treatment starts. In this contract, a subtle form of limit setting is discussed.
It is important to note here that we distinguish between rules and agreements. Rules
are like the law and cannot be changed. Patients and staff both must adhere to rules; this
enhances the predictability of the therapy and the safety of the setting. These rules are
about sexual and aggressive transgressions, bringing drugs into the treatment, and self-
harm. At the intake interview, patients are informed of these rules and told that they ex-
ist to safeguard the freedom that exists on the ward and to protect the other patients.
Indeed, nearly all patients agree that if the rules were flexible about these matters, it
would be more difficult for patients to control their self-destructive impulses. Discuss-
ing the rules with the patients before the treatment starts is done in a way that parallels
Winnicott’s (1958) offer of a spatula to an infant while examining the infant. He offered
a spatula in exactly the same way to all infants and observed how they reacted. The way
they reacted was very different, and he used this as a guide for diagnosis and treatment.
In the same vein, how patients react when being presented with the rules and when
agreeing to a verbal contract is seen as instructive as to their mental state and their psy-
chic functioning. Our experience is that when loosening the rather tight rules, the feel-
ing of safety of the patients on the ward decreases, it becomes much more difficult to do
therapy, and the dropout rate increases. Agreements can be changed more easily. They
are negotiated in the weekly patient-staff meeting and include, for instance, hours of
entrance and holidays.
From the perspective of the psychoanalytic therapy model, the nonverbal contract
about the rules is part of the therapeutic frame that makes it possible to do psychoan-
alytic work; it creates an atmosphere of felt safety and makes the treatment predictable.
However, in the MBT model, the rules are seen as having to be understood from a
range of perspectives in an open and verbal manner. Why is insulting behavior unac-
ceptable or drug use forbidden on the ward? Why are patients told that they should not
have intimate relationships with each other during treatment? In MBT, the therapist
and patient may accept that they have different perspectives and that neither view is
more correct than the other. However, the therapist can choose not to treat a patient
who persistently breaks a rule, just as the patient can decide not to have treatment. The
rules provide a focus for patients to reflect about acceptability of behaviors and inter-
actions with others, social constraints, interpersonal boundaries, and effects of personal
behavior on others. The MBT model is used at any given moment when discussing and
setting the rules with individual patients, when treatment begins, and when a transgres-
sion of the rules occurs. On the contrary, at an institutional level, the rules transcend
the individual patient, forming part of the fixed psychoanalytic frame and providing a
foundation that makes the development of a psychoanalytic process possible.
In dealing with self-destructive behavior, we find a similar interplay between the
psychoanalytic therapy and MBT models. In the psychoanalytic therapy model, self-
destructive behavior is seen as short-circuiting mentalization, as an evacuation of beta-
elements, to use a Bionian term. We have found it effective to make a treatment contract
about self-destructive behavior before the start of treatment to secure the psychoana-
lytic frame and to safeguard a feeling of safety. In the MBT model, self-destructive be-
havior is seen as an externalization of painful self-states. However, there is more stress
on the active mastering of an overwhelming situation and less on the pretreatment con-
tract to secure the therapeutic frame. The same dilemma is found in the attitude of the
nurses during crisis interventions. With the psychoanalytic therapy model, nurses felt
obliged to tolerate everything that was done to them, which actually fostered a thera-
peutic regression. With MBT, it became clear that this attitude might increase activa-
tion of the attachment system, which is in itself potentially harmful in these patients. In
the same vein, to establish a feeling of safety, the psychoanalytic therapy model recom-
mended that staff offered maximum availability, but from the perspective of MBT, this
encouraged refuge within exclusive relationships and inhibited development of self-
reliance through self-reflection.
For the patient-staff meetings, we used to prepare the meeting so that patients
would feel safe. In other words, we took care to give clear messages, to make the treat-
ment predictable, and to safeguard the analytic frame. Now with MBT, patients have an
open discussion with the staff. Individual staff members may disagree with one another.
To some extent, this models the mentalizing process, allowing patients to see how the
staff members think and recognize that people can have different views, all of which are
valid and require consideration.
Integration of the Mentalization-Based Treatment

and Psychoanalytic Therapy Models
Once the MBT model was introduced, several problems arose. The younger therapists
and nurses were attracted to it and embraced it, whereas senior therapists had a ten-
dency to continue using the familiar psychoanalytic therapy model that they had used
for many years. To address this, we initially trained the nurses in the MBT model
and considered keeping it as a model for the nurses, while the psychotherapists would
continue to practice psychoanalytic therapy. This brought differences in approach to

light, which were discussed during team meetings.
The next step was to divide the patients, as noted, according to their needs. We sep-
arated the patients into either anaclitic or introjective according to the findings of the ini-
tial assessment. The patients with low-level anaclitic borderline personality organization
were offered a less intensive form of psychoanalytic therapy with an adjunct mentaliza-
tion-based individual therapy, whereas the introjective patients continued with psycho-
analytic therapy. We were not sure whether the use of a mixed model for the anaclitic
patients would allow us to draw on the best of both worlds or whether there was a risk of
diluting the specificity of both models. We therefore monitored the use of this method,
aware that it had the advantage of allowing everybody to get to know the MBT model.
With the MBT model becoming more and more present, it became apparent that
there was a polarization between the two approaches, with a tendency to divide the
staff, and the development of two units, an MBT and a psychoanalytic therapy unit.
This created a fragmented treatment unit and weakened the therapeutic milieu because
of reduced therapeutic consistency. The solution was to create a pure MBT program in
which therapy was done by an MBT therapist, together with the nurses, all of whom
were trained in MBT. This MBT treatment group was integrated in the whole treat-
ment program and organized in series with the psychoanalytic therapy approach. Low-
level anaclitic patients started in the MBT group and, according to their progress, ei-
ther completed all their therapy in this group or transferred to a psychoanalytic therapy
group when they were functioning better, with less psychic equivalence function and
more consistent mentalizing. All staff members trained in both the MBT and the psy-
choanalytic therapy models to diminish the chance of splitting of the setting.
Clinical Applications
The Mentalizing-Focused Approach in Family and
Couples Therapy Embedded in Hospitalization-
Based Treatment for Personality Disorders
An important part of our treatment program is its focus on working with families and
couples. Indeed, congruent with MBT principles, we believe that a relational focus is es-
sential to the treatment of patients with personality disorders, particularly given the roots
of the capacity for mentalizing in attachment experiences. Furthermore, because these
patients often present for therapy with problems in their close relationships, enhancing
their capacity to mentalize in the presence of their romantic partners, parents, and off-
spring will help them to manage these relationships better and feel more resilient as a
family or as partners. Hence, therapy sessions give an in vivo possibility to foster men-
talization in the context of real attachment figures.
The Concepts of Mentalization and Attachment Applied

to Family and Couples Therapy
An essential characteristic of all family and couples therapy sessions (Table 10–2) is that
different individuals (patients and family members) are present at the same time in the
therapy room. When focusing on mentalization during these sessions, it is important to
take into account substantial individual variations in this capacity (e.g., Fonagy and
Luyten 2009). In other words, the capacity to mentalize varies not only between dif-
ferent families or couples but also between different relationships within one family
(i.e., mentalization is relationship specific) and between the different topics (more
stressful vs. less stressful topics) discussed within these relationships (Fonagy and
Luyten 2009). For example:
Ms. C, a female inpatient in her early 20s, was known to be generally good in mental-
izing toward other patients during group therapy sessions. In family therapy sessions
with her parents and siblings, she could mentalize relatively well in relation to her father
and siblings but not in relation to her mother. Mentalizing within this latter relationship
became especially difficult when she discussed her feelings around being emotionally ne-
glected during the time her mother had depression.
The relationship specificity of mentalizing is often particularly clear in relation to

parents and partners (Clulow 2001), especially because these attachment relationships
in personality disorders are often characterized by insecure attachment (Fonagy and
Bateman 2006a). In this context, it is important to address the reciprocal and dynamic
relationship that has been observed between the activation of the attachment system
within family and couples relationships and mentalizing activity (i.e., the activation of
the insecure attachment system and associated emotional arousal that interferes with
mentalization; e.g., Fonagy and Luyten 2009; Fonagy et al. 2002a; Luyten et al., sub-
mitted 2011c; Luyten et al., Chapter 2 in this volume). In patients with personality dis-
orders and family members with an insecure preoccupied attachment style, the
attachment system is (too) easily activated (i.e., they use hyperactivating attachment
strategies), and therefore feelings may run high during a session, and mentalization is
likely to collapse easily and rapidly. In these situations, we may observe that family
members use prementalizing modes (e.g., teleological mode, psychic equivalence
mode) and that nonmentalizing cycles predominate. For example:
When Ms. C and her mother started to discuss her mother’s depression, they would
quickly get stuck in a nonmentalizing cycle. Ms. C would tell her mother that having sent
Ms. C to live with her grandparents while the mother was hospitalized meant her mother
didn’t love Ms. C (teleological mode). Her mother would answer in a similar nonmen-
talizing mode by saying that when Ms. C says this, it means she wants to hurt her mother
(psychic equivalence mode) and does not appreciate all the things she has done for Ms. C.
In patients with personality disorders and family members with a more dismissive at-
tachment style, the opposite pattern may be true (i.e., they may downplay their attachment
needs by using deactivating attachment strategies), and their capacity for mentalization may
be decoupled from their feelings, leading to hypermentalizing accounts.
Interestingly, in working with couples and families, activating and deactivating pat-
terns may be observed at the level of the whole family. This is somewhat similar to the
family myths described by Ferreira (1963), which he defined as “myths that simplify
and distort the reality.” Family myths are thus considered as defensive strategies on the
level of the family, for example, to keep out painful emotions. For example:
Family X had lost their oldest son and brother from suicide 10 years ago. Although some
emotions regarding this loss (e.g., sadness and anger) could be expressed at the funeral,
the unspoken rule within this family was that life must go on and that words and emo-
tions would not change a thing. In the first session, family members talked about this loss
in a distant and impersonal way. It seemed that this family adopted a deactivating strat-
egy, especially in this context.
Therapeutic Frame
Depending on the phase in the family life cycle (e.g., Carter and McGoldrick 1988), as
well as the specific relationship problems identified by the patient (and family members
and staff), we generally distinguish the following three kinds of sessions of couples and
family therapy:
1. Marital or couples therapy sessions, in which the patient is seen together with the
partner and mainly marital and/or parental issues are addressed
2. Family therapy sessions with the patient and his or her family of origin (e.g., one or
both parents, siblings)
3. Family therapy sessions, in which patients (and partners) are seen with their off-
spring
Before starting family or couples therapy, the family therapist consults with the pa-
tient for one or two 30-minute individual sessions. These sessions are scheduled mainly
for two reasons. First, it may be important for the patient to become familiar with the
therapist and the therapeutic frame applied to couples and family sessions before inviting
the whole family. At the same time, it is important that the family therapist have no ex-
clusive relationship with the patient (which would be the case when he or she was also in-
dividual therapist) because the therapist has to be able to install a secure atmosphere for
all family members. Second, in most cases, patients are encouraged to invite their family
members themselves, and in this first session, practical arrangements can be made.
In general, we initiate couples and family sessions early in treatment. However, de-
pending on some characteristics of the family and the mentalizing capacity of the pa-
tient and the family members, we may decide first to improve a patient’s mentalizing
TABLE 10–2. Features of family and couples therapy
• Mentalization is relationship-specific and context-specific

• Clinicians work with (early) attachment figures in vivo
• Attachment relationships of patients with personality disorders are characterized by inse-
cure attachment
• The activation of the attachment system interferes with the capacity to mentalize
• Patients with personality disorders may use hyperactivating (anaclitic) or deactivating
(introjective) attachment strategies
• Families may use mainly hyperactivating or deactivating strategies
• In relationships in which mentalization fails, a cycle of nonmentalizing modes is easily
installed
capacity about his or her family in individual sessions and in group therapy before ad-
dressing family problems with the attachment figures in vivo. In some cases, family ses-
sions seem contraindicated (e.g., in cases of severe maltreatment). In general, sessions
take place once every 2–3 weeks. Experience has taught us that this frequency allows for
optimal levels of arousal (not too high, not too low). The length of the session is 1 hour.
As we describe below, promoting mentalization within these sessions is an explicit
goal of treatment, at least in the early phase of treatment. In addition, the family ther-
apist can be consulted by patient and family members for (one or more) family sessions
around specific topics, such as when the patient or the family has a crisis or when the
patient or family wants to address specific questions (e.g., about the treatment) in a
family context. If indicated, and depending on the needs of the patient and family, other
members of the team (e.g., psychiatrist, nurses, social worker) will join these sessions.
In contrast to the regular couples and family therapy sessions, promoting mentalization
is applied here in a more implicit way (e.g., by modeling mentalization in discussing the
questions of the family members and patients).
Mentalization-Related Therapeutic Interventions

With Families and Couples
In the initial phase of treatment, the therapist will meet with all family members (in-
cluding the children in family therapy) and discuss with the family and patient their
aims for therapy, which helps to develop a safe atmosphere (see also Byng-Hall 1995).
Similar to the approach used in Mentalization-Based Family Therapy (MBFT), dis-
cussed in detail by Asen and Fonagy in Chapter 5 in this volume and originally formu-
lated as SMART (Short-Term Mentalization and Relational Therapy) (Allen et al.
2008; Fearon et al. 2006), we consider problems in relationships between patients with
personality disorders and family members that derive at least in part from their diffi-
culties with mentalizing within the context of the family. Therefore, in this initial phase
of couples and family therapy, it is important to assess the capacity to mentalize, paying
careful attention to the different relationships and conditions in which mentalization
goes relatively well, as well as to the circumstances in which mentalization is impaired,
and the different attachment strategies that are used (Table 10–3). For example, as we
have mentioned, some patients with personality disorders (anaclitic patients) and their
family members will use hyperactivating attachment strategies (i.e., their feelings may
run high during the sessions and as such interfere with mentalization), whereas other
patients with personality disorders (introjective patients) will use deactivating attach-
ment strategies, decoupling mentalization from their feelings, which leads to pseudo-
mentalization. In both cases, it is crucial to be in touch with the level of emotional
arousal of all family members and to maintain optimal levels of arousal whenever pos-
sible. For example, when hyperactivating strategies are used and thus feelings may run
high, it is important to downregulate and contain the emotions in the family (e.g., by
using the “mentalizing hand”: raising the hand to stop the dialogue rather like a police
officer stopping traffic) and focus on one dyad or one individual. For example:
In Ms. C’s case, when feelings were running high between her and her mother, and men-
talizing about themselves and each other became difficult, it was important to focus on
this dyadic relationship for a while before reopening the session to the rest of the family.
Sessions in which more deactivating strategies are used may seem less heated and
easier for the therapist to manage. However, it is important to upregulate the emotional
expression in this context to more optimal levels of arousal by encouraging these pa-
tients (and family members) to explore and identify their emotions and eventually in-
tegrate thoughts and emotions. Otherwise there is a danger of pseudomentalization
(Luyten et al., Chapter 2, in this volume). Furthermore, because different individuals
are present, different strategies may be used at the same time. For example, in couples
therapy sessions, we often observe an approach-avoidance conflict between partners
(e.g., Clulow 2001) in which one partner uses a hyperactivating attachment strategy
and the other uses a deactivating strategy. As the hyperactivated strategy of one partner
is responded to by a deactivating strategy of the other partner (and the other way
around), this may result in a vicious circle in which emotions of the first partner run
very high (and mentalization stops), and the partner responds in an even more detached
way (i.e., reaction decoupled from affect). We may observe similar patterns in our work
with families, such as in the case of family X:
As described earlier, family X used a deactivating strategy in the first session; emotions
were decoupled from their words. During the next session, Anna, the second oldest child
in the family who was hospitalized in our treatment program, started to talk about her
feelings of loss. However, the more she shared her pain and seemed overwhelmed by her
sadness (hyperactivating strategy), the more all other family members downplayed their
(and her) emotions and the importance of this loss (deactivation), which made her even
more emotional (hyperactivation).
TABLE 10–3. Some therapeutic interventions related to mentalization
• Pay attention to relationships and conditions in which mentalization goes well and those in
which mentalization is impaired.
• Pay attention to the attachment strategies used by different family members (hyperactivat-
ing, deactivating, or both).
• Focus on mentalization, an essential part of couples and family therapy. For some families,
mentalization is the focus of treatment, and for others, it is a necessary phase before using
more traditional family therapy interventions.
At that time, the therapist took a very active stance and decided to focus on the pro-
cess and the regulation of Anna’s feelings. Later in this session, the therapist tried to
identify the emotions of the other family members and link their emotions and words.
Focusing on the process for a while made it possible to afterward address and discuss this
loss (focus on the content). During the next part of the therapy, they slowly learned to
share their pain and to accept that different emotions and perspectives could coexist. As
the family therapy evolved, other members of the family were able to express their pain.
Promoting mentalization is always an important part of the family and couples

therapy provided in the hospitalization-based treatment. However, for some families or
couples, mentalization may become the main focus of treatment, whereas for others,
the process of mentalization may be an explicit focus during the early phase of treat-
ment (and, if necessary, again at certain points later in treatment). More traditional
family and couples therapy interventions (e.g., intergenerational work, communication
skills) may become the explicit focus later in treatment. However, this initial phase of
focusing on mentalization and attachment is essential because it makes more traditional
family and couples interventions more grounded and effective.
Mentalization plays an important role in all kinds of family and couples therapy
(Safier 2003). Yet as illustrated in this clinical application, focusing on mentalization
becomes essential when working with patients with personality disorders and their
family members because the capacity to mentalize within these relationships often fails,
and they often experience difficulties in this area (Allen et al. 2008; Fearon et al. 2006).
Mentalizing in interaction with family members (e.g., partners and parents) is not an
easy task and has elsewhere been called mentalizing in the trenches (e.g., Tobias et al.
2006).
It is important to integrate mentalization-focused couples and family sessions in
hospitalization-based treatment for personality disorders because it offers these pa-
tients the opportunity to learn to mentalize accurately in their attachment relation-
ships. Individuals who can mentalize in the presence of their romantic partners,
parents, or offspring will manage these relationships better, will feel more resilient as a
couple or family, and will resolve conflicts better with these significant persons. Finally,
the capacity to mentalize varies not only between patients and families but also between
therapists in interaction with certain families and individuals (Diamond et al. 2003).
Therapists must be aware of their own capacity in interaction with certain families and
couples and to be conscious when they stop mentalizing. Therefore, the treatment set-
ting should provide an opportunity for family or couples therapy peer supervision and,
if necessary, should offer the option of co-therapy.
Mentalization-Based, Treatment-Oriented
Meetings With the Nursing Staff
As part of our attempts to integrate aspects of the MBT model in our hospitalization-
based therapeutic program, twice-per-month meetings for the nursing staff were im-
plemented recently. In these meetings, supervised by a psychotherapist trained in
MBT, staff discuss daily situations from a mentalizing perspective. The meetings are
open to all nurses, not only the nurses of the MBT group. More specifically, in these
meetings, practical situations from the ward are considered from a mentalizing per-
spective, the theoretical background of MBT is discussed, and role-plays are used to
practice clinical interactions. The meetings are based on the framework outlined by
Allen et al. (2008), particularly when trying to understand and handle daily situations
on the ward. For example:
At the end of the day, 10 minutes before most of the nursing staff leave the hospital,
Ms. D gets increasingly upset. After ostentatiously walking up and down the hall, clearly
visible to the nurses on night shift, she is asked to go to her room. After a while, other pa-
tients become worried because Ms. D is banging on the walls of her room, and they alert
the nursing staff. One nurse finds Ms. D very upset in her room, stating that something
catastrophic will happen and that she’s totally losing control.
Situations like this are common on the ward and probably well known to most in-
patient services that treat BPD. Although being confronted with a patient who seems
overwhelmed by her feelings is known territory, dealing with it in a therapeutic yet ef-
ficient way remains a challenge. Clearly, Ms. D needed help to downregulate her high
level of arousal. In the two weekly meetings with the nursing staff, we discussed how the
theoretical and technical framework of MBT can offer us some additional insight in
this kind of situation.
Apart from describing Ms. D’s behavior and the resulting actions from the nursing
staff, these meetings helped staff to understand the situations more in terms of mental
processes. Ms. D seemed unable to make use of thoughts about her inner state that
would allow her to experience her fear as a product of her own mind. The absence at
that moment of some kind of psychic buffer to protect against the experience of her in-
ner world as being real is perceived as an experience in psychic equivalence mode; being
afraid means that there is a catastrophe (Bateman and Fonagy 2004).
The nurses involved in this incident reported that they were getting increasingly
nervous and—literally—running out of ideas. They became more and more anxious,
feeling controlled by Ms. D. Although highly aversive for the nurses, this kind of “con-
trolling” the mind of caregivers, traditionally known as projective identification, could be
described from a mentalizing perspective as an attempt from Ms. D to restore the co-
herence of her own self-experience, which was lacking at that moment.
While discussing the nature of our interventions in situations like this, we identi-
fied types of interventions that at first seemed appropriate because they offered the pa-
tient some support and comfort. However, they did not work well (Table 10–4).
The first type of intervention considered was an attempt to comfort and calm down
Ms. D by saying something like: “What could possibly happen or go wrong that you’re
so afraid of?” or “Do you really think that?” We identified this type of intervention as
trying to convince the patient in a rational, cognitive way that her ideas were incorrect.
Apart from getting stuck in rational arguments about the seriousness of the threat, this
type of intervention asks the patient to think even more about the scenario he or she
fears. Stimulating the fantasy about the perceived threat when the patient is experienc-
ing his or her mind in a psychic equivalence mode might stimulate an even more in-
tense and overwhelming fear.
The second type of intervention considered was a kind of magical thinking by say-
ing something like: “Everything will be all right” or “Tomorrow is a new day.” In our
experience, this type of intervention could succeed in restoring some hope in more
high-level structured patients who could really find some comfort in it, but with bor-
derline patients, it was more likely to make them feel that they were not being taken se-
riously or not being heard.
We were not surprised that we could not find an ideal intervention. However, there
seemed to be similarities in all responses that more or less succeeded in lowering the
level of arousal (see Table 10–4). All of the interventions involved some kind of marked
mirroring of Ms. D’s affective state. In line with MBT conceptualizations, this mirror-
ing had the best effect when it was sufficiently in accordance with the supposed affect
state of the patient (congruent) while at the same time different from the expression of
fear of the caregiver himself or herself and thus also marked. In addition, it seemed im-
portant that this mirrored expression was not only literally congruent (i.e., an accurate
verbalization of the affect state) but also sufficiently accompanied by a mirroring of the
level of emotional arousal itself. An accurate verbalization of what a patient might be
feeling by a nurse who remained calm and controlled often did not result in a lowering
of the level of arousal. In situations like this, although her feeling state was accurately
described to her, Ms. D could not “find” a representation of herself in the caregiver.
The quality and form of intervention are as important as the accurate content, and the
depth of the patient’s affect needs to be conveyed through tone of voice, for example, or
the general attitude of the therapist. The congruent and marked mirroring is then fol-
lowed by a careful reconstruction of the patient’s mind states, linking situational aspects
and behavior of himself or herself and others to mental states. For example:
In the debriefing of the nursing staff the next day, the nurse involved expressed the feel-
ing of having been manipulated or even blackmailed by Ms. D.
Such a feeling in professionals working with BPD is not exceptional. On many oc-
casions, this kind of behavior of patients is easily interpreted as a deliberate attempt to
make therapists feel a certain way: “She wants to terrorize us” or “She wants to make us
feel helpless.” The patient’s efforts to stabilize his or her incoherent self through ex-
ternalization are then interpreted as bad intent because of confusion between the care-
giver’s feelings and the patient’s intention. This is contrary to the mentalizing formu-
lation and risks inappropriately attributing malevolent motives to a patient whose
primary motive is to obtain relief from frightening internal states.
When the overwhelming feeling of fear cannot be thought of as “just” a feeling,
mere words and expressions of comfort will not help. When the patient is in this state,
only direct physical action will be perceived as real care (i.e., a teleological mode of ex-
perience). Both nurse and patient alike may then feel that something needs to be done.
Undertaking action seems the only way out—for example, by giving the patient some
sedating medication or by staying longer than planned with the patient, not to restore
mentalization but for the physical presence in itself. Other examples are physical con-
tact or physical changes in the situation (e.g., sleeping in another room). If the nursing
staff are functioning in this teleological mode, then the patient’s capacity to regulate
himself or herself mentally will not be enhanced. On the contrary, the caregivers will
contribute to the overwhelming affect becoming a real threat that has to be dealt with
in physical rather than in mental reality: as long as the door is closed, as long as the
medication works, the patient is safe.
This pattern may well repeat itself every time the level of arousal increases. As a re-
sult, such patients can be viewed as difficult or not suitable for dynamic treatment.
When crisis situations heighten the pressure on the team members, they may cling to
known patterns, in which the amount of care given to the patient is increased (e.g., add-
ing individual psychotherapy to the patient’s treatment program) and responsibilities of
the patient are taken over, as expressed, for instance, in not leaving the patient alone for
more than half an hour, checking the patient’s room more than usual, or forbidding the
patient to leave the hospital. In such circumstances, therapists may unwittingly affirm
to the patient that the situation is indeed catastrophic and that he or she is in real dan-
ger (the team functioning in a psychic equivalence mode of experience). Apart from
this, the offered and well-intended “care” may result in a continuous overstimulation of
the patient’s attachment system: by increasing the care and taking over responsibilities
as a reaction to the patient’s distress, the team may drive the patient toward a clinging
attachment reflex, thereby making the necessary “thinking about feeling” attitude
nearly impossible. In the case of Ms. D, this resulted in her needing physical support to
be able to walk around, and during some of her hysterical outbursts, she had to be phys-
ically stopped and contained by the nurses.
TABLE 10–4. Therapist interventions for patients with borderline

personality disorder
Not helpful
Trying to dissuade the patient in a rational way from his or her “wrong” ideas
Stimulating fantasy about what could go wrong, in a patient who is functioning in psychic
equivalence mode
Making comforting statements without recognizing what the patient is experiencing
Using your physical presence in itself as soothing, without thinking about mental states
Remaining calm and emotionless in your reactions at all times
Helpful
Monitoring your own mentalizing capacity and that of colleagues in an open and trustful manner
Using congruent and marked mirroring to downregulate overwhelmed patients (successful
interventions with overwhelmed patients have this feature in common)
Understanding that aversive “controlling” of your feelings is an attempt by the patient to restore
coherence in his or her self-experience
Thinking twice about interpreting the patient’s intentions on the basis of your own feelings
Thinking about creating a positive working alliance without stimulating attachment too much
In line with the MBT model, one of the main aims of our weekly discussions with
the whole team (staff meetings) is to find a balance between providing a therapy culture
with enough safety and trust by building, maintaining, and, if necessary, repairing a
positive working alliance and ensuring that we do not overstimulate the patient’s at-
tachment system (see Table 10–4). Such overstimulation is known to bring down the
very capacity we aim to strengthen through our therapy (i.e., the ability to mentalize
while being under emotional pressure), especially for the group of anaclitic patients.
In our attempts to understand and discuss situations like the one with Ms. D during
meetings, we focus not only on what happened with the patient but also on the evolu-
tion of our own ability to mentalize throughout these kinds of events. This is not always
easy because it can be confused with failure or the feeling of not being up to the job.
Looking at one’s own possible contribution to a difficult situation puts the nurse in a
vulnerable position. In our experience, a strong coherence and trust within the nursing
staff is an absolute requirement in the treatment of BPD, as is the use of the mental-
ization model, which includes monitoring one’s own and one’s colleagues’ mentalizing
abilities. Taking responsibility for patient-therapist enactments does not make this eas-
ier. However, if applied by all members of the nursing staff in an open manner and in an
atmosphere of trust, the exploration of both the therapists’ and the patients’ capacity to
mentalize at the same time is experienced by members of the nursing staff and by pa-
tients as very helpful.
Conclusion
Over the last 30 years, the clinical setting used as an exemplar in this chapter evolved
from a mixed sociotherapeutic community–psychotherapeutic setting toward a model
of psychoanalytic-oriented hospitalization with a focus on the psychoanalytic process.
We showed how a coherent model of this process could be used to organize the treat-
ment, and we investigated both the outcome of the treatment and the relation between
process and outcome. The results of this research showed that a considerable subgroup
of patients did not respond well. These findings led us to adapt our treatment to the
needs of the patients. For all patients, we relied on a coherent three-dimensional model
of an object relations, felt safety, and mentalization approach, with each dimension cor-
responding to specific treatment interventions. With this overarching model as a back-
ground, we organized an MBT group within the treatment program for the anaclitic
patients with low-level borderline personality organization, whereas the introjective
patients were treated along an explorative classic psychoanalytic therapy model. Pa-
tients could shift from the MBT group to the classic psychoanalytic therapy groups or
vice versa according to their needs, personality characteristics, and phase of the treat-
ment. Integrating MBT within the therapeutic climate evoked dynamics between the
MBT and the psychoanalytic therapy models; between the team members in the staff
meetings; between patients and staff in the community meetings; and between those
involved in the organization of the setting, the setting of rules, and so on.
Although we decided to organize a specific MBT program, with the group psycho-
therapy done by MBT therapists and nurses together (in contrast with the psychoana-
lytic therapy group), MBT also was integrated into the existing psychoanalytic therapy
groups. Nurses in the whole setting joined the MBT supervision group, and MBT has
become a leading model in the family approach. In some exceptional cases, individual
MBT is offered to patients who are in psychoanalytic therapy group treatment. The in-
dication for MBT or psychoanalytic therapy according to pretreatment characteristics
needs further study, as does the integration of both models, if increasingly efficacious
treatment is to be developed. Currently, we are investigating the effectiveness of this
adapted treatment program in a new process-outcome study.
Suggested Readings
Bartak A, Spreeuwenberg MD, Andrea H, et al: Effectiveness of different modalities of psycho-
therapeutic treatment for patients with cluster C personality disorders: results of a large
prospective multicentre study. Psychother Psychosom 79:20–30, 2010
Chiesa M, Fonagy P, Gordon J: Community-based psychodynamic treatment program for se-
vere personality disorders: clinical description and naturalistic evaluation. J Psychiatr Pract
15:12–24, 2009
Fonagy P, Luyten P, Bateman AW, et al: Attachment and personality pathology, in Psychody-
namic Psychotherapy for Personality Disorders: A Clinical Handbook. Edited by Clarkin J,
Fonagy P, Gabbard G. Washington, DC, American Psychiatric Publishing, 2010, pp 37–88
Vermote R, Lowyck B, Luyten P, et al: Process and outcome in psychodynamic hospitalization-
based treatment for patients with a personality disorder. J Nerv Ment Dis 198:110–115,
2010
Vermote R, Lowyck B, Luyten P, et al: Patterns of inner change and their relation with patient
characteristics and outcome in a psychoanalytic hospitalization-based treatment for person-
ality disordered patients. Clin Psychol Psychother 2010 Epub ahead of print
Part II
Specific Applications
CHAPTER 11
Borderline Personality
Disorder
I n this chapter, we examine mentalization-based treatment (MBT) in relation to the

disorder it was originally developed to treat: borderline personality disorder (BPD)
(Bateman and Fonagy 2004, 2006a). We consider some of the general principles fol-
lowed by MBT therapists in the treatment of BPD. In Chapter 1, we discussed key as-
pects of the difficulties patients with BPD experience in contemplating behavior in
terms of mental state. Here we discuss the key features needed in psychotherapeutic
work to address the problems of mentalizing characteristic of BPD.
Perhaps the best that can be claimed for the MBT approach to BPD is that this ap-
proach structures treatment, organizes interventions according to specific principles
based on an understanding of the development of the disorder, is wary of therapy tech-
niques that may be harmful because of the core pathology of unstable mentalizing, and
has been subjected to, and continues to be subjected to, research. We should point out
273
that the aims of MBT are modest (see Table 11–1). This is not a therapy aiming to
achieve structural/personality change or to alter cognitions and schemas (Young et al.
2003). Rather, it is a therapy to enhance capacities of mentalization and to make them
more stable and robust so that the individual is better able to solve problems and to
manage emotional states (particularly within interpersonal relationships), or at least to
feel more confident in doing so. Our intention with the patient is to promote a men-
talizing attitude to relationships and problems, to instill doubt where there is certainty,
and to enable the patient to become increasingly curious about his or her own mental
states and those of others. It is assumed that as a result, problem behaviors attributable
to limitations in mentalization will be addressed.
Some General Considerations

The therapist’s mentalizing therapeutic stance should include 1) humility deriving
from a sense of “not-knowing”; 2) patience in taking time to identify differences in per-
spectives; 3) openness to legitimizing and accepting different perspectives; 4) active
questioning of the patient about his or her experience, asking for detailed descriptions
of experience (“what” questions) rather than explanations (“why” questions); and 5)
careful eschewing of the need to understand things that make no sense (i.e., refraining
from saying explicitly that something is unclear) (Table 11–2).
An important component of this stance is monitoring and acknowledging one’s
own mistakes as a therapist. This practice not only models honesty and courage, and
tends to lower arousal because the therapist takes responsibility, but also offers oppor-
tunities to explore how interpersonal problems can arise out of mistaken assumptions
about opaque mental states and how misunderstanding can lead to massively aversive
experiences. In this context, it is important to be aware that the therapist is constantly
at risk of losing the capacity to mentalize when faced with a nonmentalizing patient.
Consequently, we consider therapists’ occasional enactments as an acceptable concom-
itant of the therapeutic alliance, something that simply has to be owned up to. As with
other instances of breaks in mentalizing, such incidents require that the process be
“rewound” and the incident explored. Hence, in this collaborative patient-therapist re-
lationship the two partners involved have a joint responsibility to understand enact-
ments.
The Content of Therapeutic Interventions

MBT is a psychotherapeutic approach with its roots in psychoanalysis. While working
with a specific aim of increasing the capacity for mentalization, it does not specify the
narrative content that the psychotherapist is invited to address with the patient. The
therapist’s task is a relatively simple one. It consists of identifying nonmentalizing in the
Borderline Personality Disorder 275
TABLE 11–1. Therapist characteristics in mentalization-based therapy
In mentalization-based therapy, the therapist shows:

• Humility deriving from a sense of “not-knowing”
• Patience in taking time to identify differences in perspectives
• Eschewal of the need to understand things that make no sense (i.e., do not refrain from
saying explicitly that something is unclear)
• Courage to accept openly his or her own mentalizing errors and other errors
• Ability to legitimize and accept different perspectives
• Active questioning of the patient about his or her experience
• Willingness to explore own and others’ mental states
• Curiosity about changing mental states
• Capacity to demonstrate changing his or her mind as a result of better understanding
patient’s narrative and working with the patient to address this mentalizing failure with
a view to enhancing this capacity in the patient. In this sense MBT may be thought of
as a psychological equivalent to physiotherapy addressed to a particular muscle group.
The topic of interventions then is specified by the patient’s concerns. However, inter-
ventions are not “random” and are constrained by several considerations.
First, MBT is a relational approach that gives priority to the patient’s interpersonal
concerns. Therapists therefore are likely to focus on content having to do with rela-
tionships. In addition to applying commonsense psychology to the incidents provided
by the patient, the therapist is guided by the general framework provided by psycho-
dynamic approaches to relationships, particularly attachment theory (Fonagy and Tar-
get 2003).
Second, our assumptions about the nature of the failure of mentalization guide in-
terventions. We identified four polarities in Chapter 1. Mentalizing in BPD can often
be excessively automatic or implicit. It is simply perceived, nonconscious, nonverbal,
and unreflective. It relies on parallel and therefore quite rapid processing, which is re-
flexive and requires little effort, focused attention, or intention. The therapist’s aim
when encountering conclusions that have been rapidly and effortlessly arrived at by the
patient is to slow down thinking and move the patient toward explicit mentalization—
which is more interpreted, conscious, verbal, and reflective and requires attention, in-
tention, awareness, and effort. Of course, this is only a different way of describing the
approach that lies at the heart of most traditional interpretive psychodynamic work.
We should include a cautionary note here in regard to patients with BPD. When
patients show confusion about mental states that results from their dominant tendency
to make reflexive, automatic assumptions about the internal states of others, psycho-
therapists often aim to address and provide broader understandings for the issues that
trigger intense emotional reactions (e.g., challenging interpersonal situations, issues of
shame or guilt, feelings of inadequacy). This demand from the therapist for conscious
reflection and explicit mentalization, however, is inconsistent with the patient’s capac-
ity to perform these tasks under high levels of arousal. This of course makes it partic-
ularly hard to change deeply ingrained implicit dispositional interpersonal ideas that
rely on automatic and preconceived judgments about self and others.
Patients often are focused on cues about mental states available from direct per-
ception, the “exteriors” provided by physical and visible features such as facial expres-
sions or gestures. They pay attention to and draw implications from someone else’s
actions or, indeed, their own actions. The therapist should aim to move the patient’s fo-
cus onto mental “interiors,” onto thoughts, feelings, and experiences that may offer ad-
ditional information about a person’s actions. This shift involves not only slowing
patients down and getting them to explicate assumptions they have made about the
thoughts of others, but also encouraging complexity in relation to thought processes
and subtleties of feelings that might characterize a person’s experience. This effort ap-
plies as much to patients’ perceptions of their own mental states as to their judgments
about the mental states of others.
Patients with BPD tend to over-rely on the propositional logic of emotion in judg-
ing subjective states (Baron-Cohen et al. 2008). They extend the special logic of emo-
tion to thoughts and beliefs. We all tend to assume that emotions in others are
consistent with our own affective states, but when the logic of emotions is extended to
cognitions, the patient makes a (false) assumption of equivalence: I am thinking this way,
and thus this must be the way you think, too. The therapist should try to move the patient
away from this collapse of the appearance-reality distinction. The therapist’s attention
should particularly focus on the patient’s susceptibility to emotional contagion and
oversensitivity to certain emotional cues that may dominate discourse. When patients
appear to be so readily overwhelmed by affect, the therapeutic aim should be to help
them integrate their affective knowledge about self and others with more reflective and
cognitive knowledge (Blatt 2008). Conversely, when patients are in pretend mode they
may show considerable cognitive understanding of mental states but be out of touch
with the affective core of these experiences. The therapist needs to address specific dif-
ficulties with integrating cognitive interpretation of emotional experiences with the
bodily sensations associated with types of emotional arousal by focusing on the physical
aspects of the emotional experience. For example, when patients refer to affect states
but are unable to link these effectively to cognitions, working with them to identify the
specific physical locus of the emotional experience may make it more real, more avail-
able to be thought about or discussed at the same time the “feeling is felt” (Allen et al.
2008). For instance, feeling “bad inside” may, when explored and mentally represented,
become a sadness about one's failures that can be thought about while the bad feeling
continues to be experienced.
Similar considerations of lack of integration apply to working with the self-other
distinction in psychotherapy. One aspect of this technique is a simple rule of thumb:
TABLE 11–2. Aims of mentalization-based therapy in treatment of borderline

personality disorder
1. To enhance embryonic capacities of mentalization

2. To manage emotional states, particularly within interpersonal relationships
3. To promote a mentalizing attitude to relationships and problems
4. To instill doubt where there is certainty and rigidity
5. To promote curiosity about the person’s own mental states and those of others
patients talking in a nonmentalizing way about their own state can be profitably moved
to considering the mental state of others, while patients who are overly preoccupied
with their description of others can be asked to consider the impact of what they are de-
scribing on their own functioning. Moving thoughts and feelings between self and
other in a continuous and consistent way is one of the core elements of the MBT ap-
proach. The therapist should take care not to accept equivalence but to aim for differ-
entiation in this process.
Therapist Attitude
The attitude of the therapist is crucial. The therapist will stimulate a mentalizing pro-
cess as a core aspect of interacting with others and thinking about oneself. In part, this
will occur through a process of identification in which the therapist’s ability to use his or
her mind—and to demonstrate delight in changing his or her mind when presented with
alternative views and better understanding—will be internalized by the patient, who
gradually becomes more curious about his or her own and others’ minds and conse-
quently becomes better able to reappraise him- or herself and understanding of others.
But in addition, the continual reworking of perspectives and understanding of oneself
and others, in the context of stimulation of the attachment system and within different
contexts, is key to a change process, as is the focus of the work on current rather than
past experience. The therapist’s task is to maintain or reinstate mentalizing in both self
and patient while simultaneously ensuring that emotional states are active and meaning-
ful. Excessive emotional arousal will impair the patient’s mentalizing capacity and po-
tentially lead to acting out, whereas inadequate emphasis on the relationship with the
patient will allow avoidance of emotional states and a narrowing of contexts within
which the patient can function interpersonally and socially. The addition of group ther-
apy to individual sessions dramatically increases the contexts in which this process can
take place, and so MBT is practiced in both individual and group modes (see Chapter 3,
by Bateman and Fonagy, and Chapter 4, by Karterud and Bateman, in this volume).
The Not-Knowing Stance

The “not-knowing” or mentalizing stance is part of this general therapeutic attitude and is
key to ensuring that the therapist maintains his or her curiosity about the patient’s mental
states. The therapist must accept that both therapist and patient experience things only
impressionistically and that neither of them has primacy of knowledge about the other or
about what has happened. This is more easily written than it is enacted in therapy. Both pa-
tient and therapist may behave as if they are sure about what the other is thinking or feel-
ing. For example, when did you as a therapist last say to a patient, “You must be feeling...”?
The use of the word “must” implies that you know what the patient is feeling, even if the
patient has not expressed the feeling. No doubt your motive for making the statement was
to increase the therapeutic alliance through empathy. Of course, you might be correct
about the feeling of the patient, but equally you might be wrong. Our own representation
of a feeling can never be the same as that of the patient. The problem in treatment of BPD
is that the patient will all too readily agree with the therapist’s suggestions, taking on the
therapist’s mental state and thereby circumventing the mental processes of discovering ex-
actly what he or she does feel. In MBT it is better to ask, “What is it that you feel about
that?” Only if the patient struggles to answer should the therapist nudge the patient by say-
ing, “If it was me, I would feel...” or “It sounds to me like you feel...,” both of which are
less prescriptive and both of which are “marked” as an abstraction arising from the ther-
apist’s experience. Although all this might be implicit when you are saying to the patient,
“You must feel...,” the latter’s confused state and lower mentalizing capacity will ensure
that the patient experiences the statement of how he or she feels as a fact rather than as an
invitation to consider the feeling further. Unwittingly, the therapist has taken over the pa-
tient’s mental states rather than stimulating their independent development.
A common confusion has been that being a not-knowing therapist is equivalent to
feigning ignorance. Nothing could be further from the truth. The therapist has a mind
and is continually demonstrating his or her ability to use it. The therapist may hold al-
ternative perspectives to the patient, and if so, this provides the perfect opportunity for
further exploration. For example:
A patient informed her therapist that she thought the therapy was a waste of time and
that she had not changed. She was thinking of giving up therapy. The therapist asked her
to reflect on when this feeling had first started. As she did so, he was aware that his view
differed in that he thought the patient had changed, albeit to a limited extent. So he con-
trasted his view with that of the patient, mentioning the ways in which he thought she
seemed different. This was not an attempt to reassure her or to persuade her that her
negative view of herself and the therapist and their achievements was wrong. This in it-
self would be markedly off the model, as we strongly advise against trying to show pa-
tients that their beliefs and experience are incorrect, particularly when they are
functioning in psychic equivalence. The therapist’s aim in exploring their differences in
experience and perspective was to stimulate a richer and more complex consideration of
the patient’s feeling that therapy was a waste of time. The patient was unable to accept the
therapist’s statement initially and simply replied that the therapist was only saying en-
couraging things because he was being professional. The session continued with the
therapist saying, “Oh, I hadn’t thought of it like that. I think it would be more profes-
sional to discuss a failing therapy with a patient rather than to pretend things were get-
ting better when they were not.” Gradually the patient and therapist managed to identify
a better focus for therapy and to define more carefully the patient’s disappointment about
not improving more rapidly and her fears that she could never change.
The beauty of the not-knowing stance is that it reminds the therapist that he or she
does not need to understand what the patient is saying or to struggle to make sense of
it within another framework such as the patient’s traumatic past or cognitive schemas.
The MBT therapist eschews the need to understand. The therapist should feel under
no obligation to understand the nonunderstandable. Patients with BPD become mud-
dled as they talk about themselves and others when they become aroused, as do normal
people. But feelings disrupt mentalizing more rapidly in patients with BPD, and as the
patient’s mentalizing processes are lost, the therapist is likely to understand less and
less. This is a moment for the therapist to intervene, most straightforwardly by saying,
“I am not sure I am understanding this. Can you help me do so?” The cardinal error un-
der these circumstances is for the therapist to take over the mentalizing and to try
harder and harder to make sense of what the patient says and then to deliver this un-
derstanding. When relieved of having to understand, the novice therapist is in a more
confident position because this allows him or her to be less fearful of making errors.
Therapist Error
All therapists sometimes get things wrong. The questions that need answering are, what
should be done when something goes wrong and what has happened to make it go wrong.
Clearly, therapist errors range from the mild to the severe, and we will discuss here only
those that are misunderstandings rather than those that are boundary violations. Ther-
apist errors offer opportunities to revisit what happened and to learn more about con-
texts, experiences, and feelings engendered in both patient and therapist as a result of the
error. In MBT, the therapist takes initial responsibility for the error until it becomes
clearer that there was a contribution from the patient. Let us consider an example:
The therapist was to be away on the day of the patient’s session the following week, and
he told the patient that he needed to change the session day so that they would not miss
an appointment. The patient said, “Okay. We can sort it out at the end.” At the end of the
session, the therapist (having been so involved in the session—or so he suggested to oth-
ers afterwards!) forgot about rearranging the appointment, and the patient did not men-
tion it. The therapist remembered a minute after the patient had left and ran after her,
fortunately catching up with her before she left the building. When he said to the patient,
“I’m sorry I forgot to rearrange the session. Can you come back for a moment so that we
can do it?” the patient replied wryly, “Nearly forgot, did we?” Ignoring this, the therapist
rearranged the appointment.
The following week the patient quipped, “This is the session that nearly did not
happen!”
The therapist apologized and said, “I wondered what had been going on that meant
I forgot at the end of the session. I was thinking about it and I am not sure at all.”
PATIENT: It was because you didn’t want to see me.

THERAPIST: I don’t think that had occurred to me, but certainly I should have re-
membered to rearrange the session, and that was my responsibility.
PATIENT: I always think that people like me when I’m not here.
THERAPIST: In what way?
PATIENT: When I am with them, people just feel pissed off with me, but when I
am not here, they think that maybe I’m not so bad.
The dialogue continued with the patient expressing a sense that she would have
liked to have missed the session as a result of the therapist’s failure to rearrange it, so that
she could feel good. Clearly this needed more exploration because it was not immediately
understandable. So the therapist asked about what she meant. Importantly, the therapist
took initial responsibility for what had happened. Only later in the session did the ther-
apist say that he was also curious about what had stopped the patient from asking for the
new appointment. Rapidly the patient became aggressive:
PATIENT: So, now it suddenly becomes my fault, does it? It was you who forgot
to rearrange it, so we should be discussing your problem, not mine.
THERAPIST: I agree that it was my problem and that it was my memory that was
the issue, and yet it is intriguing that you don’t feel able to help me with my
memory.
PATIENT: Not my job.
This interaction has the potential to close down the patient’s ability to reflect on
her state and that of the therapist, so the therapist’s task is to ensure that both he and the
patient openly juxtapose their mental states as they consider which aspects of the in-
teraction were primarily related to the patient and which to the therapist. To do this,
the therapist has to balance reference to his own responsibility for something that has
happened with stimulation of the patient’s ability to explore her own contribution. Ex-
cessive emphasis on the patient’s share of the responsibility will alienate her and in-
crease the likelihood of closing rather than opening her mind.
Tailoring Interventions
The therapist has to ensure that any intervention is consonant with the patient’s men-
talizing capacity and not with his or her own. Many therapists overestimate the mental
TABLE 11–3. Optimal mentalizing interventions
Mentalizing interventions should:

• Be consonant with the mentalizing capacity of the patient
• Take into account the patient’s affective state and arousal of attachment
• Balance the patient’s arousal state by using moves that are contrary to the patient’s arousal
level
• Follow the principle that high arousal suggests the need for intervention to deactivate the
attachment system
capacities of patients with BPD. A patient with difficulty in mentalizing self and other
cannot understand complex statements related to self and other within the patient-
therapist relationship—for example, “You think that I think that you....” Such inter-
ventions are likely to increase confusion when there is already perplexity about self and
other, especially if the patient is currently unable to mentalize. At other times, the pa-
tient may be able to differentiate what is in his or her own mind and contrast it with
what is in someone else’s mind. At these times, more complex interventions become
possible. In MBT, therapists follow the general principle that the greater the patient’s
emotional arousal, the less complex the intervention should be. Supportive comments,
gentle exploration of a problem, and clarification require less mental effort from the
patient and so are considered “safe” interventions during high states of arousal. In con-
trast, interpretive mentalizing and mentalizing the transference heighten arousal and
so carry the danger of stimulating use of secondary attachment strategies, either of
hyperactivation leading to overarousal or deactivation inducing pretend mode, both of
which decrease mentalizing. We therefore suggest that these interventions be used
with care (see Table 11–3). They are likely to be most beneficial when the patient is op-
timally aroused, that is, able to remain within a feeling while continuing to explore its
context—so-called mentalized affectivity (Jurist 2005).
On the principle that interventions must be in keeping with a patient’s mentalizing
capacity, other techniques commonly used by therapists are deployed with caution in
MBT. When a patient asks a direct personal question, for example, it is initially as-
sumed that this is arising in the context of anxiety, indicating that the patient is attempt-
ing to structure the mentalizing process. Immediately reflecting on the question asks
the patient to perform more mental work at a time when he or she is struggling to
maintain mental processing. So the MBT therapist takes on the mental work to help re-
duce the internal anxiety of the patient at any time when the patient’s mentalizing ca-
pacity is vulnerable to collapse. If unable to answer the question, the therapist should
say so and give reasons; it may be a personal question that the therapist is unwilling to
answer, he or she may not know the answer, or the patient may have stimulated some
confusion. It is far better to say, “I don’t know how to answer your question, and it con-
fuses me, so may I think about it?” than it is to reflect the question by saying, “What do
you think?” The former response indicates that the therapist is now responsible for
working out what is happening, whereas the latter response places further mentalizing
responsibility back with the patient (and to this extent, has the potential to overload the
patient’s capacities).
Therapist Mind
A constant temptation exists for therapists to piece things together, to make sense of
things according to their own models of mental function—in short, to mentalize on the
patient’s behalf—and then deliver their understanding or insight to the patient. In prin-
ciple, this aspect of therapist activity is antimentalizing: the therapist takes over the mind
of the patient rather than stimulating the patient to develop his or her own mentalizing
process. This leads to a number of problems. First, the aim of treatment is to stimulate
mentalizing process when it is not present or to maintain it when it becomes vulnerable to
collapse. This is unlikely to happen if the therapist “secretly” (that is, silently, within his
or her own mind) pieces things together to make them into a more coherent narrative ac-
cording to the therapist’s own theories and understanding of human function. Second,
the coherence of the therapist’s understanding might have adverse consequences for ther-
apy by inadvertently stimulating pretend mode if the process of understanding is circum-
vented. Unable to make personal sense of the therapist’s understanding, or at best able to
use only a cognitive understanding, the patient takes over the model of the therapist and
uses it to develop meaningless representations. These representations have no depth;
they do not link with earlier representations and understanding or integrate with emo-
tional experience, so they fail to stimulate integration of mentalizing processes. As a re-
sult, the understanding becomes sealed off from the external world; it lacks utility outside
therapy and cannot be applied in an ever-widening range of circumstances and contexts.
All therapies have the potential to stimulate pretend mode, and the MBT therapist needs
to be continually aware that he or she might inadvertently create this state of mind in the
patient and so induce harm.
Authenticity
Another important aspect of MBT is that the therapist’s mental processes must be
available to the patient. Mental processes are opaque. This opacity, combined with the
BPD patient’s characteristic vulnerability to loss of mentalizing within relationships
and sensitivity to external cues indicating mind states, such as facial expressions (Lynch
et al. 2006), means that the mentalizing therapist needs to try to make his or her own
mental processes transparent to the patient while trying to understand the patient,
openly deliberating while “marking” statements carefully. This effort requires direct-
ness, honesty, authenticity, and personal ownership, which is problematic partly be-
cause of the dangers of boundary violations in the treatment of borderline personality

disorder. Our emphasis on the need for authenticity is not a license to overstep the
boundaries of therapy or to develop a “real” relationship; we are merely stressing that
the therapist needs to be mentally available to the patient and must demonstrate an
ability to balance uncertainty and doubt with a continued struggle to understand. This
becomes particularly important when the patient correctly identifies feelings and
thoughts experienced by the therapist. The therapist needs to be prepared for ques-
tions that put him or her on the defensive, such as “You’re bored with me” or “You don’t
like me much either, do you?” Such challenges can arise suddenly and without warning,
and the therapist needs to be able to answer with authenticity. If the therapist does not
do so, the patient will become more insistent and evoke the very experience he or she is
complaining of (if indeed the therapist was not already feeling it at the time).
A patient’s accurate perception of what is in the therapist’s mind needs validation:
“You are bored with seeing me, aren’t you?” is likely to be asked from a position of psy-
chic equivalence in which the patient him- or herself may be feeling bored. Within psy-
chic equivalence, the patient cannot distinguish self and other easily and so operates
from a perspective that others have the same experience.
If the therapist is indeed feeling bored, it is important that he or she say so in a way
that stimulates exploration of what is boring within the patient-therapist interaction.
An MBT therapist will take equal responsibility for creating boring therapy and move
to making this a focus of therapy for that moment: “Now that you mention it, I was
feeling a bit bored, and I am not sure where that is coming from. Is it related to what
you are talking about or how you are talking about it, or is it more me at the moment?
You know I am really not sure.”
If the therapist is not bored, then he or she needs to find a way to express this that
will open up the possibility of exploring what stimulated the patient’s question. To do
this, the therapist first needs to be open about the current feeling, rather than to at-
tempt to stimulate the patient’s fantasies about what the therapist is feeling. We suggest
that asking the patient, “What makes you think I am bored?” without clarifying first
whether or not this is the case is likely to induce pretend mode once again or, alterna-
tively, simply lead to a persistence of psychic equivalence fantasy. It is better to tell the
patient what you are experiencing within the therapy at that moment: “As far as I am
aware, I was not bored. In fact, I was trying to grasp what you were saying. I felt mud-
dled. But now I am intrigued that you and I were having such a different experience of
this at the moment.” The aim here is to stimulate the exploration of alternative per-
spectives, and if this is to occur, the different perspectives have to be clear.
Patient-Therapist Relationship
Another important element is the principles the MBT therapist follows in the use of the
transference as an aspect of the patient-therapist relationship. It has been suggested that
transference is not used in MBT (Gabbard 2006). The answer to the question of whether
MBT is a transference-based therapy or not probably boils down to how transference is de-
fined and how it is used (Clarkin et al. 1999a). Perhaps it is our vigilant attitude to the use of
transference that has led some critics to suggest that MBT is in fact “transference-focused
therapy lite.” Certainly, it is correct that we have cautioned practitioners: first, about the
commonly stated aim of transference interpretation—namely, to provide insight—and sec-
ond, about genetic aspects, such as linking current experience to the past, because of their
potential iatrogenic effects. But equally, we train MBT therapists to “mentalize the trans-
ference” as a key component of therapy, and we have set out a series of steps to be followed.
These steps are discussed in more detail in Chapter 3 of this volume.
Once again, the issue is the patient’s mentalizing capacity and its relationship to
arousal. Complex interventions, such as those related to details of patient-therapist inter-
action or the genesis from the past of current states, require a thoughtful and reflective pa-
tient if they are to be effective. A nonmentalizing patient holding rigid mental perspectives
and having limited access to the richness of past experience is unlikely to be able to hold
other perspectives in mind while comparing them to his or her own, particularly if they are
complex and subtle. The individual is likely to feel overwhelmed; far from stimulating a
mentalizing process, such interventions will compound nonmentalizing by increasing anx-
iety. The patient panics, feeling incapable of considering the therapist’s fully mentalized and
coherent intervention. Structuring of mental processes occurs, and the patient becomes
more rigid and more insistent about his or her own point of view. For example:
A patient had been talking to her male therapist about her experience with her father.
There were many similarities between that experience and the way she treated the ther-
apist. She talked about her worries that the therapist would decide to stop seeing her be-
cause she was often late for her sessions. The therapist suggested that this experience
linked with her relationship with her father.
THERAPIST: Perhaps you see me like your father.

PATIENT: How would I know?
THERAPIST: You treat me in the same way as you felt you were treated by him.
Your father never turned up when he said that he would. In the end, you
didn’t want to see him anymore.
PATIENT: That could be true, but how would I know it was right? It could just be
rubbish. It makes you sound like a clever bastard and lets you off the hook
basically.
The patient continued on this theme. This suggests that the therapist’s intervention
had stimulated further structuring of the relationship organized around a clever therapist
and a stupid patient. The fact that the therapist might have been right about the link
misses the point. The therapist was taking the understanding of the current process be-
tween them far beyond the level at which the patient was able to consider it. No mental-
izing was stimulated. To achieve mentalizing in the context of the therapist-patient
relationship, the therapist is required to take a more leisurely approach to interpreting

the transference in MBT. We have recommended a multistep approach, starting (as in
most instances) with validation of the patient’s experience. Routine psychodynamic prac-
tice skirts the potential of iatrogenic invalidation by appearing to “convert” the patient’s
current experience in relation to the therapist to something quite “other” (to do with an-
other person, such as the patient’s father, or another emotion—for example, aggression as
a defense against love). The therapist has to start the process of interpretation by accept-
ing the patient’s experience in relation to him or her as real, and then explore its impli-
cations for their current relationship. It is essential, too, that the therapist’s contribution,
including his or her own distortions, is explored. Accepting responsibility for misunder-
standing makes a collaborative stance in relation to the “transference experience” easier
to achieve. For instance, in the example above, the therapist should start by accepting the
patient’s distress in which she fears that she might unwittingly cause problems for the
therapy by consistently coming late but feels unable to do anything about this. He should
then take time to spell out with the patient what she thinks the impact of her lateness is on
him, what he might be feeling about it and not saying, and why he might not wish to do
so. In the course of this, the therapist might well realize that he has made critical com-
ments about the patient’s lateness and may well have come across as insufficiently sym-
pathetic with the patient’s struggles to make arrangements for her children, to deal with
inadequate public transportation, and so forth. With his having accepted responsibility
for being unduly critical, the patient and therapist might arrive at a collaborative under-
standing of the situation between them in terms of the patient’s hypersensitivity to being
criticized and found wanting because of her deep fear that this would be followed by
abandonment. At this point the therapist may be ready to present an alternative perspec-
tive, linking the patient’s experience in relation to the therapist to her feelings about her
father’s unreliability and critical attitude:
THERAPIST: It would not surprise me if my slightly insensitive comments about

your lateness made you think that I was about to give up on you as you felt
your father did. Now, that must be a worrying thought!
The therapist then monitors the patient’s reaction. The patient might violently
disagree or enthusiastically affirm the therapist’s comments. In either case, her reaction
can be validated and explored as the next phase of transference work, following the
steps outlined above.
Countertransference
Transference cannot be discussed without some brief comments on countertrans-
ference (defined as those experiences, both affective and cognitive, that the therapist
has during sessions and that he or she thinks might further develop understanding of
mental processes). While the use of transference often involves markedly cognitive
mentalizing in the therapist, countertransference, by definition, links to the therapist’s
self-awareness and often relies on the affective components of mentalizing. Some ther-
apists tend to default to a state of self-reference in which they consider most of what
they experience in therapy to be relevant to the patient. This default mode needs to be
resisted, and therapists need to be mindful that their own mental states might unduly
color their understanding of the patient’s mental states and lead to equating these states
without adequate foundation. The therapist has to “quarantine” his or her feelings—
and how this is done informs the technical approach to countertransference. Recom-
mendations for working with countertransference are outlined in Table 11–4.
We frame our work with countertransference with an exhortation for the therapist to
be “ordinary.” Inexperienced therapists frequently have ideas about how a therapist should
behave and act in therapy that lead them to become wooden, unresponsive, and dedicated
to technical application. We suggest that being ordinarily human is a better way forward
when working with countertransference. We do not license therapists to behave in any way
they please or to say whatever they like—any more than they would do in a respectful re-
lationship with a friend. Rather, we recommend that the therapist openly work on his or her
state of mind in therapy in a way that moves the joint purpose of the relationship forward,
keeping mentalizing online. To do this, the therapist will often need to speak openly from
his or her own perspective rather than from an understanding of the patient’s experience—
and the key word here is openly. Countertransference experience expressed verbally by the
therapist is an important aspect of therapy, but when it is being expressed, it must be marked
as an aspect of the therapist’s own state of mind. It should not be attributed to the patient,
even though it may be a reaction to the patient.
Countertransference experience can be powerful in the treatment of BPD, with
therapists struggling with feelings of rage, hatred, hurt, or anxiety. Patients seem able
to hit the therapist’s sensitive spots and sometimes will even focus on them as they try
to control emotional processes in a session. The task of the therapist is to let the patient
know that what he or she does and says evokes a state of mind in the therapist, just as
what the therapist does and says stimulates mental processes in the patient. The patient
needs to consider such effects on the therapist within his or her own mind rather than
to ignore them or maintain that they are of no consequence. For example:
A patient who talked incessantly in sessions did so in a rather monotonous manner with-
out emotional nuances and fluctuation of tone. The therapist gradually became bored
and uncertain about the point of what she said. He stopped listening.
THERAPIST: It is a bit difficult for me to say this as your therapist, but I am find-
ing it difficult to listen to you. I keep switching off. Can we have a look at
what is happening? I was able to listen at the start of the session but realize
that I was not after you talked about your attempt to get a job. Can we go
back to around then? I need to consider why my mind wandered.
PATIENT: That’s not very nice. I was trying to tell you how upsetting it has been
not to be able to work.
TABLE 11–4. Countertransference and the therapist
Countertransference requires the therapist to show:

• The capacity to be ordinary
• The ability to use common sense
• The ability to “mark” his or her experience
• Facility to work openly on his or her own state of mind and perspective
• Reflective capacity about his or her own state
THERAPIST: I understand that, which is why I’m not sure what it is about what we
are talking about that makes it difficult for me. I think there’s something
about it that makes it sound to me that you don’t really care about it.
PATIENT: I’m just saying things, I suppose, but I do care about it.
THERAPIST: Can you say in what way you care? For me, it’s perhaps more that
when you say you care, it is unclear that it matters to you. I don’t know
what to take seriously.
Gradually patient and therapist explored the quality of the interaction that led the
patient to say things without emotion and led the therapist to become bored. In this ex-
ample, the therapist has notably taken the boredom from his own perspective rather than
trying to focus on it as part of the patient’s feeling. Following this discussion, the thera-
pist realized that he had misunderstood the importance of the patient’s failure to obtain
employment, and he was able to say that.
In the preceding example the therapist’s feelings are relatively mild and perhaps
not so difficult to express. It is more problematic when countertransferences are neg-
ative and are accurately perceived by the patient, particularly as patients with BPD are
highly sensitive to negative affect. Therapists need to become skilled in expressing their
negative experience in a way that helps exploration to progress and furthers mentaliz-
ing. For example:
A patient was admitted to the hospital during the weekend on an emergency basis, having
felt suicidal. At the next session, the patient was talking about her admission and her feeling
that she had to be protected. The therapist felt somewhat frustrated that she had been ad-
mitted, as he felt that it might not have been necessary. The patient suddenly challenged
the therapist.
PATIENT: You are cross with me that I was admitted, aren’t you?
THERAPIST: Now that you mention it, I am a bit frustrated about it.
PATIENT: Are you going to stop seeing me?
THERAPIST: That had not occurred to me, but I think my frustration is related to
the fact that I had no idea that you might need hospital admission at the
moment, and your feelings of suicide arising at this time are a mystery to me.
So I wonder what I have been missing about your ability to cope with the
feelings. That frustrates me.
PATIENT: So I shouldn’t have gone into the hospital?
THERAPIST: I can see that I am implying that, but before we get there, can we go
back to the last session to see if we did miss something? Perhaps that will
tell us a bit more about your need to go into the hospital rather than cop-
ing with the feelings in some other way.
In the above vignette, the therapist is stating her experience of the patient’s admis-
sion while at the same time accepting some responsibility for it. She tries to rewind to
an earlier point, a common technique in MBT that is discussed further in Chapter 3 of
this volume, to consider whether there were any precursors to the suicidal feelings that
had been missed in therapy.
Conclusion
The MBT therapist is ordinary and has a natural tendency to be uncertain while trying to
stimulate a process of detailed exploration about what is happening in the patient’s mind.
He or she needs to become less of a therapist and yet not a friend, or simply a supportive lis-
tening ear, but rather someone who enriches mental processes. This is no easy task for most
of us, but with limited training and moderate levels of supervision, mental health practitio-
ners are able to achieve this. In the development of these skills, the “bumbling” effect and
the exploratory attitude so well described by Epictetus (1925) will always be to the fore: “To
do anything well you must have the humility to bumble around a bit, to follow your nose, to
get lost, to goof. Have the courage to try an undertaking and possibly do it poorly. Unre-
markable lives are marked by the fear of not looking capable when trying something new.”
Suggested Readings
Bateman A, Fonagy P: Mentalization Based Treatment for Borderline Personality Disorder: A
Practical Guide. Oxford, UK, Oxford University Press, 2006
Krawitz R, Jackson W: Borderline Personality Disorder: The Facts. Oxford, UK, Oxford Uni-
versity Press, 2008
Paris J: Treatment of Borderline Personality Disorder: A Guide to Evidence-Based Practice.
New York, Guilford, 2008
Porr V: Overcoming Borderline Personality Disorder: A Family Guide for Healing and Change.
Oxford, UK, Oxford University Press, 2010
Van Luyn B, Akhtar R, Livesley WJ (eds): Severe Personality Disorders. Cambridge, UK, Cam-
bridge University Press, 2007
CHAPTER 12
Antisocial Personality
Disorder
A ntisocial personality disorder (ASPD) is characterized by a number of descriptive

clinical features: a failure to conform to social norms with respect to lawful behaviors;
deceitfulness; impulsivity or failure to plan ahead; irritability and aggressiveness; reck-
less disregard for safety of self or other; consistent irresponsibility; and lack of remorse.
None of these features is endearing to others. The self-serving attitude and the unpre-
dictability of people with ASPD makes others wary of them. Unsurprisingly, ASPD is
one of the most common diagnoses in prison populations and in those attending pro-
bation services (National Institute for Health and Clinical Excellence 2009a). Treat-
ment is considered to be difficult, and patients with ASPD receive poor mental health
care from psychiatric and psychological services (Crawford et al. 2009). In penal insti-
tutions, individuals may be offered a group-based cognitive-behavioral treatment fo-
cusing on their offending behavior and/or anger management. Consideration is rarely
given to the possibility of treatment focusing on their wider personality difficulties. In
this chapter, we argue that many of their descriptive personality characteristics are re-
lated to abnormalities in mentalizing and that an understanding of these may offer a
route to more effective treatment.
289
Mentalizing
Mentalizing simply implies a focus on mental states in oneself or in others, particularly
in explanations of behavior (Fonagy et al. 2002a). That mental states influence behavior
is beyond question. Beliefs, wishes, feelings, and thoughts, whether inside or outside
our awareness, determine what we do. Yet explanations of behavior in terms of others’
mental states (mentalizing) are relatively more difficult to produce compared to expla-
nations that refer to aspects of the physical environment (nonmentalizing). The latter
are far less ambiguous because the physical world is more fixed, less readily changeable,
and more easily observable. Mental states are less fixed and are rapidly changeable; a
simple contemplation of alternative possibilities may lead to a change in beliefs. Thus,
a focus on mind leads to far more uncertain conclusions than a focus on physical cir-
cumstance, because it concerns a mere representation of reality rather than reality it-
self. It also brings other dangers with it. We may act according to incorrect beliefs
about others’ mental states and underlying motivations in a particular situation, some-
times with tragic consequences. For example, we may experience someone as charming
and trustworthy enough to invest our life savings with them, only to find that they steal
our investment.
Dimensions of Mentalizing and

Antisocial Personality Disorder
As discussed in Chapter 1 of this volume, mentalizing is a multidimensional construct,
and breaking it down into dimensional components is helpful in understanding men-
talization-based treatment (MBT). Broadly speaking, mentalization can be considered
as four intersecting dimensions: automatic/controlled or implicit/explicit; internally/
externally based; self/other oriented; and cognitive/affective process. Each of these di-
mensions possibly relates to a different neurobiological system. The key to successful
mentalizing is the integration of all the dimensions into a coherent whole.
None of us manages to integrate all components of mentalizing all of the time, nor
should we. Normal people will, at times, move from understanding themselves and
others according to their perceptions of what is in the mind, to explanations based on
the physical environment: “I must have wanted to, because I did it”; “If they behave like
that, they obviously want to spoil everything.” This is particularly true in powerful af-
fective states when our cognitive processes fragment in the face of a wave of emotion.
So personality pathology does not simply arise because of a loss of mentalizing. It oc-
curs for a number of reasons.
First, it matters how easily we lose our capacity to mentalize. Some individuals, for
instance, are sensitive and reactive, rapidly moving to nonmentalizing modes in a wide
range of contexts.
Antisocial Personality Disorder 291
Second, it matters how quickly mentalizing is regained once it has been lost. We
have suggested that a combination of frequent, rapid, and easily provoked loss of men-
talizing within interpersonal relationships, with associated difficulties in regaining
mentalizing and the consequent lengthy exposure to nonmentalizing modes of experi-
ence, is characteristic of borderline personality disorder (BPD; Bateman and Fonagy
2004). Individuals with BPD may be “normal” mentalizers except in the context of at-
tachment relationships, in which they tend to misread minds, both their own and those
of others, when emotionally aroused. As their relationship with another person moves
into the sphere of attachment, the intensification of the relationship means that their
ability to think about the mental state of another can rapidly disappear. When this hap-
pens, prementalistic modes of organizing subjectivity emerge—psychic equivalence
and pretend modes—which have the power to disorganize these relationships and de-
stroy the coherence of self-experience that the narrative provided by normal mental-
ization generates.
Third, mentalizing can become rigid, lacking flexibility. People with paranoid dis-
order, for example, often show rigid hypermentalization with regard to their own inter-
nal mental states yet lack any real understanding of others (Dimaggio et al. 2008; Nicolo
and Nobile 2007); at best, they are suspicious of motives, and at worst, they see people
as having specific malign motives and cannot be persuaded otherwise. The mental pro-
cesses of people with ASPD are less rigid than those found in people with paranoid dis-
order. Their mentalizing shows flexibility at times, but when uncertainty arises, they use
prementalistic modes of thinking to organize their mental processes and interpret the
world and their relationships.
Finally, the balance of the components of mentalizing can be distorted. Patients
with narcissistic personality have a well-developed self-focus but a very limited under-
standing of others. In contrast, patients with ASPD are experts at reading the inner states
of others—even to the point that they misuse this capacity to coerce or manipulate oth-
ers—while being unable to develop any real understanding of their own inner worlds. In
addition, they lack the ability to read certain emotions accurately (an externally based
component of mentalizing) and fail to recognize fearful emotions from facial expres-
sions. This implies dysfunction in neural structures such as the amygdala that subserve
fearful expression processing. Marsh and Blair (2008) in a meta-analysis of 20 studies
showed a robust link between antisocial behavior and specific deficits in recognizing
fearful expressions. This impairment was not attributed solely to task difficulty.
The link between ASPD and the affective component of mentalizing is well estab-
lished developmentally. Youths with conduct problems have been shown to have a hy-
poactivation of their amygdala in response to pictures normally considered emotionally
arousing, particularly where a potentially painful aggressive act was depicted (Jones et
al. 2009; Marsh et al. 2008). Amygdala hyporesponsiveness may indicate a dysfunction
in limbic structures that leads to reduced responsiveness of the amygdala to fearful
faces, with consequent impairment in recognizing distress cues in others and thus a lack
of empathy and deficient control of aggressive behavior. Alternatively, we may see these
abnormalities as reduced sensitivity to threat-indicating stimuli (fearlessness). Al-

though preferential amygdala responses to fearful faces normally are likely to subserve
the modulation of vigilance in threatening situations rather than the recognition of so-
cial cues, constitutional fearlessness would stop infants from regularly seeking their at-
tachment figure when experiencing distress, and intersubjective experiences of relating
in an attachment context, we have suggested, may be critical for the normal develop-
ment of social cognition (Fonagy 2003). In contrast to the findings of reduced respon-
siveness, amygdala hyperresponsiveness was observed in some individuals, who showed
a hyperactivation of the amygdala on seeing a hand shut in a door or a foot being
stamped on (Decety et al. 2009). Here amygdala responses in conduct-disordered
youths correlated with parents’ ratings of daring behavior and sadism. Increased
amygdala response may indicate excitement at or enjoyment of others’ pain. Hence, for
some individuals these images may generate an unusual level of enjoyment rather than
empathetic concern. In either case, the dysfunction of emotional resonance or empathy
appears to be linked to vulnerability for antisocial behavior, and the clinical and theo-
retical exploration of this relationship appears warranted.
Antisocial Personality Disorder and

Prementalistic Modes of Functioning
The significant descriptive phenomena of ASPD are a consequence of a shift from
mentalistic modes of functioning to prementalistic ways of perceiving the world. We
assume that in some individuals, perhaps those who experienced attachment-related
trauma such as severe parental maltreatment or exposure to domestic violence, the ac-
tivation of the attachment system inhibits aspects of mentalization. However, in con-
sequence, modes of experiencing internal reality that antedate the developmental
emergence of mentalization reappear. This shift in subjectivity in turn accentuates dis-
torted and disorganized internal representations, generating a deep sense of internal
discomfort. This is then dealt with by the constant and unremitting need for external-
ization of self-destructive alien aspects of the self (Fonagy and Bateman 2007), present-
ing as a constant pressure for projective identification.
As described earlier, prementalistic mental functioning is characterized by psychic
equivalence, pretend mode, and teleological understanding of the world. In psychic
equivalence mode, no alternative perspectives are possible. The suspension of the sense
of “as if” and the experience that everything is “for real” make the apparently exagger-
ated reaction of patients understandable in view of the seriousness with which they ex-
perience their own and others’ thoughts and feelings. In individuals who present with
antisocial behavior, the failure to see an underlying intention and the superficial un-
derstanding of others based on appearance may be a profound source of difficulty.
Judging people by external cues in a very rapid implicit judgment is a substantial source
of difficulty in many interpersonal contexts. What is often described as concrete think-

ing is a consequence of mentalizing that is excessively based on external cues and is
implicit and nonreflective. The extreme reactions of individuals with ASPD are
understandable given their overemphasis on external indicators of internal states, un-
checked by reflection, which can generate deeply disturbing expectations of the inten-
tional states of others. To make matters worse, the absence of affective mentalizing
reduces the person’s capacity to imagine the pain or discomfort experienced by another.
The normally functioning nature of cognitive mentalizing capacities can create a sin-
ister impression of someone whose manipulation of the mental states of others is not
limited by any kind of understanding of the affective impact their actions might have.
This is a complex process, to which we shall return.
In the absence of an appropriate balance between cognitive and affective mental-
ization, thoughts and feelings can come to be almost disassociated, to the point of near
meaninglessness, as pretend mode reemerges. The inconsequential nature of subjective
reality for individuals with ASPD may enhance their capacity to act on others in a pu-
nitive and callous fashion. When in pretend mode, these individuals can sometimes re-
flect on their own antisocial actions. However, they frequently talk about the impact of
their actions in a way that does not translate into a real experience of regret and mostly
remains in the domain of empty words. Psychotherapy thus can be a meaningless ex-
ercise because internal states no longer carry meaning.
Early modes of conceptualizing action in terms of visible goals dominate motiva-
tion in ASPD. This is characteristic of the teleological mode of thinking. Within this
mode, there is a primacy of the physical. Experience is only felt to be valid when its con-
sequences are apparent to all. Affection, for example, is true only when accompanied by
physical expression. The stereotypical depiction of a successful antisocial individual as
bejewelled, driving luxury cars, and demonstrating acts of loyalty through violent at-
tacks on enemies may be a fantasy of scriptwriters, but it is based on an appreciation of
the massive value placed by antisocial individuals on appearance and “face.”
Sense of Self, the Alien Self, and

Patients with ASPD need relationships. Such relationships may be either within a gang
culture or in more personal contexts. In both situations, interactions are commonly
quite rigid and predictable, organized, for example, along hierarchical lines with re-
spect from others as a key organizing factor. In our view, it is not necessarily the case
that antisocial relationships create ASPD but rather that individuals with limited men-
talization drift toward individuals with whom they can have highly predictable patterns
of interaction, even if these interactions are quite limited and inflexible. However, the
intensity of these relationships should not be underestimated. An individual who is
apparently callous and uncaring about others whom he or she feels no contact with or
links to can feel an intense sense of loyalty to and identification with someone whose
behavior is experienced as congruent with his or her own. Patients with ASPD often
feel that only a handful of people truly understand them, and these individuals, usually
with similar antisocial tendencies, can come to be of enormous emotional significance
in their lives.
A relationship with a partner or other gang members may become vital because it
stabilizes the mind of the individual. Such relationships are valued for two reasons.
First, these social relationships are affirming and validating of self-states, which is a rare
experience for those whose behavior tends to attack and destroy the subjectivity of
those they are with. If a person’s experience of terror of the minds of others has led to
a need to obliterate intersubjectivity in all but a very narrow and predictable range, so-
cial relationships will not function well as a way of developing the complexity of self-
representation. Second, and conversely, social relationships can function as vehicles for
externalization of alien aspects of the self. These are often equally simple and predict-
able self-other relationships where the other is forced to play host to an unbearable in-
ternal experience. Individuals with ASPD maintain the stability of their subjective
sense of self, not only by interpreting the world according to teleological understand-
ing (“If my partner does what she is told and provides me with the appropriate respect
through her actions and how she looks at me, then I know who I am”), but also through
the rigidity of the externalization of the alien self. This rigidity presents serious prob-
lems for treatment. The rigidity of the interpersonal constellation has to be challenged,
and yet the challenge might induce violence because, in ASPD, change in personal re-
lationships, much like a reorganization of a gang structure, threatens to unleash vio-
lence as a survival mechanism.
In ASPD, the alien self is firmly and rigidly located outside: a partner may be seen
as mindless and subservient (“Women need to be treated like dogs at first. They need
firm training and only gradually can they be let off the lead”); a system may be por-
trayed as being only authoritarian and as attempting to subjugate through unwarranted
attention (“The police pick on me, follow me around, and think they can dominate
me”). These characterizations stabilize the patient’s mind. Doubt and uncertainty are
not apparent. Psychic equivalence mode predominates, making representations of
mental states even more rigid and unchangeable. Any threat to the schematic repre-
sentational structure—for example, a partner demanding an unacceptable level of in-
dependence, or the police suddenly becoming helpful and friendly—is experienced as a
threat and therefore triggers arousal, particularly within the attachment system. As
arousal increases in the face of a feared loss of agency and sense of self, the capacity for
understanding others is further restricted. This further amplifies the fear of loss of con-
trol and loss of agency, making any external threat feel even more realistic and danger-
ous. This feeds into the vicious cycle of reduced mentalizing leading to increased fear of
an internal threat, in turn generating a stronger tendency for projection, mental rigid-
ity, and a terror of loss of control over internal states. With collapse of the self immi-
nent, the need for the other as a vehicle for the alien self becomes overwhelming. It is
a matter of survival, and an adhesive, addictive pseudo-attachment to this individual
may develop. For example:
A 29-year-old man was concerned that the girlfriend of his brother was making negative
comments about him to his partner, even spreading rumors that he was seeing another
woman. During the week, his own girlfriend taunted him when they were out drinking
together by saying she was having an affair with a friend of his and so didn’t care if he was
having a relationship with another woman. He grabbed his girlfriend by the throat and
told her, “Try to say it again if you can.” As she tried to speak, he prevented her from do-
ing so by squeezing her throat harder. He told her he would let her go if she said that she
had said nothing. She did say that and so he let her go, but then he pushed her to the floor
and told her to look up at him and apologize for upsetting him and to swear she would
not say things like that to him again. She dutifully did so, aware that his violence could
grow worse.
A 23-year-old man was sure that the police were deliberately targeting him, and he did
indeed have some evidence for this. He kept on “bumping into” officers on a regular basis
outside his house. On one occasion the community police officer, whom he knew from
past arrests, spoke to him to ask him how he was getting on. Initially he responded by say-
ing that he was fine, but when the officer said that he hoped he was managing to sort out
his accommodation, which had needed considerable external window and roof repair, the
patient became suspicious about why the officer was being so pleasant. The conversation
that ensued became challenging for both people, with the patient asking the policeman in
a sneeringly aggressive way, “What has it got to do with you, Officer?” and telling him,
“You can keep your nose out of my business.” When this was explored in group therapy,
it became apparent that the policeman’s pleasant attitude had made the patient anxious
because it conflicted with his representation of the police as provocative and confronta-
tional.
In the first example, the patient’s girlfriend threatened his self-esteem and he con-
trolled the emotional effect of her comment by forcing her to say that she had not said
what she had (in fact) said, thereby ensuring that she was subjugated. She was forced to
carry the subjugated, humiliated, alien self that her comment had brought the patient
perilously close to reexperiencing in himself.
Gilligan (2000) has creatively and persuasively focused our attention on self-
esteem and the regulation of shame as key factors in the pathology of ASPD. We are
suggesting that the alien self is a shameful self, crushing self-esteem by inducing feel-
ings of overwhelming humiliation. If, as we have just argued, emotional states are ex-
perienced in the psychic equivalence mode, the return of the alien self will feel devas-
tatingly destructive to the self. Shame experienced in the psychic equivalence mode is
ego-destructive. The patient has to do something immediate and urgent in order to
survive. He or she has to ward off humiliation and shame at all costs. The individual
cannot accept the return of the alien self and therefore tries to control the source of
threat, which is seen as “out there.” Avoidance—for example, walking away, or manag-
ing the feeling mentally—can only occur if mentalizing is retained and awareness of the
mental state of the other remains, at least partially. Recognition of the other person as
having a separate mind inhibits violence. It is the loss of mentalizing of the other that
allows a physical attack, because the other person then becomes no more than a body or
threatening presence.
It has been suggested that threats to self-esteem trigger violence in individuals
whose self-appraisal is on shaky ground, because they narcissistically exaggerate their
self-worth. Patients with ASPD inflate their self-esteem by demanding respect from
others, controlling the people around them, and creating an atmosphere of fear. This
type of behavior maintains pride, prestige, and status and ensures an experience of the
external location of the alien self. Loss of status is devastating, and if it occurs, the alien
self is returned and reveals internal states that threaten to overwhelm the individual.
Experience becomes even more firmly rooted in psychic equivalence. Patients in this
mode 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 warding off their ex-
perience of rapidly lowered self-esteem and loss of hierarchical position. Emotional ca-
pacities such as guilt, love toward others, and fear for the self can prevent a person from
engaging in violent behavior, but the loss of mentalizing and the limited ability of these
patients to experience such feelings prevent these inhibitory mechanisms from being
mobilized. Fear for the physical self is absent, and dangers associated with violence be-
come secondary. Psychic equivalence experience and pretend mode can operate simul-
taneously. The onset of pretend mode means that concerns about the risk of being
caught are experienced as unreal; an illusory sense of safety and a lack of reality are
manifest. The internal state no longer links with external reality: “It happened like in
the movies”; “It didn’t seem real.”
The Developmental Roots of Violence

Human infants are born with the potential to be aggressive and violent. Interpersonal
aggression is a crucial evolutionary adaptation. In certain human environments, vio-
lence is likely to contribute materially to the survival of the individual’s genes. In other
human contexts, however, violence is seriously maladaptive. Violence undermines the
possibility of safe collaboration—that is, it marks out the individual as a potential threat
to the establishment of collaborative relationships between others and to the creation
of an interpersonal environment that would enable communication, meaning genera-
tion, and creativity.
Thus, violence is something of which we should be potentially capable, but we
should be able to desist from violence if the environment in which we find ourselves
does not require physical aggression for our survival. Not surprisingly, there are indi-
vidual differences in the development of aggression and violence. Most preschoolers
make extensive use of physical aggression (Tremblay et al. 2004). Longitudinal studies
such as the National Institute of Child Health and Human Development (NICHD)
study (NICHD Early Child Care Research Network 2004) have demonstrated that the
earlier the onset of problem behaviors, the higher the risk for continued aggression and
violence. Only a small proportion of individuals (perhaps 5%–10%) are persistently
physically aggressive. The majority progressively desist from aggression over the first
decade of life (Cote et al. 2002, 2006; NICHD Early Child Care Research Network
2004). Those with a persistent violent trajectory have family environments that mark-
edly differ from those who gradually desist. In the Canadian accelerated longitudinal
study of over 10,000 individuals followed between 2 and 11 years, parenting differen-
tiated persistently aggressive trajectories (Cote et al. 2007). Those with high levels of
stable aggression had experienced less positive interactions; less positive consistent in-
teraction with their parent; more hostile, ineffective parenting; and greater family dys-
function.
In our view, attachment plays a critical role in guiding the development of a young
child toward a persistent as opposed to a desisting trajectory. Following John Bowlby’s
(1982) biological model of attachment, we may suggest that the early attachment rela-
tionship serves as a signaling system to newborns, identifying for them the kind of en-
vironment they might expect. An early choice of developmental trajectory is necessary
because, as we have seen, there is an evolutionary (reproductive) cost to following the
physical aggression trajectory. An environment where the caregivers do not have time
or resources to devote attention to the infant is far more likely to lead to the later use of
violence than an environment where the infant’s needs are attended to and supported.
We know a considerable amount about the biology of attachment and its role in ensur-
ing the regulation of the infant’s neuronal system. Secure attachment ensures that so-
cial cognitive capacities, such as emotional understanding and social cognition, are
adequately learned. Where caregivers do not have time or resources to devote attention
to the infant’s state of mind, to some degree the child’s capacity for self-regulation will
be undermined, but this may in fact be helpful if impulsive aggressive behavior in-
creases the child’s chance of survival.
People with ASPD typically have never had the opportunity to learn about mental
states in the context of appropriate attachment relationships. Alternatively, their at-
tachment experiences may have been cruelly or consistently disrupted; for yet others, a
nascent capacity for mentalization has been destroyed by an attachment figure who cre-
ated sufficient anxiety about their thoughts and feelings toward the child for the child
to wish to avoid thinking about the subjective experience of others. It is the proclivity
for instrumental aggression that best distinguishes psychopaths from their nonpsycho-
pathic antisocial and conduct-disordered counterparts. In contrast to reactive (affec-
tive) aggression, which typically is impulsive and stems from frustration and anger,
instrumental aggression is deliberate, calculated, and goal-directed behavior. The lack
of responsiveness to socialization plays a major role in the etiology of such behavior—
nothing deters it. In contrast, trauma plays a greater role in reactive aggression, inasmuch
as trauma sensitizes individuals to stress, lowering the threshold for emotional reactiv-
ity (Allen 2004, and see Chapter 16 in this volume). Blair and colleagues (see Blair et al.
2008) propose that psychopaths are less vulnerable to potentially traumatic stressors by
virtue of their emotional underreactivity.
It is important to retain an awareness of the possibility that violence is rooted in the dis-
organization of the attachment system. A child may manifest an apparent callousness that is
actually rooted in anxiety about attachment relationships; in actuality, the child may not be
callous and unemotional (Frick and Viding 2009) but may be terrified and perhaps striving
for a more reliable attachment (Fonagy 2004). It is with individuals in this category that we
are primarily concerned here. A harsh early childhood could signal greater future need for
interpersonal violence as well as undermine the normal development of cognitive and af-
fective means of expressing underlying mental states. In favor of this model are studies that
demonstrate that the association between childhood maltreatment and externalizing prob-
lems is probably mediated by inadequate interpersonal understanding (i.e., social compe-
tences) and limited behavioral flexibility in response to environmental demands (i.e., ego
resiliency) (e.g., Mayberry and Espelage 2007).
More important, the absence of caregiver attention, which on the one hand deprives
the infant and child of a comprehensive understanding of the minds of others, on the other
hand also leaves the person free to cause others to have emotional experiences that they
would not wish to undergo. Simon Baron-Cohen et al. (2008) suggested that emotion un-
derstanding is based on self-affect propositions, in contrast to understanding others’
thoughts, which is mediated by agent-attribute propositions; thus, interpersonal emotion
understanding invariably starts from a self-state. In understanding the other person’s cog-
nitive state, one separates physical reality from mental reality (“agent-attribute proposi-
tions”). The proposition “John thinks it is raining” is true irrespective of the presence or
absence of rain. By contrast, ascribing affect is based on extending or generalizing from
one’s own experience (“self-affect-state propositions”). Normally a statement such as “I am
pleased you are in pain” cannot be used because it is not possible to ascribe to someone else
an affect that falls outside one’s own range of experience (i.e., one does not feel pleased to be
in pain oneself). The dysfunction of affect attribution in ASPD is thus inherently linked to
the failure of generalizing from one’s own emotional state (i.e., failure of empathy). We con-
sider that the absence of interpersonal understanding is what makes the perpetration of vi-
olent acts possible. As mentalizing, particularly emotional empathy, is acquired with
development, violence is ontogenetically increasingly inhibited. As we have seen, with
arousal, particularly the arousal of the attachment system, the capacity for mentalizing is in-
hibited (Zeki 2007). The majority of neuroimaging studies of children prone to violence
have demonstrated lower levels of activation in emotion-sensitive brain areas such as the
amygdala on seeing images of individuals undergoing a painful experience (Marsh and Blair
2008). Such an amgydala hypoactivation is consistent with the assumption of an absence of
emotional empathy in individuals with antisocial personality disorder.
A proper understanding of the nature of this empathy has recently been provided by
Pierre Jacob (2010), a French philosopher. Jacob proposes a simulation model of empathy
(expanding the views of de Vignemont and Singer [2006]) that may be of great value in un-
derstanding antisocial personality disorder. Jacob identifies four conditions that define em-
pathetic experience and differentiate it from a range of overlapping constructs such as
sympathy, contagious emotional experience, and standard or cognitive mindreading. He
draws on four criteria which in combination define empathy and point to the “gap” in the
experience of those with ASPD. First, he distinguishes vicarious experience from standard
experience, with empathic experience being considered in the former category. For example,
the standard experience of pain is caused by bodily injury, and its anticipated sensory motor
consequences make it map onto body parts. Empathic experience, by contrast, is caused in
a person other than the person having the standard experience; it includes the disarray as-
sociated with pain, but not the sensory motor components. Thus, a vicarious experience of
fear in person A is caused by the standard experience of fear in person B. Second, in agree-
ment with Baron-Cohen et al. (2008), empathy is seen as linked to affectivity in that both the
person who is having the standard experience and the person who is empathizing experi-
ence an emotional state. There can be no empathy without this affective sharing. This links
to the third condition, an interpersonal similarity condition that has to be met. There has to
be interpersonal similarity between the empathizer and the target. This distinguishes empa-
thy from sympathy. A sympathetic nurse does not experience empathetic pain. There is a
fourth important condition for empathy, which is ascription. Empathy requires that the em-
pathizer ascribe the affective state not to him- or herself but to the person who is the target
of empathy. Emotional contagion, for example, does not have this property of ascription. It
may be vicarious, nonstandard, and affective, but it is experienced within the empathizer
without being ascribed to the target.
Jacob’s vital suggestion is that the vicarious component of empathy is provided by en-
active imagination (e-imagination), which he ascribes to the “offline” functioning of the vi-
sual system. We know that inputs from memory generate visual images comparable to
those that might be generated by standard perception (de Vignemont and Singer 2006).
Neuroimaging studies have demonstrated the activation of comparable networks of the
brain whether an individual is personally exposed to a painful experience or observes a loved
one having the same experience (Singer et al. 2004). It is assumed that enactive imagination
generates from internal inputs some aspects of the external experience. In empathy, parts of
the same brain systems that would be engaged in direct experience run offline (based on
memory images). The experience of pain has a sensorimotor and an affective component.
In empathic pain, only the affective component of the pain system is operating. We “feel”
the pain of the person (the “target”), but only at the emotional level generated by e-imag-
ination. The pain then is more like a sense of emotional disarray that is given meaning by
observing the target. We suspect that in violence-prone individuals, the affective compo-
nent of enactive imagination may be compromised by a combination of genetic and early
environmental factors, and hence these individuals’ capacity for e-imagination is impaired.
To put it simply, they have trouble “feeling the other’s pain.” More specifically, we presume
that the experience of trauma may have a direct impact on the capacity for enactive imag-
ination. It is suggested elsewhere in this volume (Allen et al., Chapter 16) that traumatic
experiences appear to interfere with the processing of emotional experience. The anxiety
created in relation to the actual experience of emotional or physical pain disrupts the enac-
tive imagination. Generation of a memory that would activate the affective component of
pain (necessary for empathy) is excessively imbued with anxiety (associated with helpless-
ness or other overwhelming negative affect at the time of the traumatic experience), and the
individual will understandably resist undertaking the creation of the internal inputs neces-
sary to “run offline” the emotional components necessary to feel empathy.
The key issue of treatment, then, is the activation of e-imagination (the affective com-
ponent of the relevant perceptual systems). While it is by no means a panacea, reviews in-
dicate that restorative justice, which involves confronting the offender with the victim in a
way that optimizes the chance of e-imagination occurring (face-to-face conferences, vic-
tim-offender mediation, restitution, reparation payment), leads to offenders committing
fewer repeat crimes (11%–37%; Sherman and Strang 2007). Intriguingly, restorative jus-
tice reduces repeat offending more consistently with violent crimes than with less serious
crimes.
In summary, we suggest that in the treatment of ASPD, the clinician has to understand
the pathway that leads to loss of control and has to accept the patient’s need to structure in-
teractions with others in a way that maintains externalization of the alien self. The patient
with ASPD has experienced developmental disturbance in the attachment relationship,
with experiences of shame and humiliation at the fore. Robust development of mentaliza-
tion is lost, leaving a lifelong sensitivity to internal emotional states. Within psychic equiv-
alence, any experience of shame, however small, is experienced as a collapse of the self in a
mental context in which there is no buffer of secondary representational levels to cope with
the experience. The threat to the self, which is in effect a return of the shameful alien self,
has to be controlled to survive. Rather than manage the underlying mental state of terror
through representation and emotional processing, the person with ASPD relieves inner
alarm by controlling the physical environment. The essence of treatment is to stimulate af-
filiative bonds without simultaneously provoking the threat of shame and humiliation. At
the same time, feelings of trust, honesty, and openness within the context of the attachment
process have to be nurtured.
Mentalization-Based Treatment and

Structure
Following the formal assessment, the treatment program for ASPD has four components:
1. Introductory meeting
2. Group therapy weekly for 1 hour
3. Individual therapy monthly for 50 minutes

4. Crisis management and psychiatric review
In the introductory meeting, the practicalities of the program are explained, the
diagnosis is discussed, comorbid disorders (e.g., depression, substance misuse, alcohol
dependence) and their treatment are considered, and an outline of mentalization and its
relevance to ASPD is provided. This is rediscussed in group therapy when the therapists
themselves initially outline the general structure and boundaries of the group along
with the rationale of the treatment. Patients are informed that no reports for court, pro-
bation, housing, or other bodies can be provided, other than a statement of the number
of treatment sessions attended, until a patient has been in treatment for 4 months. The
rationale given to patients for this is that we cannot provide a fair assessment of their
difficulties and their motivation to change until more collaborative work has been done.
We suggest that any formal reports that are required within the 4-month period should
be done by an independent psychiatrist instructed by the patient’s legal representative.
Patients are also informed that any reports that are written during treatment are done
jointly with them, within the mentalizing process. A draft report is done first by the
therapist, the patient reviews what has been written and discusses his or her perspective,
and then the report is rewritten. Whenever possible, the therapist and patient arrive at
a joint understanding of the problems and provide a pathway for addressing those dif-
ficulties.
Patients with ASPD are wary during any unfamiliar interpersonal interactions and
are especially so during the first few meetings with a mental health professional. The
act of asking for help can induce feelings of inadequacy in the patient, and it is impor-
tant the therapist avoid provoking any such feeling during the initial interviews. Often
patients complain of depression rather than features of ASPD itself, and it is useful to
investigate depressive symptoms before exploring personality characteristics, because
investigating depression is less likely to threaten self-esteem. Mood carries less stigma
than does antisocial behavior, and it is less bound up with personal status. Comorbidity
of other psychiatric disorders is common in ASPD, and the assessor needs to differen-
tiate between symptoms of a comorbid disorder and the features of ASPD itself if treat-
ment is to be planned appropriately.
Principles
We have always emphasized two principles underpinning MBT for personality disor-
der. First, there must be a focus on techniques that facilitate the development of men-
talizing, and second, there must be a concomitant avoidance of interactions that either
maintain nonmentalizing or increase it. These principles apply in MBT-ASPD. Some
techniques in common use in psychotherapy aim to stimulate consideration of the ef-
fect of one’s actions on others. These types of interventions are less effective in those
patients with ASPD who do not experience the mental pain and the internal affective
states, such as guilt, that they may recognize are associated with the other’s state of
mind. It is only useful in those patients in whom conflict, when engendered by recog-
nition of painful experience of the other, is aversive through a process of empathic iden-
tification. This may be present in some patients with less severe ASPD, but more
commonly it is only rudimentary; the experience of the other person, insofar as it af-
fects the other person, is of little interest. Attempts to generate conflict and guilt in
ASPD—for example, by asking patients in group therapy to think about the victim—
are therefore relatively ineffective in inducing change.
The poor ability of the patient with ASPD to experience psychic pain related to
other people’s experience informed the structure of the MBT program for ASPD de-
scribed earlier. Structural components designed to be aversive, such as time-outs, or
discharge due to failure to meet stringent attendance contracts based on the effect on
others of an individual’s absence, are not used. An argument based on exhortation that
absences affect the ability of others to use the group successfully has no effect; patients
with ASPD have limited concern about the effect of their absence on others and will
rarely make any concession about previous nonattendance when they do attend, simply
saying that they were unable to come. Nevertheless, we continue to place considerable
emphasis on the group process and attendance; we link attendance at the group to the
provision of the monthly individual sessions. An individual session is offered monthly,
but the interval between individual meetings will be longer if the patient has not at-
tended the group. An individual session is offered only after attendance, not necessarily
consecutive attendance, at three group sessions.
Interventions focusing on improving self-regard and promoting social and inter-
personal success are emphasized. Only when a positive and hopeful atmosphere has
been created are patients likely to respond to withdrawal of positive reinforcement of
their self-regard. The basic position of the MBT therapist is to try to understand what
is happening in the patient’s mind; it is not to reduce socially inappropriate behaviors in
order to make individuals conform to some predetermined, socially acceptable way of
life. If the therapist becomes identified as an agent of control, forcing the patient to
submit to rules and regulations, therapy will become impossible. Nonetheless, acts of
violence toward others or toward property are major topics in treatment. Like the ac-
tion of self-harm by the patient with BPD, such acts are the final component of a chain
of mental experiences that has to be carefully identified and explored in treatment.
Therapist Stance
The therapist stance, a key feature of MBT-BPD, is just as important in MBT-ASPD.
At the same time that the not-knowing stance (linked with a positive attitude) remains
the key component of the approach, the therapist’s attitude also needs to convey au-
thenticity, honesty, directness, respect, and courtesy. We discuss authenticity in more
detail in our chapter on borderline personality disorder (Chapter 11, this volume).
Directness, honesty, and openness on the part of the therapist actively promote trust.
Patients with ASPD distrust mental health professionals, and therapists distrust in-
dividuals with ASPD. Mutual trust can begin only if the patient recognizes that the
therapist is being honest about what is going on in his or her own mind. A therapist ex-
perienced as “weak”—the ASPD patient’s frequent interpretation of hesitancy, opaque-
ness, and secrecy on the part of a therapist—will create difficulties because the patient
cannot see him- or herself in the mind of the therapist, and so the patient’s subjective
sense of self crumbles. It is better for the therapist to state that he does not know what
he thinks about something, or to say he cannot agree to do something until he has
thought about it, than to vacillate. Even this level of uncertainty at the start of treat-
ment can create anxiety. Patients need to feel that they know where they stand with a
therapist—even if the therapist’s viewpoint contrasts with their perspective. One pa-
tient, in the process of developing a rudimentary trust in his therapist, said, “At least
I know where I am with you—you call a spade a spade.” With this short statement, the
patient indicated that he experienced a sense of safety with the therapist, perhaps based
largely on an experience that the therapist, who was straightforward in his interaction
with the patient, had no secret agenda and respected the patient’s viewpoint even if he
disagreed with it.
Developing a Code of Conduct in the Group

In group therapy, the group’s key task is to develop a shared code of conduct. However,
we would emphasize once again that it is the process of developing the code that is of
importance rather than the establishment of a code in itself.
Patients with ASPD develop a code of conduct within their subculture in much the
same way as others. They often explain their conduct toward others as resulting from
the context and culture within which they live. Phrases such as “He deserved it, then,”
“He had it coming,” “You warned him and he didn’t take notice,” “You have to make
sure that people know not to mess with you,” and “You had to do it because your place
on the housing estate was being threatened” abound in any conversation among them.
The group therapist needs to harness these comments to generate a discussion about
violence and interactions with others. Violence in ASPD is rarely random, in part be-
cause it is rooted in disorganization of the attachment system. Close relatives and part-
ners are more likely to disrupt a patient’s mentalizing capacities by overstimulation of
their attachment processes simply because of their daily physical proximity. Patients
offset this danger by withdrawal or by living according to an ethical code, for example
one that prohibits violence toward women. Transgression of an unwritten code is one
of the few things that can induce guilt and concern. For example:
A patient reported that he had head-butted his girlfriend at home and then smashed her
head on the kitchen table. She had been admitted to the hospital with a broken nose. He
remembered little of the events other than they had both been drinking and she had
started complaining to him about their financial problems. He told her to “leave it
alone,” but she continued to rebuke him for not sorting out the house bills. He left the
living room and went into the kitchen. When she followed him, still being critical, he
grabbed her and threw her against the kitchen table and smashed her head on it. He then
went out. When he visited her in the hospital the next day and “saw what I had done,” he
felt acutely ashamed of his actions.
He reported this in the group and the other participants told him that he should not
have attacked her: “You should never attack a woman”; “Even if she provoked you, you
should have gotten out of the house before it happened.” He agreed and said that when
he realized later what he had done, he apologized to her for the first time ever. He went
on to say that he had also given her his word that he would not do such a thing again. See-
ing her bruised face had shocked him. It was this that made him feel that he “must be an
animal to have done something like that to her.” He felt that he deserved punishment,
but she had decided that she would not press charges against him.
The therapists explored the code of conduct toward women with the members of
the group who, among them, showed remarkable unanimity about what was and was not
acceptable particularly in relation to women. Gradually the discussion moved toward ac-
ceptable behavior in a wide range of contexts, including the group itself.
The process of developing a code involves constant focus on behaviors outside and
within the group. Episodes of violence and aggression become a significant focus.
Therapists ask about any internal forewarning the patients themselves might have had
(self and affective dimensions), signals they had received from and given to others (ex-
ternal focus), what others needed to show or do in response (external focus), and any
predetermined preferred response (internal focus).
Power
Treating a patient as an adult who has responsibility for his or her actions is a key com-
ponent of all therapy, but it is all too easy for a therapist working with ASPD patients to
say something that either is experienced as condescending or actually is inadvertently pa-
tronizing. If either is the case, the MBT therapist immediately apologizes in order to re-
verse the therapist-patient power differential stimulated by the remark and reduce the
threat to the patient. Patients feel safer if they experience the therapist as someone who
follows rather than leads, for example, or as someone who is in some way inferior. This
ordering can be attained within the context of therapy by accepting criticism or by ac-
knowledging personally critical statements without becoming defensive. For example:
One patient continually contrasted the “soft, fine” hands of the male therapist with his
own, which he characterized as rough and hard, and concluded that the therapist had
never done any manual work. This was initially accepted by the therapist as a humorous
interplay. At times the therapist would remark in a self-deprecatory way on his own “soft
and fine” hands. It was only later that the therapist questioned the meaning of the con-
trast. In discussion, it was apparent that manual work represented being a man, the im-
plication being that the patient was more of a man than the therapist.
Another patient teased one of the therapists about his elevated status as a professor:
“You’d think you would know that if you were a proper professor”; “Where are you pro-
fessor then, junior school?”
It is essential not to challenge these hierarchical aspects of the relationship too

early. Just as we caution against the use of mentalizing the transference too early in the
treatment of BPD, so we take care not to stimulate momentary feelings of inferiority or
humiliation in patients with ASPD. The function of the relationship the patient has
with the therapist—most commonly, the therapist carrying an aspect of the alien self of
the patient—can only be explored once an atmosphere of safety has developed.
Taking the example of the therapist’s “soft and fine” hands, a transcript taken from
a video of a session 3 months later runs as follows:
THERAPIST [looking at his hands]: You mentioned my soft and fine hands again. They are
looking well manicured today, too.
PATIENT: Been polishing them, have you?
THERAPIST: Not on this occasion. But I was wondering what it was that had made you
suddenly remark on them again.
PATIENT [laughing]: They are just the same softy stuff as ever, and I just noticed.
THERAPIST: Can we just go back to what we were talking about before you mentioned
them again? I think it was when you were talking about how helpful the discussion
had been in the group last week.
PATIENT: Yes, the group was good last week because everyone was there.
Therapist: Can you say how everyone being there made it good?
PATIENT: Well, it was good.
THERAPIST: In what sort of way?
PATIENT: It was, just was, good. I don’t really want to say much more about the group
anyway, although I think it does me good.
THERAPIST: I am glad that it is doing you good. I was just thinking about whether there
was a link between talking about the group doing you good and noticing my hands
again. But I can’t quite see what it is.
PATIENT: Dunno.
The therapist can now choose to leave the topic, because the patient appears to be
avoiding further exploration, or can insist on discussing it a bit longer. The decision
will depend on the therapist’s sensitivity and on his understanding of the current sta-
bility of the patient-therapist relationship. On this occasion, the therapist pressed on:
THERAPIST: If we can, I would like to spend a little more time on it, as I think it might be
quite important.
PATIENT: Well, you better say what is important about it because I don’t think it is.
THERAPIST: I was thinking that when you feel something is important to you, it [also]
makes you feel something more uncomfortable, and when that happens you focus
on me instead.
PATIENT: Well, Professor, aren’t we getting clever.
THERAPIST: In what way is that so clever?

PATIENT: Probably isn’t, but so what if I find something useful.
THERAPIST: That’s what I am asking, I suppose.
The patient and therapist manage warily to discuss this further, trying to identify how the
patient’s feelings of involvement momentarily threaten his ability to maintain his image
of himself as an independent man, leading him to demean the therapist in order to ele-
vate his self-esteem. The therapist would not have been able to do this at the time his
“soft and fine” hands were first mentioned. On this occasion he was able to “rewind” and
explore carefully, while avoiding overstimulation of the dynamic related to who was hu-
miliating whom.
It is all too easy to inadvertently undermine the self-esteem of patients with ASPD.
Self-enhancement is important for patients, particularly in the group, and this can be
harnessed to the benefit of the group process. People are generally motivated to per-
form when they are aware that their performance is being evaluated by others—espe-
cially when narcissistic elements are present, which they often are in ASPD. But to
become motivated in this way, each patient must initially experience his or her own im-
portance as an individual in the group. Patients with ASPD exert less individual effort
toward group goals when roles within the group are indistinguishable. There is no self-
esteem boost if it is not apparent that the outcome was due to oneself. Generosity to
others is not a primary characteristic, and so it is important that each patient feels he or
she has a personal role in the group. The therapists can help to establish this, but often
it is the patients who do so. One group did this by organizing a system of nicknames,
which were apparently acceptable to each individual because of the attached humor:
“Combat” for the individual who commonly wore combat trousers and was always ar-
guing in the group; “Commentator” for the patient who commented on everyone else
but talked little about himself; “Leper,” short for leprechaun, for the patient from Ire-
land; “Handsfree” for the patient who often muttered to himself; “Foreign” for the pa-
tient from Asia. While this sort of apparently acceptable nicknaming of each individual
benefits the group to the extent that it structures roles and allows each patient to feel he
or she is seen by others as a person with unique characteristics, it also brings with it dan-
gers of isolation, bullying, and unspoken hierarchy, all of which need to be addressed at
some point. We suggest that this should be done primarily by focusing on the internal
states of individuals rather than asking patients to recognize the effect on another per-
son of being characterized in a particular way.
Focusing on Internal States

Having the capacity to mentalize others, that is, to understand what is in their mind and
how they feel, makes it hard to hurt them, primarily because we feel them from the in-
side. This is empathy. As discussed earlier, patients with ASPD are able to read the
minds of others accurately yet, at the same time, seem unable to empathize with them.
They are unmoved by and apparently unaware of the emotional pain they evoke in oth-
ers. Accordingly, they lack the normal violence inhibition mechanism: they fail to men-
talize in the sense that an impulse to do harm, to exploit, and to weaken does not evoke
an inhibiting aversive recognizable mental representation of the other person’s poten-
tial emotional distress. They simply do not care. But their pathology is not solely re-
lated to this well-honed capacity to read others while not experiencing empathic
responses. They find it equally problematic to reflect on their own mental states, and
particularly their affective experience. To avoid the unnerving discomfort of not know-
ing how they feel about something, they determinedly concentrate on others’ motiva-
tions and doggedly try to show someone else the error of his or her beliefs and actions,
exploit the other person for their own gain, or plot appropriate revenge. To tackle these
issues, the MBT therapist focuses more on how the patient feels or is made to feel by
others than on how the patient thinks someone else feels about what the patient has
said. In other words, the therapist does not initially push the patient to consider the
motives and mental states of others, but rather asks him to reflect on his own experience
of what he is describing or his experience of others, for instance in the group. Allowing
the patient to describe the failings of the others is necessary, but at the same time the
MBT therapist will ask the patient how it leaves him feeling. For example:
A patient described in detail his younger brother’s family party, attended by numerous
members of his extended family. As he described the eventful evening, he talked about
everyone else but himself, yet he had defused a number of arguments between his parents
and his younger brother. His parents, who were drunk at the time, accused him of spoil-
ing the party, an accusation he did not understand at all. The group asked him why his
parents thought he was spoiling it, and the only way he could understand this was to won-
der if his parents had wanted a row with his younger brother. When asked how he felt
about it all himself, especially about the accusation that he had spoiled everything, he
could only answer that he didn’t know. When pressed about it, he became distinctly un-
comfortable and said it was not important, as he had decided that he was going to “sort
his father out” for the way he had treated him at the party.
The therapist’s intervention of guiding a patient to focus on his own internal state
is something the patient is likely to find very difficult, and therapists need to beware of
humiliating a patient who, more likely than not, will neither know how to describe how
he feels nor be able to reflect on himself for fear that it will show him to be misguided.
Nevertheless, it is important that patients begin to monitor how they feel and what it is
that makes them react to others in the way they do.
In summary, the MBT therapist initially emphasizes consideration of self, and of
how others make us feel, before asking patients with ASPD to consider what they make
of other people’s mental states.
Suggested Readings
Campher R (ed): Violence in Children: Understanding and Helping Those Who Harm. Lon-
don, Karnac, 2008
Cleckley H: The Mask of Sanity: An Attempt to Clarify Some Issues About the So-Called Psy-
chopathic Personality, 5th Edition. New York, Dolan, 1988
Gilligan J: Violence: Reflections on Our Deadliest Epidemic. London, Jessica Kingsley, 1999
Siever LJ: Neurobiology of aggression and violence. Am J Psychiatry 165:429–442, 2008
Youth Violence: Strategic Approaches to Prevention. Ann NY Acad Sci 1036:ix–xii, 1–415, 2004
Zulueta F: From Pain to Violence: The Traumatic Roots of Destructiveness. West Sussex, UK,
Wiley-Blackwell, 2006
CHAPTER 13
At-Risk Mothers of
Infants and Toddlers
Cindy DeCoste, M.S.
Linda Mayes, M.D.
Perhaps the most human of endeavors are our efforts to try to understand both our-
selves and other persons, especially those we care most about. Seeing the world
through the lens of underlying mental states or interpreting what can be observed in
the language of what cannot is key to mentalization. Similarly, the capacity to under-
stand or describe one’s own and others’ behavior in terms of underlying mental states
and intentions, referred to as reflective functioning, is a uniquely human ability that is
intrinsic to emotional regulation and productive social relationships. Mentalizing and
reflective functioning especially come into play when parents try to adapt to and un-
derstand their infant. When adults undertake the care of an infant, whether by choice
or necessity, they are faced with the task of trying to understand how their infant’s vo-
cal, facial, and bodily communications give clues to what their baby needs. From cries
309
of hunger to cries and expressions of discomfort, adults acting as parents have the dif-
ficult task of interpreting from a behavior what their infant is feeling, thinking, and
wanting. When a parent says of her 1-month-old, “When he can’t hear my voice, he
sometimes feels alone and he cries,” she is already seeing and hearing the world, not
just through her infant’s crying behavior, but through a mental narrative based on her
assumptions about what her infant is feeling and thinking.
Even in the best of circumstances, parents also come up against their own worries
about their parenting role and their expectations of themselves in that role. Being able
to reflect on how becoming a parent feels and on how those feelings affect their behav-
iors toward the infant is an equally important aspect of mentalizing in the parenting
role. That same parent, interpreting her baby’s cry as one of loneliness, might also add
something about her own postpartum depression and her awareness that sometimes
she is not very responsive to her baby or that it is when, in her own sad reverie, she stops
talking to others that the baby seems more fussy or loudly distressed.
Parents’ reflective functioning is not so different from mentalizing in all other so-
cial relationships, and especially in intimate ones, save for one key distinction. In the
case of parents and very young infants, there is a greater need for the adult to try to find
meaning and a window on the infant’s mental states solely from the baby’s behaviors.
Explicitly understanding—and accepting—that all the baby’s behaviors are an expres-
sion of an emerging infant mind is a special task of assuming the responsibility of the
parenting role. In these moments, repeated often across the days and weeks of infant
care, parents have the responsibility of being more “on task,” as it were, of trying to take
their infant’s behaviors and read from changes in those behaviors whether or not they
have accurately interpreted their baby’s needs. In turn, in those countless moments, the
infant has the experience that somebody is making the effort to physically care for them
and also to put words to states that are not visible. When a parent says, “You’re hungry,
frightened, lonely, excited? You want...? You remember...? You know...? Mommy is
trying to figure out what you’re saying,” she is giving voice to internal experiences that
the baby, as yet, has no words for. These words and phrases, coupled with effective acts
of physical care, link bodily sensations of distress or pleasure with the experience of
having those sensations responded to and thus made manageable.
In this chapter, we discuss those circumstances in which parents are unable to reg-
ularly or predictably think about the internal landscape of their infants’ needs and feel-
ings, but rather more often read these only from what they can observe directly or from
how their infants’ behaviors affect them. “He cries just to upset me,” “He is always cry-
ing when I pick him up,” “He never smiles at me,” and “I never know what he wants”
are all examples of statements in which a parent ignores or expresses confusion at the
task of learning about what their baby is feeling, needing, and thinking. There are many
challenges to mentalization or reflectiveness regarding one’s own and others’ mental
states, and these challenges are especially compounded in circumstances of parental
care. Surely for all parents, there are moments in which it is simply not possible to take
a reflective or mentalizing stance. Acute stress impairs reflective abilities by, in effect,
At-Risk Mothers of Infants and Toddlers 311
diminishing more playful, reflective cognitive activity and prioritizing action-oriented

appraisal and quick decisions. To put it another way, when a baby is reaching for a hot
pan of water, this is not the time to reflect on how curious he is about the world around
him. Or when a couple has just had an argument over who will pick the baby up in the
middle of the night when he cries, it is unlikely that the baby’s next cry will be a moment
for reflecting on his needs.
However, what we are most concerned about in this chapter are not the everyday,
common moments when mentalization is not possible. Rather, we focus on how cir-
cumstances of early adversity and chronic stress may chronically impair a parent’s ca-
pacity to mentalize about his or her infant. Among the conditions that can effectively
compromise an adult’s or parent’s capacity for mentalizing are depression and anxiety,
substance abuse and addiction, severe poverty and environmental deprivation, and cur-
rent and chronic posttraumatic stress disorder. In each of these conditions, the de-
mands of caring for another may be sufficiently stressful to “turn mentalizing off,” as it
were. Even more difficult is when the infant’s behaviors themselves—unsoothable cry-
ing, turning away from the breast or bottle—are so stressful that the adult is unable to
reflect either on her own or the infant’s needs. The cry becomes an insult, a stimulus for
rejection or retaliation. We are especially focused on substance abuse and addiction be-
cause of the high rate of comorbidity with early childhood trauma, other affective dis-
orders, and compounded environmental stressors including single parenthood, social
isolation, domestic violence, and joblessness. Indeed, from a number of perspectives,
addiction may be thought of as a stress regulation disorder in which individuals turn to
drugs as one means of managing their emotional distress, and in which, because of a
combination of genetic and experiential factors, they are also more sensitive to negative
emotions and stress (Sinha 2001).
One frequently cited profile of addiction includes increased stress reactivity, damp-
ened reward sensitivity (so that rewarding conditions, such as relationships, are less ef-
fective in regulating negative emotional experiences), and impulsive behavior with
poor consequence appraisal. This profile also contributes to poor mentalizing or re-
flective functioning. In a poorly reflective state, the addicted parent may find the in-
fant’s cries or fussing additionally stressful and turn away rather than reach out to care
for the baby. The infant in turn becomes more upset, which only adds to the adult’s
stress, perpetuates the parent’s turning away from the infant, and possibly stimulates
the adult’s turning to drugs to diminish the intolerable negative affective state. In this
model, interventions for substance-using adults who are also parents focus on how they
experience caring for the baby and how they experience their parenting role, instead of
solely on how drug use may make it difficult for the individual to care for the infant.
Traditionally, drug treatment services for mothers who are addicts have offered treat-
ments focused on decreasing drug use and achieving abstinence. In this chapter, we
suggest an alternative approach that focuses on how the adult understands his or her
own parenting role and response to the infant and how the infant affects the adult (the
basic transactions of mentalizing), and how stress leads to both drug use and difficulty
caring for the infant. The model we propose does not supplant traditional abstinence-
focused drug treatment; rather, it proposes an important addition that will directly af-
fect the adult’s parenting and the infant’s well-being, an outcome that traditional drug
treatment with substance-using parents has not consistently or effectively achieved.
In the sections that follow, we describe two mentalizing interventions for mother-baby
pairs where the mother has a history of substance abuse. The first intervention, Holding
Tight, is a residential program for pregnant and parenting women in Finland. The second,
Mothering From the Inside Out, is an outpatient intervention for mothers in substance
abuse treatment in the United States. Both interventions focus on enhancing mothers’ ca-
pacity to recognize and make meaning of their own emotions and responses to their baby
and make inferences about the underlying meaning of their baby’s interactions. For each in-
tervention, we provide a theoretical rationale, a description of the therapeutic approach, a
summary of preliminary research findings, and brief clinical vignettes. In the final section,
we offer general guidelines and considerations for designing new mentalization interven-
tions for high-risk populations.
Holding Tight: A Residential Program for

Substance-Using Mothers and Their Babies
Clinical and Theoretical Background
Efforts to provide specialized treatment services for pregnant and parenting women with a
substance abuse problem have increased during recent years. These developments have
arisen from growing scientific findings on the negative effects of substance abuse on preg-
nancy and development of the child, estimated economic costs of those effects, and limited
availability of substance abuse treatment services for this group (Daley et al. 1998; Mayes
and Truman 2002). The treatment approach described here, Holding Tight, has emerged
from clinical experience in residential settings, in which we have found that a woman’s re-
lationship with her children is a critical factor in her efforts toward abstinence.
Substance abuse is one of the most challenging risks to parent-infant relationships that
clinicians encounter. Despite the magnitude of the problem, the topic has received inade-
quate attention in the infant mental health and substance abuse literatures, in part because
of cultural differences between the professionals that define therapeutic approaches in the
infant mental health and the substance abuse fields. We suggest that maternal abstinence
and enhancement of the parent-child relationship are both important aims. It is commonly
believed that abstinence facilitates more effective parenting, but we propose that more per-
sistent parental abstinence can be achieved through an intensive treatment focus on parent-
child relationship rather than (or in addition to) a focus on abstinence. We suggest that this
relates to the relationship between central reward pathways in the brain and the capacity to
invest in another person (as one does in parenting) or to become addicted. Many of the
abused substances have been shown to affect the dopaminergic pathways in the brain, areas
associated with initiation of behavior, hedonic reward, and motivation. These central
dopaminergic pathways are also critically involved in an adult’s capacity to invest in the care
of the new infant. Drug abuse may be seen as a co-optation or hijacking of this endogenous
value system. As a consequence, once this system is co-opted by an addiction, the individual
is less able to invest in caring for an infant or any other person, and there is competition be-
tween investment in craving the drug and investment in caring for the infant (Leckman and
Mayes 1998). In the treatment model described in this chapter, the mothers are helped to
invest in their child instead of in substances and to reset the focus of the reward system by
intensively facilitating and enhancing the mother’s satisfaction with positive interaction ex-
periences with her baby and with being a parent. The individual becomes less focused on
her relationship with and craving for the drug and more on her preoccupation with, and in-
vestment in, the infant.
The Psychosocial Context of

Mother-Infant Dyads Entering Treatment
Substance-abusing pregnant and parenting women are a group with an exceptional
number of risk factors on multiple levels. This state of affairs often creates hopelessness
and frustration in professionals and also has often led to the exclusion of this group
from studies within the substance abuse field and infant psychiatry. The mothers typ-
ically have limited economic resources, are less educated, receive little social support,
and have difficulties securing housing. Their pregnancy is often unplanned, and they
suffer from depression, anxiety or more severe psychopathology, low self-esteem, and
feelings of shame and guilt. They often have a history of childhood trauma, parental
substance abuse, abusive relationships, and negative representations of their childhood
and the parental care they received—and hence, negative models for parenting (Grella
et al. 2000; Mayes and Truman 2002; Pajulo 2001; Suchman et al. 2004b). In addition,
they often have great difficulty in recognizing and dealing with their emotions and thus
have tended to shut down difficult feelings by using substances.
In addition to the direct biophysiological substance effects per se, all these factors
have a cumulative negative effect on the well-being of the mother and the child and on
the quality of their relationship. Currently, the quality of early care and the postnatal
caregiving environment, combined with the neurophysiological vulnerability of the
drug-exposed child, are considered to be most important for the prognosis of child de-
velopment and psychosocial outcome in later years (Carmichael Olson et al. 2001;
Lester and Tronick 1994; Mayes and Truman 2002).
Despite the clear need for support in their parenting role, substance-abusing women
have special difficulties attending and staying in treatment. They have often experienced
many difficulties in their social relationships and have a fear of those in positions of author-
ity and little confidence or faith in their own maternity and parenting. At the same time,
they often have high expectations for their children and for themselves and are easily of-
fended by their children and disappointed in their parenthood. They are in a situation
where they have to make several great changes at the same time and in multiple areas in
their life: making room for the child in their mind, taking responsibility for the child, giving
up substances, reaching for a new social network, and dealing with practical life arrange-
ments and authorities.
The Substance-Abusing Mother With Her Baby

The substance-exposed mother and child are difficult regulatory partners for each other, as
the exposed infant often has an impaired ability to regulate his or her states of wakefulness,
sleep, or distress and consequently needs more parental help. At the same time, the mother
is usually less able to read the child’s communicative signals (Beeghly and Tronick 1994)
and finds it more difficult to cope with a distressed and difficult-to-soothe infant. This com-
bination easily leads to a viciously negative cycle that culminates in withdrawal from inter-
action and increased risk for child neglect and abuse (Kalland 2001). Substance-abusing
mothers have been found to be less sensitive in interaction with their children; to be less
emotionally engaged and less attentive, resourceful, flexible, and contingent; to experience
less pleasure in the interaction; and to be more intrusive in their behavior (Eiden 2001;
Johnson et al. 2002; LaGasse et al. 2003; Mayes and Truman 2002; Pajulo et al. 2001). Sub-
stance-exposed children have been found to show less positive emotion during the interac-
tion, more distress to novelty, a slower recovery from interruptions, an impaired response
to stress, and a diminished ability to persist in a task or maintain an alert, attentive state
(Bendersky and Lewis 1998; Eiden 2001; Eiden et al. 2002; Johnson et al. 2002; Molitor et
al. 2003). The pair shows fewer moments of dyadic interaction, and the quality of the dyadic
interaction lacks enthusiasm and mutual enjoyment and includes more dyadic conflict and
less mutual arousal (Burns et al. 1991, 1997; Eiden 2001; Mayes et al. 1997). Studies on
child attachment profiles have shown that a higher percentage of substance-exposed chil-
dren have insecure and, in particular, disorganized attachment compared to normative
samples (Beeghly et al. 2003; Espinosa et al. 2001; Rodning et al. 1991; Swanson et al.
2000).
From the baby’s point of view, the most important of all the existing risk factors found
in the situations of substance-abusing mother-baby pairs is that the mother is unable to pay
enough attention and keep the baby’s experience and needs in her mind. This is where the
concept of reflective functioning has a central role.
Perinatal Period: A Time of Motivation, Upheaval,

and Early Representations of the Baby
The basis for intensive treatment intervention for women who are pregnant is most
fundamentally to protect the child, inasmuch as maternal substance use during preg-
nancy presents clear toxicological risks to fetal development. Often, the safety and well-
being of her infant provides strong motivation for a woman to work toward abstinence.
On the other hand, pregnancy can also be a period of increased fear, anxiety, and guilt
regarding the health of the child, each of which may compromise a woman’s full en-
gagement in substance abuse treatment. The pregnancy is usually unplanned, and the
guilt is often reinforced by societal stigmatization of addicted mothers (Daley et al.
1998), which in turn may make it difficult for pregnant substance-using women to seek
treatment.
The perinatal period is a time of enormous psychological change and upheaval,
which makes it an especially important and difficult time from the intervention point of
view (Raphael-Leff 1991; Slade 2002). In psychoanalytic theory and research, the im-
portance of mental representations during this phase is of growing interest. Mental
representations about maternity and about being a child are strongly activated during
pregnancy and early motherhood (Ammaniti et al. 1995; Stern 1995). The relationship
between representations of their experiences of being parented and current maternal
behavior has special significance for high-risk populations such as substance-addicted
mothers, since they so often have negative, fragile, or idealized representations of their
own childhood and own parenting—and hence of their own parenting capacities (Pa-
julo et al. 2001, 2004; Suchman et al. 2004a). Interventions aimed either toward absti-
nence or abstinence with supportive guidance regarding expected infant and caregiver
behavior do not seem to have an effect on the mothers’ interactive behavior; that is, the
mothers do not show increased sensitivity to their children’s needs. Changes may often
occur in the mothers’ attitude and perception of the child, but these changes often are
not reflected in the behavior between mother and child. These modest changes in ma-
ternal attitudes may or may not be experienced by the child as any change in the par-
ent’s behavior.
Program Description and Specific Techniques

Treatment Units
Since 1990, six residential treatment units designed for pregnant and parenting women
with a severe substance abuse problem have been established in different parts of Fin-
land. The units are part of the child protection field in the social welfare sector (Fed-
eration of Mother and Child Homes and Shelters), and they all share the same
approach and way of working. The personnel in the units represent different educa-
tional backgrounds and working experiences in the fields of substance abuse, family and
infant work, child protection, and psychiatry. A typical unit has a leader (usually a social
worker), one social worker, one special worker (e.g., social worker, occupational ther-
apist, or psychologist), and eight clinical counselors who work in three shifts. During
the first 6 months, the treatment staff of each unit, as a group, receives an intensive ini-
tial training that concentrates on early parent-child interaction, attachment, and child
development within the context of maternal substance abuse. The units have the ca-
pacity to serve five mother-baby couples, on average, and one place for a whole family
to live in. They are situated within the ordinary city area, with their own house and gar-
den. The treatment occurs throughout each day on all days of the week.
The average duration of treatment has been 8 months, and the treatment has usu-
ally started 2–4 months before delivery. The referral to the unit is made by a social wel-
fare agency, a delivery hospital or a well-baby clinic, or by the mother herself due to her
primary problem with alcohol and/or other drugs. The use of a residential facility gives
the mothers a substance-free environment and model of healthy living, which is an im-
portant intervention in itself: to make healthy food, take care of oneself personally, re-
ceive support in improving physical health, and organize one’s daily life, rhythm, and
use of leisure time. An important task is for the staff, together with the mother/family,
to establish the outpatient treatment and follow-up plan for the time after the residen-
tial treatment period. Accumulated clinical experience suggests that most of these
mothers benefit from this initial highly structured holding environment.
Structure of Intervention
In the units, each mother and each baby have their own individual counselor as well as
working familiarity with all of the staff. All mothers and all staff participate in weekly
group meetings focused on a specific parenting theme—for example, on different roles
in being a parent, feelings evoked by parenting, or ways to deal with their child’s tan-
trums. Each mother participates in planning her daily living, her treatment aims, and
the work with her family and social network, and she has responsibilities for helping
with the daily routines in the unit. When needed, detoxification and other medical or
mental health treatment are provided outside the unit. The mother is supported in her
participation in those programs, and openness of the collaboration among the unit, so-
cial welfare agency, and well-baby clinic is emphasized. Mothers are expected to stay
substance free, but one to two relapses are allowed during the treatment period. All re-
lapses are also discussed together in the group meetings.
Content of Intervention
The treatment aims to create a holding environment at three levels: 1) helping the
mother hold the baby and her relationship with the baby in her mind (Winnicott 1957);
2) helping the mother’s social network and the unit personnel hold the mother in mind,
and 3) through supervision, evaluation, and research work, holding the treatment units
together by showing continuous interest in developing their work. The two main aims in
the treatment are to intensively support the mother in her efforts toward abstinence and
simultaneously to support her relationship with the child. This approach is based on the
clinical finding that the specific challenges and the most worrisome deficiencies found in
parenting of these mothers include their inability to keep their baby in mind and to stay
emotionally connected and present to the baby. The mother often cannot adjust her own
needs, rhythm, and behavior in ways that are responsive and sensitive to the baby, and the
baby is not able to follow the mother in her actions. The mother often has great difficulty
anticipating and following the child in its next developmental stage and new skills, in part
because of her unrealistic expectations for the child and in part because of her difficulty in
differentiating the child’s needs from her own.
Parenting is supported through discussions and support in daily situations with the
child, through weekly group meetings around a parenting theme, and through the set-
ting of small concrete aims for each week. The mothers are also helped in dealing with
authorities and in repairing and building up a new social network during the treatment
period. This support is felt to increase their own psychological resources and make it
possible for them to focus on their child. The residential format of treatment makes in-
tensive support possible, as daily situations between the mother and the baby form a
natural and rich working arena. There are multiple moments each day to work on in-
teraction experiences, help parents shift from a negative to a positive attitude toward
their own parenting and their child, effect change in maternal representations, enhance
reflective capacity in the mother, and facilitate change in the mother’s interaction be-
havior. Additionally, the residential setting affords more concentrated therapeutic time
for a mother to reveal and explore her perceptions of her relationships with her own
parents and to understand how those perceptions play out in her current relationship
with her child.
Enhancement of Reflective Functioning

The relationship work is considered most important for the outcome of the treatment,
for both mother and child. It is also the area of the work that requires the most careful
and ongoing training, clinical experience, and regular supervision. During pregnancy,
this work helps the mother keep the child in her mind in many ways, by supporting her
to prepare for the delivery and life together, to make room for the child in concrete and
psychological ways, to name the baby, to imagine what he or she will be like, to think of
the child in the future, to imagine what will be the most wonderful or difficult times for
them together, and to think how she as a parent would like to be similar to or different
from her own parents. The mother is helped to recognize different and often ambiva-
lent feelings in herself and to work with depressive feelings and anxiety. Being able to
begin such work prenatally is especially critical and facilitative, because negative per-
ceptions of the infant and the derailment of the mother-child relationship almost al-
ways begin during pregnancy.
After the birth of the child, the mother is helped to reflect on her child’s intentions
and to see the child’s actions and affects as meaningful. It is equally important that the
clinician be able to do the same: to be interested in the mother’s intentions and to help
her focus on experiences and give them value and meaning. The containing relation-
ship between the clinician and the mother also emphasizes that the mother’s negative
feelings are to be tolerated and attuned to, not avoided, distanced, or criticized.
Specific Techniques to Enhance Reflective Functioning

“Growing: birth-to-three”. The personnel of the units are trained in the “Growing:
birth-to-three” method (Doan-Sampon et al. 1993), in which the parent-child interac-
tion is considered the primary way to support and promote child growth and develop-
ment. The training provides techniques to support mutually satisfying interactions
between parent and child, as well as strategies to enhance communication between the
clinician and the caregiver. Through the method, the child’s development is carefully
documented. The intervention includes discussions with the mother about her own
child’s development (picking up the areas of most concern for her) along with discus-
sions on normal development, the next steps to be expected in this child’s development,
the role of a parent in enhancing development, the importance of gaining new skills for
the child, and the amount of help the child needs from the parent at different ages. The
method is used also specifically as the vehicle for enhancing maternal reflective func-
tioning. Generally, the clinician shows interest in the mother’s feelings and asks about
them, while being careful not to interpret conflict or ambivalence too early. In Bion’s
(1962) words, the clinician provides the “alpha-function,” a state in which the mother is
able to think about what she is thinking—an activity that is the beginning of reflective
functioning. The clinician’s task is to help the mother focus on important and perhaps
difficult feelings; often this is the opposite of what she is used to doing, namely, avoid-
ing painful thoughts and using substances for that purpose.
One important aspect of supporting reflective functioning in the mother is to in-
terpret the baby’s needs for the mother when she is unable to do so by herself. Such in-
ability does not automatically mean inadequate caregiving in terms of feeding or other
basic care. The mother is often “technically” adequate, but may be either intrusive or
silent and withdrawn in her interaction behavior. The clinician can use the “voice of the
infant” to help the mother to understand her baby. This often is not threatening for the
mother and frequently leads to her doing what needs to be done. Each developmental
step of the child can also be described from the point of view of the baby, like a letter or
message sent by the baby to the mother.
Use of videotaping. Different situations between the mother and baby are video-
taped: playing, feeding, comforting, getting the baby to sleep. The tapes are then
watched together with the mother, noting moments when the mother feels that she is
“clicking” with the child or other positive moments that she feels good about. Also,
these videotaped interactions may usefully highlight moments when the baby is signal-
ing that she or he is becoming tired or beginning to withdraw from interaction. Watch-
ing the tapes helps the mother to learn to read her child and also to recognize her own
feelings at that particular moment. The mother is supported to search for the cues, spe-
cific for this child, from which she can conclude how the baby is feeling. For example,
watching a situation in which the baby is getting tired and turns his face and gaze away
from the mother, the tape is stopped and the mother is asked what she feels when seeing
that particular moment and behavior of the child. Often the mother may interpret the
child’s signals of getting tired as dislike or rejection of her by the child. The mother
feels distressed about this and tries to regain the child’s attention by stimulating him
more. The child becomes even more distressed and starts to cry, the mother feels help-
less and feels disappointed in herself and the child, and all this leads to a negative in-
teraction experience for both of them. In the intervention, the mother is helped step by
step, using the videos, to become aware of the separation between her own feelings and
experiences and those of the child.
Strengthening the mothers’ capacity for previewing. Previewing refers to the intui-
tive knowledge that parents have about the next step in their child’s development (Stern
1985). In at-risk dyads, the parent’s capacity to preview the child’s development is often
disturbed. The clinician’s task is to enhance previewing by offering the mother mental
representations of the next upcoming skill (Trad 1993). This can happen verbally or by
the use of material provided through the videotaped interaction. The mother is sup-
ported in her efforts to facilitate her child’s developmental progress or in her “scaffold-
ing” of her child’s learning (Cazden 1983). She is also supported to trust the capacity of
the child when help is not needed, as opposed to giving intrusive and overdirective
parenting. Each new developmental step is put in a relational context for the mother. For
instance, instead of saying, “Oh, she is trying to crawl,” the clinician will say, “Oh, I can
see how she is trying to come after you and crawl when you leave the room.” In this way,
the clinician shows the mother two things at the same time: how important it is to ac-
knowledge these new developmental steps, and the important role the mother has in the
child’s mind as being the one to whom the child wants to show these new skills.
Keeping balance within the triad. Through the training, the personnel learn to fo-
cus on three relationships: those between the clinician and the mother, mother and
child, and clinician and child. This focus is important because most of these mothers
have difficulty trusting and feeling safe in a relationship. The triangle between mother,
infant, and clinician can become intensely painful, and therefore the balance among the
three relationships must be given much attention. If the clinician gives too much at-
tention to the mother, the infant may remain invisible in the treatment. If the clinician
gives too much attention to the infant, this may elicit jealousy in the mother, in two dif-
ferent ways: the mother may feel intimidated in her own motherhood, thinking that the
clinician is a better parent than she is; or she may feel jealous about the fact that the
child gets the attention that she needs for herself. Finding the balance in this triangle
requires not only keeping the infant visible, but remembering that everything that be-
longs within the relationship between the mother and the infant needs to be returned
to where it belongs. For example, if the mother turns to the clinician and asks him or
her to take care of her infant while she goes shopping, the clinician will ask the mother,
in a firm but friendly manner, to tell her infant how long she will be away and when she
will return. Saying this is important, not because the child will yet understand the con-
tent of what the mother is saying, but to encourage the mother to pay attention to her
child’s experience at that particular moment of separation. It is also a message for the
mother that this is something important happening between the mother and her child,
not between the clinician and the child.
Preliminary Research Data

Our main interest was to explore individual differences in the situations of these
mother-baby pairs, factors related to these individual differences, and the role of ma-
ternal reflective functioning in treatment outcome.
Subjects and Procedure

Participants were 34 mother-baby pairs who lived in three of the treatment units de-
scribed above and who entered the unit during pregnancy or straight after delivery (i.e.,
within 2 weeks). All data collection, including reflective functioning (RF) interviews,
was carried out by the treatment unit staff. Data collection time points during the res-
idential treatment period were as follows: during pregnancy (background data, mater-
nal RF), at 1 month of child’s age (delivery and somatic data), at 3 months (psychiatric
symptoms), and at 4 months (mother-child interaction, maternal RF, child develop-
ment). Follow-up information was collected when the baby was 1 and 2 years of age.
Scoring of the video measures and RF interviews were made by separate, reliable, and
experienced outside raters who were blind to other data and to each other’s ratings.
Background and Other Descriptive Data

From the background data (Table 13–1), it is evident that this was a group with an ex-
ceptionally large number of risks in addition to the substance abuse problem per se.
Most of the mothers were drug users, and their most commonly used substances were
illegally used buprenorphine, hashish, and amphetamine. Maternal sensitivity in inter-
action was found to be on average weak, and unresponsiveness in interaction behavior
was common; however, there was also rather large individual variation in both dimen-
sions (Care Index [CI]; Crittenden 2003). All children were developing within normal
limits at 4 months of age (Bayley Scales of Infant Development [BSID II]; Bayley
1993). A high percentage of mothers reported depression and other psychiatric symp-
toms: over 30% were screened as having postnatal depression (Edinburgh Pre-postna-
tal Depression Scale [EPDS]; Cox et al. 1987), and many mothers received higher
scores than the average Finnish psychiatric outpatient sample, for example in anxiety
(20%), paranoid symptoms (35%), and psychotic symptoms (32%) (Brief Symptom In-
ventory [BSI]; Derogatis 1993). The most commonly and highly self-reported trauma
experiences, both during the early years (0–6) and lifetime, regarded separation ex-
periences (parental divorce; repeated placements in substitution care; death, illness, or
hospitalization of close people) and substance abuse problems within the family
(Traumatic Antecedents Questionnaire [TAQ]; van der Kolk 2003). The treatment had
a planned ending for 70% of patients, and in 70% of cases the mother went home with
her baby and was the primary caregiver. More detailed results are reported elsewhere
(Pajulo et al. 2008, 2011).
Results Regarding Maternal RF

Maternal RF was assessed in late pregnancy (with those who entered the treatment unit
during pregnancy) using the Pregnancy Interview (PI) and at 4 months postpartum us-
ing the Parent Development Interview (PDI; Slade et al., unpublished protocol, 2004;
Slade et al. 2005). The interviews were audiotaped and scored from the transcribed
narratives according to the manual criteria (range of scores –1 to 9) by outside raters
blind to other data.
On the PI, the average RF total single score during pregnancy was found to be low
(mean=2.4, SD=1.3, median=2.5), but with individual variation from “lacking RF” to
“close to ordinary RF” (range 0–4.5). Also at 4 months postpartum, the average RF
total single score was found to be low (mean=3.0, SD=1.0, median=3.0), but with in-
dividual variation from “lacking RF” to “ordinary RF” level (1.0–5.0).
From individual questions/paths of the prenatal PI, the following had the strongest
correlation with the total single score: “How did you feel when you found out you were
pregnant?” and “When you think of your baby’s earliest months, what do you imagine
will be the most pleasurable times for you?” (r>0.80, P<0.001). From individual ques-
tions/paths of the postnatal PDI, the following had the strongest correlation with the
total single score: “Please describe a time in the last week when you and your child re-
ally weren’t ‘clicking’” and “How do you think your experiences of being parented af-
fect your experience of being a parent now?” (r >0.70, P<0.001). RF total single score
increased during the intervention in 63% of the cases assessed at both time points
(P=0.03, range of increase 0.5–2.5). The score decreased in one case and stayed at the
same level for the rest (31%). The lowest RF score received by the mother within the
different answerings/paths increased in 20% of the cases, and the highest RF score in-
creased in 70% of cases.
Higher postnatal maternal RF (PDI total single score) was significantly associated
with less unresponsiveness in maternal interaction behavior at 4 months of age (CI)
(r=–0.41, P=0.05). Also, the higher the “lowest” RF score within PDI paths, the less
unresponsiveness there was in maternal interaction (CI) (r=–0.5, P=0.02). In looking
at the follow-up information, differences were found in the average levels of RF be-
tween two groups of mother-baby pairs within this sample: mothers of the children
who had been placed into substitution care by a social welfare agency during the 2-year
follow-up after treatment (Group 1) on average had lower postnatal level of RF than
mothers of those children who had not been placed into substitution care (Group 2)
(P=0.05) (Table 13–2). About 40% of Group 1 mothers had postnatal RF levels “close
to ordinary” or “ordinary” (RF 4–5), compared to 0% of the Group 2 mothers.
322
TABLE 13–1. Background and other characteristics of substance-abusing mothers in Holding Tight residential treatment with
their babies (N=34)
Characteristic Mean SD Median Upper 25% Lower 25% Range

Maternal age (years) 25.1 5.8 24.0 28.7 20.2 16–38
Age of starting substance abuse 14.7 3.6 14.0 17.0 13.0 6–27
(years)
Duration of pregnancy at entering 30.8 5.8 33.0 36.0 26.5 21–39
treatment (weeks of gestation)
Duration of pregnancy at birth 39.4 1.7 39.0 40.0 39.0 34–42
(weeks of gestation)

Birth weight of the child (grams) 3,329 456 3,285 3,590 3,012 2,130–4,410
Child development (BSID II MDI) 97.5 7.0 98.0 104.5 93.0 85–111
at 4 months
Care Index sensitivity 4.5 2.1 4.0 6.0 3.0 0–9
Care Index unresponsiveness 6.8 4.0 8.0 10.0 4.0 0–14
Length of residential treatment 9.0 4.5 7.0 12.2 6.0 3–18
(months)
At-Risk Mothers of Infants and Toddlers
TABLE 13–1. Background and other characteristics of substance-abusing mothers in Holding Tight residential treatment with
their babies (N=34) (continued)
n %
Single parenting 15 44
First child 23 68
Only basic education (≤9 years) 24 71
Long-term unemployment (>1 year) 15 44
Entering treatment unit during pregnancy 24 71
Unplanned pregnancy 22 65
Substance use during this pregnancy 27 79
Child’s father having a severe substance 29 85
abuse problem
Previous children taken into 11/11 100
substitution care
Primarily a drug problem 20 59
Polysubstance abuse problem 7 21
Alcohol problem 7 20
Excessive smoking 34 100
Withdrawal symptoms at birth 10 31
FAE/FAS diagnosis in baby 1 3
Note. BSID II MDI=Bayley Scales of Infant Development II, mental development index; FAE=fetal alcohol effects; FAS=fetal alcohol syndrome.
323
Short Case Examples From the Research Data
Higher Maternal RF
Tina, 27 years of age, enters the treatment unit when she is 39 weeks pregnant, referred
by a delivery hospital. She is expecting her second child, and this pregnancy is unplanned.
Her first child is 7 years old and has been placed in a children’s home because of Tina’s
substance abuse problem. Tina is single-parenting her child, and the father of the child
also has a severe substance abuse problem. Tina has 2 years of high school education, and
she has been unemployed continuously for 6 months. She used alcohol and drugs during
this pregnancy until the third trimester, and she has also smoked cigarettes excessively.
She started using alcohol or other drugs when she was 18 years old. She receives substi-
tution medication (buprenorphine) for her substance abuse problem during this preg-
nancy and postnatally. Her baby boy is born at 40 weeks of gestation, with birth weight of
2,990 g (6.6 lb). He has withdrawal symptoms, needs morphine medication, and is put in
the intensive care unit in the beginning. The mother visits the hospital and spends time
with her baby every day during this separation time. The baby is found to be otherwise
healthy and comes back to live in the treatment unit with his mother after 21 days in the
hospital. Tina does not have relapses into substance use during the whole residential
treatment period and is considered to be working well toward abstinence from sub-
stances. According to the self-report screens, she had mild depression during pregnancy,
but not in the postnatal period. She also does not have other types of psychiatric symp-
tomatology in the postnatal phase, according to the screens. As she enters the unit in such
a late phase of pregnancy, the PI interview cannot be used to assess maternal RF. In the
PDI interview when her son is 4 months old, Tina is assessed as having an “ordinary level
of reflective functioning” (total single score 5), which is the highest score within the
study group. Her sensitivity in interaction at 4 months of child’s age is found to be
“within intervention range” (score 6), and her interaction is characterized by a high
amount of controlling behavior (score 8) but no unresponsiveness (level 0). The length of
her stay in residential intervention is 18 months, and it has a planned ending. Tina goes
home, together with her boy, with an outpatient treatment plan that includes the
mother’s individual addiction and psychiatric treatment along with relationship-focused
support for the mother-child dyad. According to the follow-up information and assess-
ments, Tina has managed well in her parenting role, she continues to be the primary car-
egiver for her boy, and the child’s development has proceeded well.
Lower Maternal RF
Sari, 20 years of age, enters the treatment unit when she is 21 weeks pregnant, referred by
a substance addiction clinic. She is expecting her first child, and the pregnancy is
planned. Sari has been living in partnership with the father of her child, but the father has
a severe substance abuse problem and is now in prison. Sari has only a basic level of ed-
ucation, but she has been employed continuously. She used alcohol and drugs during this
pregnancy until the second trimester and has also smoked cigarettes excessively. She
started using alcohol when she was 10 years old. Her baby girl is born at 38 weeks of ges-
tation, with birth weight of 2,940 g (6.5 lb). The baby is healthy and does not have with-
drawal symptoms. They return to the treatment unit together after 6 days’ stay at the
TABLE 13–2. Results regarding maternal reflective functioning in Holding Tight

residential treatment intervention with substance-abusing mother-
baby pairs
Group 1 Group 2
Mean SD Range Mean SD Range
PDI total RF single score 2.4 0.6 1.5–3.0 3.2 1.1 1.0–5.0
PDI highest RF score 4.1 0.7 3.0–5.0 4.9 1.2 2.0–6.5
PDI lowest RF score 0.8 0.4 0–1.0 1.1 0.4 0.5–2.0
Note. Descriptive statistics of maternal reflective functioning (RF) assessed with Parent Development In-
terview (PDI) at 4 months of child’s age. Group 1=children taken into substitution care in 2-year follow-up
after treatment (n=8); Group 2=children not taken into care in follow-up (n=21).
hospital. Sari has supportive treatment contact with an addiction polyclinic due to her
substance abuse and mental health problems, and she takes antidepressant medication
both during pregnancy and postnatally. She does not have relapses into substance use
during the residential treatment period and is considered to work well in the treatment
unit toward abstinence. However, she reports experiencing severe difficulties and dis-
tress in taking care of her baby and in dealing with social relationships with other moth-
ers and staff members in the unit. Her interaction with the baby arouses great concern in
the staff members. Despite great efforts during her residential treatment period both by
herself and by the staff, she is not able to take good enough care of her child. In postnatal
measures, Sari is found to score especially high in experience of interpersonal difficulties
and paranoid symptoms. Both during pregnancy (PI) and at 4 months of child’s age
(PDI), she is assessed as having a low level of reflective functioning (total single scores 2
in each). Her sensitivity in interaction when her child is 4 months old is found to be in the
high-risk range (“total failure to perceive or attempt to soothe infant’s distressed state, no
play”; score 2), and her interaction is characterized by a high amount of unresponsiveness
(score 12), and no controlling behavior (level 0).The length of her stay in residential in-
tervention is 15 months, and it has a planned ending. Sari goes home after the residential
treatment period and continues in her individual treatment at the addiction polyclinic,
but her baby is taken into custody at 11 months of age and placed into substitution family
care. The mother is able to collaborate with professionals in this process. She meets her
child every third week, together with a social worker and the mother of the caregiving
family. In the follow-up, the child has continued to live with the substitution care family,
and her development is found to be proceeding within normal limits. After the residen-
tial treatment period, the mother continues in her individual treatment contacts, regard-
ing both addiction and mental health problems, and starts working in a part-time job.
Holding Tight: Conclusion

A great need exists for theoretically driven and accurately focused interventions among
psychosocial high-risk groups. We propose that the concept of parental reflective func-
tioning has especially strong relevance for substance-abusing mother-baby couples and
their treatment. The Holding Tight intervention described above has been designed
for mothers who have a particularly severe substance addiction problem during preg-
nancy and in the perinatal phase. The mothers are intensively supported to invest in
their child instead of in substances, and a goal is to reset the focus of the reward system
by intensively facilitating and enhancing the mother’s satisfaction with positive inter-
action experiences with her baby and with being a parent. The individual is supposed to
become less focused on her craving for the substance and more on her preoccupation
with and investment in the infant. It seems that with many of the mothers, the inter-
vention has significant impact, both in terms of abstinence and quality of parenting.
With most of the mothers, the intervention seems to have at least increased the moth-
ers’ capacity to deal with difficult situations and feelings and to collaborate with pro-
fessionals. With some mothers, not enough change has occurred. However, we believe
that although the model presented here already contains elements of enhancing ma-
ternal RF, as described above, there is still a lot that could be done more accurately and
systematically, with that focus in mind, so that even more mothers could move from
high risk to more reflective and sensitive interactions with their children. Our work is
continuing with that aim.
Mothering From the Inside Out:

An Outpatient Mentalization-Based
Therapy for Substance-Using Mothers
of Infants and Toddlers
Overview
Mothering From the Inside Out (MIO) is an individual parenting therapy developed
for women enrolled in outpatient substance use treatment and caring for children be-
tween birth and 3 years of age. The objectives of MIO are to foster balance in parental
representations of the child and increase the parent’s capacity to mentalize for or her-
self and for her child. MIO was originally conceived as a 12- to 24-week intervention in
order to examine its preliminary efficacy in a randomized clinical trial. In clinical prac-
tice, however, the length can and should vary depending on the individual needs of the
parent and child.
Background
Although quality of interactions varies widely, mothers with histories of chronic sub-
stance use are at greater risk than mothers with no drug use history for lower sensitivity
and lower contingent responsiveness when interacting with their infants and for juxta-
position of withdrawal with intrusive, overcontrolling behaviors when interacting with
their toddlers (see Suchman et al. 2006). Mothers with histories of chronic substance
use are also more likely to have experienced inconsistent and disrupted caregiving with
their own parents (Luthar and Suchman 1999), problems regulating internal distress as
adults (Sinha 2001), and alterations in neuroregulatory stress/reward processes that
make caring for young children more stressful and less pleasurable (Volkow et al.
2003). These parental vulnerabilities are often compounded by heightened irritability
in infants who have been exposed to drugs in utero (Mayes and Truman 2002).
Perhaps because of these vulnerabilities, traditional behavioral parent training has
generally failed to improve the quality of relationships of substance-using parents with
their young children (for a review, see Suchman et al. 2004a). In order to address the
unique constellation of vulnerabilities that substance-using parents face, we developed
Mothering From the Inside Out, an intervention that directly targets attachment def-
icits incurred by the mother.
MIO is based on several core tenets of attachment theory. The parent’s capacity for
sensitive and responsive caregiving is strongly related to the parent’s own psychological
representations of caregiving that originate within the context of the parent’s relation-
ship with early caregivers. When a parent’s experience with early caregivers is charac-
terized by neglect or abuse (as is the case for many women with substance use disorders),
psychological representations of the caregiving relationship tend to be characterized by
defensive omissions and/or distortions. These defenses may protect the individual from
painful memories and overwhelming affect, but they are also likely to interfere with the
individual’s ability to recognize new psychological and emotional experiences in herself
and her child. For instance, a mother whose psychological representations of herself as
a child are characterized by global negative attributes is likely to unwittingly view her
child’s personality in a global and negative way. Likewise, a mother who experienced
herself as a nuisance to her own mother is likely to unknowingly view her child as a nui-
sance. These predetermined mental models—including affect linked to the representa-
tion—tend to be automatic and beyond awareness.
Inflexible and harsh mental representations of others are closely related to com-
promised abilities to mentalize. If experience of strong emotions by the parent or the
child threatens to activate the parent’s painful early memories and experiences, the par-
ent is likely to have difficulty holding these emotions in mind or using them to make
sense of the child’s experience and behavior. Without the capacity to mentalize about
her own or her child’s experiences, the mother is unable to perceive and respond to her
own or her child’s emotional needs. These adult attachment deficits—defensive repre-
sentations and limited capacity to mentalize—are closely related to problems of becom-
ing flooded by unregulated emotion. Mothers with histories of chronic drug use are
especially vulnerable in two ways when internal distress becomes activated in the
parenting role. First, the experience of distress increases vulnerability to relapse (Sinha
2001). Second, if substance use has been chronic and recent, neurobiological hedonic
reward systems that ordinarily assist with adaptation to stress fail to do so. Chronic drug
use tends to alter neurochemistry such that the release of the neurotransmitter dopa-
mine during ordinary stressful situations (e.g., caring for a distressed child) and the
concomitant reduction of negative emotions and increase in pleasure no longer occur.
MIO directly targets attachment regulatory functions that have been compro-
mised by experiences with early caregivers and by altered neurochemistry of addiction,
exacerbated by the child’s emotional needs. Specifically, MIO focuses on fostering
shifts in the mother’s representations of the child and on increasing her capacity for re-
flective functioning in order to improve her capacity to regulate her own strong affect
in the parenting role and accurately recognize and sensitively respond to her child’s
strong affect—thus promoting her child’s growing capacity for regulation and attach-
ment security. Shifting in representations involves movement away from global, harsh,
and rigid representations and toward more flexible, emotionally balanced, and realistic
representations. Greater capacity for reflective functioning is characterized by a stron-
ger recognition of the intentional nature of behavior (the mother’s own as well as her
child’s). Improvement in these two central and related domains is expected to be ac-
companied by improvements in maternal affect regulation, in caregiving behavior, in
abstinence from substance use, and in neuroregulatory functioning (i.e., restoration of
the dopaminergic reward system).
The MIO Intervention

MIO was designed as an adjunct individual therapy program for mothers who are enrolled
in outpatient treatment for substance abuse. MIO is conducted on-site at the clinic, where
mothers have ongoing access to comprehensive services including group and individual
counseling for substance use, opiate replacement therapy (e.g., methadone, naltrexone, and
buprenorphine), psychiatric care and specialized groups for mental illness (e.g., depression,
posttraumatic stress disorder), vocational counseling, medical services, case management,
child care, and transportation. Mothers are self- or clinician-referred and are eligible to par-
ticipate if they are enrolled and present in substance use treatment, are actively caring for a
child between birth and 3 years of age, and have the mental capacity to benefit from the
program (i.e., are not severely psychiatrically or cognitively impaired).
Preliminary Assessment
The intervention begins with three assessment visits that start with a comprehensive
psychosocial evaluation (i.e., personal and family histories of substance use and psychi-
atric disorders and developmental, medical, employment, and legal histories). The
Working Model of the Child Interview (WMCI; Zeanah and Benoit 1993) is then com-
pleted so that clinicians can begin developing an understanding of the mother’s mental
representations of herself, her child, and their relationship. The PDI is completed to
determine the mother’s initial capacity for reflective functioning. The mother also par-
ticipates in two brief videotaped interaction sessions with her child, the NCAST
(Nursing Child Assessment Satellite Training) Teaching Task (Barnard and Eyres
1979) and the Curiosity Box Paradigm (Mayes et al. 1993), which are used to assess pre-
liminary sensitivity and responsiveness to the child’s cues. Finally, the mother com-
pletes brief questionnaires about psychiatric symptoms, including the Beck Depression
Inventory (BDI; Beck et al. 1996) and the BSI. The mother’s substance use and atten-
dance at all clinic appointments are monitored via clinic records and charts.
Building a Therapeutic Alliance

The most important component of the intervention—the therapeutic alliance—is the
first issue to be addressed in therapy. Mothers with substance use disorders have many
reasons to be wary of this new relationship. Most treatment providers they encounter are
part of a treatment system that is closely monitoring their drug use, their parenting, and
their illegal activity. Most mothers are likely to have experienced frustration, bitterness,
and futility directly or vicariously as a result of involvement with the child welfare or
court system. Many of the behaviors involved in maintaining a drug or alcohol habit en-
gender anger, frustration, mistrust, and withdrawal by others, causing the addicted indi-
vidual to feel angry, bewildered, and dejected. The addicted individual’s expectation of
being conned, manipulated, neglected, or condescended to make the work of building an
enduring and trusting alliance extremely challenging, delicate, and important. For this
reason, much effort during the early stages of therapy goes toward assisting the mother in
ways that she is likely to perceive as helpful. Mothers are assisted by the MIO team in
meeting basic needs (e.g., finding housing, food, child care, transportation, legal ser-
vices), getting supplies (e.g., diapers, food, toys, clothing), and solving everyday problems
(e.g., scheduling dilemmas, family conflicts, eviction notices, child welfare visits). The
clinician also works hard to understand the mother’s perspective on personal, parenting,
and family problems and to convey to the mother that her beliefs, feelings, and wishes are
going to be taken seriously in the relationship. A less obvious component of building a
strong alliance involves being very clear and consistent about the boundaries of the ther-
apeutic relationship. The therapist informs the mother in their first session about her re-
sponsibilities as a mandated reporter of child abuse and neglect and the limitations of
confidentiality in circumstances where the well-being of the child or the mother is threat-
ened. The therapist must also set firm, clear, consistent limits and avoid being manipu-
lated while also being careful not to fall into a policing or punishing role.
Mentalizing for the Mother

The therapist interacts with the mother in ways that recognize the latter’s intentional-
ity, conveying that the mother’s behavior is best understood if they both assume that
she has ideas, beliefs, feelings, and wishes that determine her actions and others’ reac-
tions to her. Initially, during each session, the therapist allows the discussion to go
where the mother’s affect is. The initial topic is therefore likely to be a problem that
preoccupies the mother, which may not be related to parenting. If this is the case, the
therapist goes with the mother and explores the meaning of the issue to her. This may
involve exploring emotional reactions to external events (e.g., excitement and fear
about being reunited with the child, relief or sadness that a partner is going to jail, sat-
isfaction and anxiety when a child welfare case is closed, or joy and anxiety about being
pregnant). Or it may involve exploring expectations, beliefs, or emotions underlying
self-destructive behaviors (e.g., choosing to remain with an abusive partner, falling
asleep during counseling sessions, spending money beyond her means, being late for a
meeting with a probation officer). It may involve exploring thoughts and feelings asso-
ciated with physical sensations (e.g., physical cravings, fatigue, physical agitation). Or it
may involve exploring inconsistencies between content, behavior, and affect (e.g., neu-
tral statements made with sad affect).
When the mother is focused on an interpersonal conflict, the therapist will invite
her to engage in moment-by-moment mentalizing about the interactions. During this
process, the therapist might initiate mentalization to distinguish intrapersonal reality
from interpersonal reality (e.g., distinguishing internal anxieties and expectations from
what is occurring between the mother and the other person, thereby recognizing in-
ternal dynamics and distinguishing them from external dynamics). The therapist may
also focus on helping the mother to tease apart strong and complex emotions (e.g., in-
tense anger, hostility, or fear). Regardless of the focus, the therapist is careful not to
make intrusive or expert-like statements about the mother’s mental states. Instead, she
or he adopts an inquisitive stance about the mother’s underlying intentions and encour-
ages the mother to do the same when focusing on herself and others. The therapist is
careful to stay in control of the sessions and to control their pace to prevent the mother
from becoming overwhelmed by strong affect. The therapist also maintains the bound-
aries and consistency of the sessions, scheduling them at the same time each week
whenever possible, meeting at the same place, and starting and ending sessions on time.
Exploring Mental Representations

The therapist listens for patterns in the mother’s perceptions of herself and the child
that seem to occlude or distort personality characteristics, emotions, and intentions in
ways that interfere with her capacity to understand and empathize with herself and the
child. Evidence for possible patterns of this type includes distracting irritations with the
child, unrealistic expectations for self or child, emotional indifference or coolness to-
ward self or child, role reversals, idealization of the child or their relationship, absence
of detailed perceptions of the child, or insensitivity to the child’s emotional or physical
pain. The therapist also listens for split-off, unintegrated parts of representations (e.g.,
when the mother describes her child as an “angel” in one moment and as a “devil” in the
next with no integration); global, undifferentiated representations (e.g., when the
mother describes her child as “perfect” or as having “a bad character” or herself as a
“bad daughter” or a “lazy mother”); overly harsh representations (e.g., when the
mother describes her child as having “no manners” or “bad taste,” as “hating” a sibling,
or as being “clueless,” “rude,” or “selfish,” or describes herself as “never learning” or
being “a bad apple”). The therapist notes these representations to the mother and in-
vites the mother to help her or him understand more about these perceptions (e.g.,
when, how, and with whom they originated and when they are felt most intensely). The
goal here is for the therapist and the mother to have a better understanding of the
mother’s representational world and how it plays out in interactions with the child (and
also with other adults, including the therapist). The therapist will help the mother to
make sense of representations by examining them in context and exploring underlying
emotions and also to understand how these representations might interfere in the
mother’s ongoing relationship with her child.
Mentalizing for the Child

If the mother has become more regulated in the session after mentalizing about a pre-
occupying stressor, the therapist shifts the focus to the child. The therapist is careful
not to focus on the child too early in the session (unless the mother initiates the discus-
sion) because the mother’s ability to mentalize for the child is likely to be compromised
until she reaches a point where she herself feels grounded and contained. The therapist
may initiate the shift in focus by asking something like “How do you think this affects
the baby?” or “What do you think is going through the baby’s mind when this is hap-
pening?” This type of question may seem quite foreign to the mother at first, and she
might say, “I never thought about that” or “What do you mean?” or “The baby doesn’t
realize any of this.” This response provides a segue that allows the therapist to provide
some developmental guidance about the baby’s mental capacities at different ages.
The therapist now speaks to the mother about the child in a way that conveys to her
that the child’s behavior is best understood if they assume the child has ideas, beliefs,
feelings, and wishes that determine the child’s actions and also the reactions of others to
the child. When the mother has concerns about a specific interaction, the therapist will
invite her to engage in moment-by-moment mentalizing about the interaction (men-
talizing for the baby and the mother).
Using Videotaped Interactions

Videotapes of interactions made during the preliminary assessment can also be used for
moment-by-moment mentalizing for the mother and the baby. The therapist will pre-
view the interaction session for moments when the mother and baby seemed especially
in sync, moments of joyful play, moments when the mother or baby seemed frustrated
and out of sync, moments when the child was disengaging or distressed. At each of
these junctures, the therapist adopts an inquisitive stance about the interaction (e.g.,
“What do you think was going through his mind just then?” “I wonder if he understood
what you wanted him to do.” “Do you think he might have sensed that you were upset
just then?”).
There are also opportunities for the therapist to observe the mother and child together.
Mothers will often bring their young babies into the therapy session with them. Mothers
with toddlers may bring them to the clinic day care. The baby’s presence provides an op-
portunity for the therapist to mentalize for the child in the mother’s presence. One tech-
nique involves “speaking” for the child; the therapist will suggest to the mother what the
child might be thinking or feeling at a given moment (e.g., “Mommy, where did you go?
I was worried you wouldn’t come back,” “Mommy, who is this strange lady who wants to
play with me?” “Mommy, I’m not interested in this activity anymore; these toys over here
are much more interesting,” “Mommy, you’re talking so loud; I heard you the first time, but
I don’t want to leave yet”).
The therapist also helps the mother distinguish between her own and her child’s
thoughts and emotions. For example, when the mother seems to be assuming that her child
feels exactly what she is feeling, the therapist might ask, “Do you think your baby is worried
about that, or might you be worried also?” “Do you think the baby knows how to take care
of you? It’s quite natural that this might be a strong wish of yours.” The therapist also helps
the mother distinguish her internal reality from external reality. For example, if a mother
conveys that she believes her child is safe in a situation of questionable safety, the therapist
might say, “Do you think the child really is safe, or might this be a very strong wish that you
have?” On the other hand, if the child is not in danger but the mother is anxious about giv-
ing the child independence, the therapist might say, “Do you think the situation is danger-
ous, or do you think you might just be very worried about the child?” Finally, the therapist
helps the mother distinguish intrapersonal reality from the mother-child interpersonal re-
ality (e.g., “Do you think the child is really trying to trick you, or might you be afraid that he
might be like others who have?” “Does the baby really know how to deliberately upset you,
or is that what you’ve come to expect from other important people in your family?”). When
suggesting an alternative perspective, the therapist is careful to pose it as a question that the
mother can accept or reject. The therapist is also careful to ask only those questions that are
based on a thorough knowledge of the mother’s interpersonal experiences. The therapist
herself or himself must have a strong capacity for reflective functioning in order to make ac-
curate inferences about the mother’s intentional states.
Providing Developmental Guidance

Because the mother’s background knowledge about child development (particularly so-
cial and emotional development) may be limited, the therapist will provide develop-
mental explanations for the child’s behaviors whenever they are directly relevant to the
mother’s concerns and the child’s developmental needs. The therapist provides the
guidance in a brief, simple, timely manner and avoids adopting a didactic stance. For
example, the therapist might explain what the child’s clinging behavior in an unfamiliar
setting might mean from an attachment perspective. Or the therapist might identify
behaviors that anger the mother as simple communications of the desire to disengage
from one activity and do something else.
Using the Developmental Continuum

Throughout the treatment, the therapist monitors where the mother is functioning on
any given day on a developmental progression that begins with experiencing a secure
alliance with the therapist, then extends to feeling grounded and contained, and then
further extends to mentalizing for the child. Each stage is a prerequisite for the next,
and from week to week the therapist may find that the mother is functioning at a dif-
ferent level along the developmental continuum, depending on many internal and ex-
ternal factors. The therapist therefore expects the therapeutic process to be dynamic
and is flexible in changing the focus from fostering the alliance to helping the mother
get regulated to reflecting about the child from one session to the next, depending
upon the mother’s level of functioning on that given day.
Monitoring Transference and Countertransference

Exploring content at the representational level is likely to evoke transference and coun-
tertransference issues over the course of therapy. The therapist can often find herself or
himself feeling pulled toward experiencing the mother’s own feelings of helplessness,
frustration, anger, and guilt about the circumstances of the child. The therapist is also
likely to witness parenting beliefs and behaviors that are clearly not in the child’s best
interest and yet not sufficiently harmful to warrant a report to child welfare. Working
with a mother while knowing that her substance use disorder (and possibly psychiatric
disorder) is having an emotional impact on the child can be emotionally draining work.
The therapist can also feel a strong pull to ally with the child and adopt a harsh and pu-
nitive stance toward the mother. All these reactions are natural, but they can also derail
the therapy. Monitoring countertransference can be extremely challenging for the in-
dividual therapist because of the close proximity and the intensive nature of the work.
Regular (e.g., weekly) group supervision serves a critical function, allowing the thera-
pist to examine countertransference issues with other skilled clinicians who are re-
moved from the immediacy of the relationship. Maintaining a reasonable caseload,
working as part of a treatment team, having ongoing access to a clinical supervisor, and
having ample time off will also help prevent deleterious effects of countertransference
and burnout.
Preliminary Randomized Pilot Study

Study Overview
In a recently completed randomized clinical trial, the preliminary efficacy of MIO was
tested in comparison with the Parent Education Program (PEP), an individual inter-
vention that provided case management and developmental guidance but not mental-
ization- or representation-based therapy (Suchman et al. 2010; Suchman et al., in
press). Forty-seven mothers enrolled in outpatient treatment for their substance use
were randomly assigned to MIO or PEP. All mothers were assigned to 12 weeks of ei-
ther MIO or PEP and completed assessments at baseline, during the treatment period,
and posttreatment. All mothers were then given the option of completing an additional
12 weeks of their assigned treatment before entering an 8-week follow-up period or,
alternatively, beginning the follow-up period immediately. Mothers who entered and
completed the second treatment phase completed assessments again before beginning
the follow-up period. For all mothers, assessments were repeated at the end of the
8-week follow-up period. In this chapter, we report on the treatment outcomes for
47 mothers following the first 12-session treatment phase. (Data from extended treat-
ment and follow-up phases are currently being analyzed.)
Sample
Mothers enrolled in substance use treatment at one of three APT [Addiction Preven-
tion and Treatment] Foundation clinics (two methadone and one general outpatient)
were eligible to participate if they were caring for a child between birth and 3 years of
age. Mothers were referred by their substance use clinicians and completed an initial
screening and informed consent procedures before enrolling in the study. After com-
pleting baseline assessments, mothers were randomly assigned to one of the treatment
conditions. Of 56 referred mothers who were eligible to participate, 47 completed
baseline measures and were assigned to treatment (23 MIO, 24 PEP).
Demographic characteristics. The average age of the mothers in the sample was
30.1 years (SD=6.5), and the average child age was 17.7 months (SD=13.8). The ma-
jority of mothers were single (64%), Caucasian (70%), high school educated (79%),
and unemployed (81%) at the time of enrollment. At baseline, 60% of the mothers re-
ported having open child welfare cases. Between-group differences on these variables
were nonsignificant except for marital status; significantly more mothers were married
in the MIO condition.
Psychiatric characteristics. A majority of mothers had primary opiate use disorders

(72%) and were enrolled in methadone maintenance (68%). The remaining mothers
were diagnosed with cocaine (13%), cannabis (6%) and alcohol (4%) use disorders. At
baseline, lifetime exposure to trauma was reported by 100%, significant psychiatric dis-
tress was reported by 27%, and significant depression was reported by 15% of the
mothers. There were no significant group differences (MIO vs. PEP) on any psychiat-
ric variable.
Measures
Maternal reflective functioning (RF). The PDI was coded for RF using methods
originally developed by Fonagy et al. (1998) for use with the Adult Attachment Inter-
view (Main and Goldwyn, unpublished manuscript, 1998) and then adapted for use
with the PDI. The PDI is a 1.5-hour semistructured interview that consists of 17 ques-
tions asking the parent to describe commonly occurring, emotionally challenging as-
pects of parenting (e.g., times when the parent and her child were not getting along;
when the parent felt angry, needy, or guilty as a parent; or when the parent felt her child
needed attention). The PDI transcripts were coded by a Ph.D. psychologist who was
trained by one of the authors (N.S.) to reliability and remained blind to treatment as-
signment, assessment time point, and any other information about the mother-child
pair. Responses to each question are rated on a 10-point scale representing the level of
reflective functioning shown in the mother’s response. A rating of 1 indicates a com-
plete absence of any recognition of mental states (i.e., events are described solely in
terms of behavior and individuals solely in terms of global personality traits). A rating
of 3 indicates a limited capacity to acknowledge mental states, without any understand-
ing of how mental states function. A rating of 5 indicates the presence of a rudimentary
capacity for reflective functioning—a basic understanding of how mental states work
together and influence behavior. A rating above 5 indicates an increasingly elaborate
and sophisticated understanding of how mental states function and influence behavior.
The mean of individual item scores was used to represent total RF at each time point
(baseline and posttreatment). An overall score of 5 is considered to represent average
reflective functioning. An overall score of 3 or lower is considered to indicate clinical
risk. An overall score of 6 or above is considered to represent increasingly optimal re-
flective functioning.
Mental representations of the child. The WMCI was used to measure changes in the
mother’s representations of the child. The WMCI is a 1.5-hour semistructured inter-
view that asks the mother about her perceptions of her child and their relationship. The
WMCI is intended for use with parents of children up to 5 years of age. The interview
includes inquiries about the mother’s perceptions of her child’s distinctive characteris-
tics and characteristics of her relationship with the child, particularly during times
when the child’s attachment needs are likely to be activated (e.g., times when the child
was upset, physically or emotionally hurt, exhibiting difficult behaviors, or separated
from the mother). Videotaped interviews were coded by a Ph.D. psychologist who was
blind to treatment assignment, assessment time point, and all other information about
the mother-child dyad. The three-part classification system ordinarily used with this
instrument did not have the necessary sensitivity to detect small but meaningful shifts in
representational quality. The rater was therefore trained by the principal investigator
to reliably code five qualitative subscales rated on a 5-point scale (1 = not at all,
3=moderate, 5=extreme) that together represent the most important representational
qualities (Zeanah and Benoit 1993). These characteristics include Openness (accep-
tance and flexibility in expectations for the child over time), Coherence (clarity and
credibility of narrative), Caregiving Sensitivity (recognition of and responsiveness to
child’s emotional distress), Acceptance (acknowledgment of parental role and respon-
sibility and the child’s dependence on the parent for safety and care), and Emotional
Involvement (expression of positive and negative emotionality toward child). A score of

3 on each subscale is considered to represent average representational quality, a score
lower than 3 is considered to represent clinical risk, and a score above 3 is considered to
represent optimal quality. A composite score using the mean of the five subscale scores
represented overall representation quality.
Caregiving behavior. The NCAST Teaching Scales were used to measure maternal
caregiving behavior with the child (Barnard and Eyres 1979). The NCAST is a widely
used standardized 73-binary-item tool for observing and rating quality of caregiver-
child interactions with children ages birth to 36 months. Mothers are asked to choose
one task to teach the child (e.g., stringing beads, drawing shapes, grouping blocks by
color) from a list of tasks that are organized in increasing order of difficulty. The teach-
ing session lasts 5 minutes.
Interaction videotapes were coded by a certified NCAST rater who was trained to
reliability by the Project Director (N.S.) and remained blind to treatment assignment,
assessment time point, and all other information about the mother-child dyad. Mater-
nal behavior during the teaching task was coded on four behavioral dimensions: sen-
sitivity to the child’s cues (mother’s responsiveness to her child’s behavioral cues),
responsiveness to the child’s distress (effectiveness in relieving the child’s distress),
social-emotional growth fostering (ability to play affectionately with her child, engage
in social interactions, and provide appropriate social reinforcement of desired behav-
iors), and cognitive growth fostering (ability to provide stimulation that is just above her
child’s current level of understanding). The Total Caregiver Score (representing the
mother’s initiated and contingent interactions) was used to represent quality of caregiv-
ing behavior.
Maternal psychiatric symptoms. Although maternal psychiatric symptoms were not

a primary targeted outcome, group differences (MIO vs. PEP) in depression, anxiety,
and global psychiatric distress were examined to identify possible indirect treatment ef-
fects. The BDI was used to assess maternal symptoms of depression. The BDI is a
widely used 21-item questionnaire rated on a 4-point scale. The BDI yields a total score
for depression ranging from 0 to 63; scores between 13 and 19 indicate mild depres-
sion, scores between 20 and 28 indicate moderate levels of depression, and scores be-
tween 29 and 63 indicate severe levels of depression (Beck et al. 1996). The BSI was
used to assess maternal global psychiatric distress. The BSI is a widely used standard-
ized 90-item, 4-point self-report measure of psychopathology. The composite Global
Severity Index (GSI) measures current overall symptomatology across multiple do-
mains and has demonstrated good reliability and validity (Derogatis 1993). T scores
above 60 on the GSI indicate risk for a clinical disorder.
Maternal drug use. Although maternal drug use was not a primary targeted outcome
for this study, we examined group differences (MIO vs. PEP) in substance use in order
to identify possible indirect treatment effects. Maternal substance use was monitored
weekly using results from urine toxicology (UTOX) screens testing for presence of opi-
ate, cocaine, benzodiazepine, and cannabis metabolites in urine samples collected
weekly at the APT Foundation clinics (mothers were granted permission to access
these clinic records during consent procedures). For each month of the mother’s par-
ticipation in the study, beginning with month 0 (the month of consent) and continuing
through the end of the 8-week follow-up period, a mother received a score of 0 if no
drug metabolites for a given drug were present in any of her UTOX screens during that
month or a score of 1 if one or more of her UTOX screens tested positive for the given
drug during that month. Thus, mothers received a score of 0 or 1 for each drug (opi-
ates, cocaine, marijuana) for each month of enrollment in the study.
Results
Attendance. On average, mothers assigned to MIO attended 72% of their scheduled
meetings with the MIO therapist, 73% of their scheduled assessment meetings, and
82% of their scheduled meetings at the clinics. Mothers assigned to PEP attended, on
average, 78% of their scheduled meetings with the PEP counselor, 78% of their sched-
uled assessment meetings, and 78% of their scheduled meetings at the clinics (be-
tween-group differences were not significant).
Treatment outcomes. To examine the preliminary efficacy of MIO, a series of analy-

ses of covariance was conducted for each major outcome, testing for group differences
(MIO vs. PEP) at posttreatment after controlling for child age and gender and baseline
scores. A one-tailed significance test was used because MIO outcomes were expected to
be better than PEP outcomes across all indices. As shown in Table 13–3, mothers en-
rolled in MIO showed significantly higher levels of RF and caregiving contingency at
the end of 12 sessions when compared with mothers assigned to PEP. Mothers in both
groups showed modest improvement in representation quality, although this main ef-
fect was not significant. Mothers in MIO also showed marginally lower levels of de-
pression than PEP mothers at the end of 12 sessions. Levels of global distress remained
within the high end of normal limits for both groups at the end of treatment. Substance
use decreased significantly for both groups at the end of 12 sessions, as displayed in Fig-
ure 13–1.
Clinical Case Studies
Case Study 1
Kelsey, 33 years of age and Caucasian, was referred by her substance use clinician and en-
tered the MIO program when her youngest son, Jerome, was 9 months old. Her first and
second children, 10- and 8-year-old sons from a prior marriage, were living at home with
Kelsey and her current husband, Jose (Jerome’s father), along with a 12-year-old son,
338
TABLE 13–3. Analysisa of MIO versus PEP outcome scores, controlling for baseline scores (N=47)
MIO (n=23), mean (SD) PEP (n=24), mean (SD)

Pre Post, raw Post, adjusted Pre Post, raw Post, adjusted F
Reflective 3.14 (0.45) 3.32 (0.46) 3.32 (0.31) 3.09 (0.48) 3.09 (0.42) 3.09 (0.31) 6.23**
functioning
Representation 13.60 (2.06) 13.92 (1.65) 13.97 (1.81) 13.71 (2.50) 13.90 (2.65) 13.84 (1.81) 0.06
quality
Caregiver 13.23 (2.54) 14.71 (1.59) 14.66 (1.81) 13.17 (2.79) 13.13 (2.25) 13.17 (1.81) 7.85**
contingency
Psychiatric

status
Depression 14.91 (9.50) 12.65 (8.42) 13.32 (6.09) 16.88 (9.33) 16.79 (8.90) 16.15 (6.07) 1.27+
Global distress 58.30 (10.99) 57.05 (8.20) 58.15 (6.05) 61.54 (11.02) 61.13 (10.52) 60.07 (6.05) 1.16
Substance use 0.10 0.10 1.96*

Note. See text for description of measures. MIO=Mothering From the Inside Out; PEP=Parent Education Program.
aAnalysis of covariance.
*P<0.05. **P<0.01 (one-tailed).

Italicized scores represent T scores where normative mean=50 and SD=10.
0.5
0.4
0.3
MIO
0.2
PEP
0.1
–0.1
1 2 3 4 5 6 7 8
FIGURE 13–1. Substance use during the first treatment phase.

MIO=Mothering From the Inside Out; PEP=Parent Education Program.
aProportion of positive toxicology screens (indicated presence of opioid, cocaine or cannabis me-
tabolites in urine sample).
Jose Jr., from Jose’s previous marriage. Jose Sr. works full-time in a warehouse for low
wages ($15/hour) and has a drinking problem by Kelsey’s report. Kelsey stays at home
with Jerome.
Kelsey completed high school and some college courses, and she has been unem-
ployed continuously for 2 years. She started using alcohol, cannabis, and cocaine when
she was 14 years old and heroin when she was 19 years old. Her last use was heroin
7 years ago. She had used heroin throughout her first two pregnancies, enrolled in meth-
adone maintenance after her first child’s birth, and has stayed clean for the last 6 years,
including during her pregnancy with Jerome. At baseline, Kelsey’s methadone dosage
was 45 mg daily, and she was detoxing by choice. Kelsey’s pregnancy with Jerome went
full term, and he showed no withdrawal symptoms at birth. Jerome has had no major
health problems.
During her lifetime, Kelsey has had four abortions and one miscarriage, lost her fa-
ther to sudden illness during adolescence, been physically abused and threatened by a
previous partner, and engaged in avoidant behaviors related to these traumas. At base-
line, Kelsey had clinical depression (BDI=31) and moderate global psychiatric distress
(BSI: GSI, T score=57). Kelsey’s baseline overall PDI score was 3 (limited RF). Her
baseline overall WMCI score was 2.6 (3 is average on a 1–5 scale). Her NCAST Total
Caregiver score was 36 (40.7=norm for comparably educated group). At baseline, Kelsey
was also free of any substances.
In MIO, Kelsey and her therapist (N.S.) first focused on ways that Kelsey felt herself
to be invisible in her current family (e.g., seeming to be always taking care of others while
ignoring her own personal needs) and reprehensible to her own mother, and on how
these unconscious expectations were interfering with acting on her own personal goals.
They then explored Kelsey’s mixed feelings about Jerome. Initially she reported that car-
ing for Jerome was much easier than caring for her other children and that she adored
him and felt they got along well. Over time, though, Kelsey complained more about Jer-
ome’s increasing willfulness—which she referred to as “a little attitude”—and expressed
regrets about having him. The therapist mentalized with her about Jerome’s experiences
and frustrations: his desire to be seen and included by her, his physical nature and intense
curiosity, and his growing interest in doing things with less assistance.
Kelsey chose to extend her therapy by 12 sessions. Over the course of the
24 sessions, Kelsey was able to find day care for Jerome and full-time employment (with
benefits) as an administrative assistant in a university research office and enroll in a bar-
iatric surgery program. She also confronted her husband on his drinking and socializing
away from home and began to feel closer to him. She found rental assistance and a larger
house in a more secure neighborhood, where she and her husband had their own room,
and successfully completed her detox from methadone without relapsing. Jerome’s ad-
justment to child care was good, and he also spent increased time with his father and
grandmother when Kelsey was at work.
Toward the end of therapy, Kelsey occasionally showed spontaneous mentalization
about Jerome. After 12 sessions, Kelsey was mildly depressed (BDI=17) and showed no
global distress (BSI: GSI, T score=48). After 24 sessions, her overall PDI score increased
to 5 (ordinary RF), her overall WMCI score increased to 2.8 (with average scores of 3 for
Openness to Change, Coherence, Caregiving Sensitivity, and Acceptance). Her NCAST
Total Caregiver Score increased to 39.
Case Study 2
Joan, 25 years of age, was referred by her substance use clinician and entered MIO when
her first child, Zeb, was 10 months old. Joan is African American, has never been mar-
ried, and lives alone with her son in an apartment. Zeb’s father is incarcerated and was
threatening and physically abusive to Joan prior to his incarceration. Joan had a high
school education and was unemployed at the time of enrollment.
Joan first used cannabis when she was 14 and alcohol when she was 20. She had used
alcohol to the point of intoxication eight times during her month of enrollment (but not
cannabis). During her lifetime, Joan had experienced multiple traumas, including the
sudden loss of a close friend and physical threat, injury, and sexual assault by a partner.
She also witnessed violence toward others. She was very worried about how her partner’s
future release from jail would affect her own safety. Joan reported engaging in avoidant
behaviors, depersonalization, anxiety, and hypervigilance related to these traumas.
At baseline, she was taking medication for anxiety and depression and scored 21 on
the BDI (minimal depression) and had a T score of 67 (indicating significant distress) on
the GSI. Her overall PDI score was 3 (limited RF), overall WMCI score was 2.5 (3 is av-
erage), and NCAST Total Caregiver Score was 28. At the beginning of the treatment
phase, Joan was withdrawn and depressed, expressing sadness about the passing of her
deceased mother’s birthday, remorse about her partner’s incarceration (her report of do-
mestic violence led to his arrest), and fear that others might see her as complaining too
much.
Throughout treatment, Joan’s therapy focused heavily on her feelings about her re-
lationship with her incarcerated partner. Initially, she was preoccupied with fear and an-
ger about the partner’s failure to respond to her calls and letters and about his ongoing
communications with other women. Over time, Joan was more able to explore her
deeper disappointments about the relationship and her desire to care for herself more.
Initially, Joan was not raising concerns about Zeb spontaneously. The only joy that Joan
experienced during sessions was in reviewing play sessions with Zeb, when she marveled
at his cleverness and cuteness. It seemed that during these reviews, she was able to focus
in a more relaxed way on Zeb.
Over time, the focus of treatment shifted to Zeb’s upcoming eye surgery and her
growing anxiety about this event. Although Joan declined the therapist’s offer to accom-
pany her during medical visits and the surgery, Joan asked her father for similar support.
Treatment ended just after her son’s successful surgery, with Joan relieved to have com-
pleted this milestone. After 12 sessions, Joan was minimally depressed (BDI=10) and her
global distress had decreased but was still high (BSI: GSI, T score=61). Her overall PDI
score decreased to 2 (no RF), her overall WMCI score increased to 2.8 and her NCAST
Total Contingency Scale score increased to 16.
MIO: Conclusion
Results of the MIO randomized trial suggest that this approach is very acceptable to
mothers in substance use treatment and to their clinicians and shows promise for im-
proving parental reflective functioning, representations, psychosocial adjustment, and
substance use. These findings are preliminary and require replication in a larger ran-
domized trial that also examines infant and toddler response to changes in maternal
caregiving behavior. There is also a need for future adaptation and testing of the MIO
model in other treatment settings (e.g., residential, home visit) and with other popula-
tions (e.g., fathers, young adults, parents of older children) in order to determine which
parents benefit the most and why.
Directions for Research

There continues to be a strong need for treatment programs that focus on the parenting
roles of substance-using adults and that support their recovery as caregivers of their chil-
dren. Traditional approaches to parent training have largely failed, most likely because
of the psychosocial, neurological, and biological complications that chronic substance
use introduces into the caregiving system. Research on the neurological mechanisms of
attachment and addiction and on the psychosocial histories of substance-using mothers,
together with observed parent-child interactions, suggests the need for interventions
that focus on the mother’s capacity for mentalization in order to improve her availability
as a secure base for her child, increase her capacity for emotional regulation, and reset
her hedonic reward system so that caregiving can be more reinforcing than drugs.
Developing New Mentalization-Based

Treatments for At-Risk Mother-Infant Pairs
Mentalization-based interventions for high-risk mother-baby pairs described here and
elsewhere (e.g., “Minding the Baby,” Sadler et al. 2006) have shown preliminary prom-
ise for improving mothers’ capacities to recognize the underlying meaning of their in-
fant’s behavior while also holding their own emotional responses to the baby in mind.
These improvements have important implications for the baby’s developing capacities
for emotional regulation, communication, self-organization, and interpretation of the
intentions and actions of others. Although each program strongly emphasizes the
mothers’ mentalization capacities in treatment, many aspects of the approaches are
unique to the individual setting, client population, and individual differences among
the clients. Adapting mentalization-based treatment to new settings requires a fresh
and considered approach that takes many aspects of the setting, population, clinicians,
individual clients, and cultural context into account. To state it simply, one size does not
fit all. The most important component in designing any intervention—including those
that are mentalization based—is flexible thinking that takes these myriad permutations
into account. Below, we discuss several important considerations in developing men-
talization-based treatments for mother-infant pairs.
Point of Entry
The point of entry for the Holding Tight intervention is the dyad, whereas in MIO, the
mother is the primary patient. Within a residential context where a team of clinicians
has ongoing contact with mothers and babies throughout the day and evening, there
are ample opportunities to observe and intervene with the mother-baby dyad. Within
the outpatient context, where therapy is an adjunct to standard substance abuse treat-
ment and multiple treatment approaches coexist, clinical contact with the mother-baby
pair and moments for quiet reflection are more limited. Priority might therefore go to
providing individual therapy meetings where the mother can become engaged in her
own mentalization process without the distraction or distress triggered by her baby’s
behavior. For some mothers entering treatment, holding the baby’s experience in mind
may be too distressing initially. Some interventions may begin with the mother as the
primary point of entry and then shift to the dyad after the mother has had some expe-
rience of mentalizing her own negative affect.
Intervention Duration
Both Holding Tight and MIO were conceived as interventions beginning (ideally) dur-
ing pregnancy and continuing through early childhood (to age 5) or as long as needed.
Although mothers with substance use histories often manage to endure multiple
changes of treatment provider, their high levels of past and ongoing exposure to phys-
ical, sexual, and interpersonal trauma strongly suggest the need for a consistent and on-
going relationship that allows ample time for the development of trust and closeness
that can, in turn, provide a platform for appropriate clinical confrontation. Likewise,
even though response to the MIO intervention was evident as early as 12 sessions, the
magnitude of the response was not always clinically significant. Clinicians often com-
mented that at session 12, the alliance was just getting strong enough to begin con-
fronting distortions and disavowals of affect more directly. The rapid changes in
children’s cognitive and motor development during the first 5 years of life also place ex-
ceptional demands on parents to interpret the meaning of the child’s behavior. We
therefore strongly suggest that interventions should not be time-limited. We expect
that the initial expense of human and financial resources incurred by more intensive in-
terventions will be amply returned by the prevention of future deterioration in the
mother’s and child’s mental and medical health status. That said, shorter interventions
may be inevitable in certain circumstances, and our early findings indicate that a short
intervention is more beneficial than no intervention.
Clinician Training and Expertise

Mentalization-based interventions for high-risk mothers and babies require a certain level
of knowledge and clinical skill among a clinic’s staff in order to provide the intervention
effectively. Although the theory underlying the approach is complex, training of Master’s-
level clinicians is feasible. Master’s-level clinicians usually arrive at training with a solid
foundation of basic psychotherapy skills and often with valuable frontline clinical experi-
ence. Although latitude can be taken in preparing clinicians, the effective assimilation of
clinical skills requires an initial period of training, during which the treatment model and
underlying theory are introduced in an accessible, not overly academic way. Ample time is
also needed for teaching and observing the trainees practicing specific techniques de-
signed to engage the mother in the mentalization process. A solid understanding of early
child development gained during or prior to the initial training will help the clinician to
guide the mother’s mentalization efforts within an appropriate developmental context
(e.g., understanding the child’s relational needs, attention span, response to separations at
12 months vs. 24 months). Because mentalization-based treatment is a process-oriented
(versus content-oriented) therapy, the chance to observe demonstrations and practice
during role-plays is essential. Ongoing weekly supervision that involves reviews of video-
taped therapy sessions is the most efficient way for clinicians to build appropriate skills
and avoid the pitfalls of (and potential harm from) poor implementation.
Infant Age and Maternal Parity Upon Entry

Mentalization about the infant ideally begins during pregnancy when the mother first
becomes aware of the baby’s presence. Thoughts about the baby’s gender, physical ap-
pearance, personality, family resemblances, and other features are adaptively activated
as the mother psychologically prepares to give birth and meet her baby for the first
time. The mother’s hopes and dreams for her baby, as well as fears and anxieties for the
baby, emerge into consciousness as she begins to make psychological room for the baby
in her mind. Also activated are the mother’s unmet attachment needs and affiliated
emotions stemming from her own experiences with early caregivers when she was an
infant and toddler. Although she may or may not be explicitly aware of these activated
memories and experiences, they are poised to influence how she responds to her baby
and the baby’s needs. Mothers who are at high risk for mental health and substance use
disorders are likely to have experienced disruptions in their own early attachment re-
lationships that predispose them to difficulties in mentally anticipating the baby’s ar-
rival (e.g., overly firm or idealized expectations for themselves or the baby, absence of
emotional investment in the relationship, or ambivalent or aversive feelings toward the
baby). Ideally, the mentalization-based intervention begins during pregnancy, when
there is time to establish a trusting alliance and explore the mothers’ thoughts and emo-
tions about the pregnancy and the baby before the baby arrives. It is not always possi-
ble, though, to engage substance-using mothers in treatment at the time of pregnancy.
Mothers may realistically believe that accepting professional help will lead to losing
child custody. They may also be engaged in idealizing the mother-baby relationship
during pregnancy and not anticipate the stresses of caring for an infant until after the
birth. Often, it is when infants turn 18 months of age and begin to strongly express
their own individual preferences that the mother’s tolerance shifts to an aversive stance.
It is at this juncture that many mothers will begin seeking support for parenting stress.
With representations of the baby and the self-as-caregiver more firmly established, a
more intensive therapy may be required to catch up with the mentalization work that
was missed during the first 2 years.
Intervention Format
Mentalization-based interventions for high-risk mothers of infants and toddlers are
currently being developed using individual, dyadic, group, residential, outpatient, and
home visit formats. The wider the range of settings prepared to use this approach, the
greater the continuity of treatment as the mother transitions from one provider to the
next. In our clinical observations, each format has specific advantages (and disadvan-
tages). Individual and dyadic work promotes the closest therapeutic alliance and the best
chance for the clinician to understand the complexity of the dyad’s context, relation-
ship, and individual characteristics. The group format can serve several critical func-
tions. Mothers with substance use problems must remove themselves from unsafe or
craving-inducing relationships. They also may not experience conventional organiza-

tions (e.g., churches, schools, or clubs) as sources of emotional support when they most
need it. At the same time, their compromised mentalization capacities may limit their
skills in forming new relationships. The group format—especially in conjunction with
individual therapy—provides an immediate context for social support, a venue to prac-
tice mentalization about relationships with other adults, and a chance to improve men-
talization skills. A residential format provides a microcosm for family life and relation-
ships where problems with mentalization in everyday circumstances can be addressed
in the moment with skilled clinicians. An outpatient format allows patients to enhance
mentalizing skills in a clinical setting and practice these new skills in their home family
setting. Outpatient settings also provide critical step-down support from more inten-
sive treatments. A therapeutic home milieu provides the best opportunity for developing
skills that will transfer directly to the dyad’s future everyday life. The home visit is per-
haps the most challenging format for implementing mentalization-based therapy with
mother-baby dyads. The therapist has the least amount of control over the treatment
environment in a setting where anything can be encountered, including other family
members coming and going, distracting noises and conversations, chaotic activity, and
no space to sit quietly and think reflectively. At the same time, home visits provide a
wealth of information about the dyad’s social and physical context that can accelerate
the clinician’s understanding of intrapersonal and interpersonal dynamics. With careful
planning and attention to safety, the home environment can also serve as a productive
therapeutic milieu.
Conclusion
A mother’s capacity to understand and respond to her baby as if the baby is capable of hav-
ing thoughts, wishes, intentions, and feelings has broad implications for the baby’s subse-
quent psychological well-being and interpersonal development. When this seemingly
simple capacity becomes impaired, the negative implications for the baby are profound.
Interventions in which therapists are trained to help mothers recognize and interpret the
meaning of their own internal mental and emotional experiences as well as their infant’s
have the potential to change mother-infant relational quality for high-risk dyads where di-
dactic and behavioral interventions have failed to bring about change. For mothers with
histories of substance abuse, the capacity to recognize and understanding the meaning of
difficult or negative emotions in themselves and their young children (and thus remain in
a regulated state) has the potential to prolong abstinent periods and avoid the potentially
devastating consequences of a relapse. Until now, the clinical and research domains of sub-
stance abuse and child development have seldom collaborated to develop treatment mod-
els for mothers and babies that are informed by the mechanisms of parenting stress and
relapse. Mentalization theory has now shown its potential to bridge that gap.
Suggested Readings
Kay A, Taylor TE, Barthwell AG, et al: Substance use and women’s health. J Addict Dis 29:139–
163, 2010
Lester BM, Lagasse LL: Children of addicted women. J Addict Dis 29:259– 276, 2010
Schindler A, Thomasius R, Sack P, et al: Attachment and substance use disorders: a review of the
literature and a study in drug-dependent adolescents. Attachment Hum Dev 7:207–228,
2005
Strathearn L, Fonagy P, Amico J, et al: Adult attachment predicts maternal brain and oxytocin
response to infant cues. Neuropsychopharmacology 34:2655–2666, 2009
Volkow ND, Fowler JS, Wang G: The addicted human brain: insights from imaging studies.
J Clin Invest 111:1444–1451, 2003
CHAPTER 14
Eating Disorders
Eating disorders indicate severe impairments in mentalizing. Few symptoms create

stronger reactions in therapists than those of eating disorders, particularly anorexia
nervosa, and few conditions require more forbearance and self-questioning. Working
with patients with compromised mentalizing tends to compromise the therapists’ men-
talizing, with the risk of enactments, ineffective treatment, or iatrogenic effects. Eating
disorders are challenging for mental health practitioners in both practical and intellec-
tual terms. In this chapter, the paradigm of mentalizing (Allen et al. 2008) will be ap-
plied to eating disorders in an attempt to further both understanding and clinical
practice.
The authors would like to thank the clinicians participating in the multicenter treatment and re-
search project “Minding the Body,” administered by Regional Services of Eating Disorders,
Oslo University Hospital. As an author of this chapter, Finn Skårderud is financially supported
by the Norwegian Non-Fiction Writers and Translators Association.
347
Let us begin with an example. Distorted body image is a well described, but less well
understood, clinical phenomenon of eating disorders. An emaciated patient may experi-
ence herself or himself as big and fat. Such experiences are current, often strongly held,
and difficult to negotiate with. In dialogue, the patient may convey that this sensation is
particularly strong in connection with negative affects, like fear, sadness, and anger (i.e.,
feelings are experienced in the physical realm, and one “feels with the body”). The same
person may have problems when asked to elaborate on inner states. With reference to the
concept of mentalizing, this represents a major impairment.
Peter Fonagy and colleagues (2002a) describe impaired mentalizing and bodily
concretizing in eating disorders in this way:
When psychic reality is poorly integrated, the body takes on an excessively central role
for the continuity of the sense of self (p. 405).
Not having a clear sense of themselves from within, [individuals with eating disorders]
need to find a sense of the self through getting other people to react to them, and through
treating themselves as objects, literally rather than metaphorically, because the self is ex-
perienced as a physical being without psychological meaning (p. 406).
In this chapter, we aim to present an outline for a psychodynamic psychotherapy

for persons with eating disorders, using the concept of mentalizing to provide an intel-
lectual framework. Currently, cognitive-behavioral therapy (CBT) traditions dominate
the treatment of eating disorders. This prevalence is particularly notable in the treat-
ment of bulimia and binge eating. The strength of the CBT orientation across many
clinical areas rests on the pragmatic nature of the approach, not least owing to the ex-
cellent manuals developed to support the implementation of the treatment. However,
this practical orientation sometimes comes at the expense of comprehensive theoretical
accounts, at least in relation to some clinical problems. In unskilled hands, this can lead
to practicism, literally working to a manual, without sufficient conceptual tools to mod-
ify one’s approach to therapeutic encounters appropriately according to individual cli-
ents’ needs. Here we present examples of clinical stances, techniques, and structures
that have the potential to enhance mentalizing in patients with eating disorders. Hence,
this chapter is to be considered as an outline for a mentalizing-based approach to eating
disorders.
We are convinced that treatment innovation needs to be informed by an under-
standing of the processes underpinning psychopathology if therapy is to be genuinely
therapeutic. This treatment innovation can then in turn be subject to empirical inves-
tigation. Treatment should be tailored (Fonagy and Bateman 2006a; Kazdin 2004). To
establish a basis for our clinical approach, we will first describe the psychopathology of
eating disorders by using the language of the mentalizing model. We understand these
disorders as manifestations of an underlying self-disorder. This underlying disorder
should be the central focus of psychotherapy. We will describe how the core psycho-
pathology of severe eating disorders may be understood as a distortion of mental func-
Eating Disorders 349
tion that is both more profound and less specific than distortions of cognitive schemas
related to body shape and weight: a distortion that entails dysfunction in broad sections
of social cognition (see Sharp et al. 2008) and that may be described as a consequence of
forms of impaired mentalizing.
Mentalization-based treatment (MBT) for eating disorders of course aims to re-
duce symptoms. But it also aims to enhance the psychological and social competences
that are involved in understanding both one’s own and other people’s minds. The es-
sence of MBT is its systematic attentiveness to achieving such understanding and,
hence, improved affect regulation. In a mentalization-based treatment approach to eat-
ing disorders, the main priority is not content, but function and activity: minding minds as
a competence. Patients are stuck in their view of psychological and corporeal reality. We
aim to enrich their reflective functioning by playing with their embodied realities.
A major challenge in working with eating disorders is the establishment of a good
therapeutic alliance. Again, anorexia nervosa often appears to be the most complicated
case. Patients rarely seek treatment on their own initiative. Their motivation to change
is generally low and/or unstable (Geller et al. 2001), and despite the impression of im-
proving quality of available treatments for eating disorders, research data from the last
decade suggests an increase in patients dropping out of therapy (Campbell 2009). The
strength of a mentalization-based therapy is that this approach more than most other
therapeutic traditions (e.g., cognitive-behavioral therapy) has a systematic and explicit
focus on how to work with the therapeutic relationship. Psychotherapy provides an op-
portunity to experience and to learn from failures in mentalizing that occur here and
now, in the therapeutic encounters. With roots in attachment theory, and informed by
both clinical experience and neuroscience, the therapeutic meeting is understood as ac-
tivating the attachment system. Optimal activation harnesses brain processes, making it
possible to remove the dominance of past-based constraints on the present and to re-
think and reconfigure intersubjective networks (Fonagy and Bateman 2006a).
We use the example of eating disorders to illustrate a somewhat broader use of the
mentalization concept to encompass failures of mentalization related to bodily func-
tion. Via the concept of embodied mentalizing, we suggest how the body can “fill in” in
moments of mentalizing failure. We elaborate the term to cover mental states related to
a person’s physical being, including perceptions and cognitions about one’s own bodily
and sensorimotor states.
Eating Disorders as a Clinical Challenge

In a review on anorexia nervosa, Fairburn (2005) notes that treatment outcome is generally
poor. He provokes the clinical and scientific field by asserting that, until more effective
treatments for anorexia are developed, it is waste of time and money to set up randomized
controlled studies. Despite research efforts, there is a striking paucity of empirical evidence
supporting any method of treatment for anorexia nervosa (Woodside 2005). The current
situation is slightly better for bulimia and binge eating disorder, although therapeutic effi-
ciency should not be overrated (Clinton 2010; Gowers et al. 2007).
The clinical picture is complicated by many factors. Severe eating disorders may
last for decades, cause patients to retreat from normal social and family activity, and de-
stroy and break up families—and anorexia has the highest mortality rate of all psychi-
atric disorders. Eating disorders most often start during adolescence, which is a critical
phase for many, with changes occurring to both physiology and identity. In addition, it
is a period when the brain is still immature. The psychological consequences of im-
paired somatic health result in an increase in symptoms. In Table 14–1, we sum up some
of the major challenges.
Eating Disorders and Personality Disorders

Because MBT was originally developed for borderline personality disorder (Bateman
and Fonagy 2004, 2006b), the pivotal question is: How should therapeutic approaches
originally developed for borderline patients be modified to be optimal for persons with
different subtypes of eating disorders? Despite important differences, there are striking
similarities in the modes of experiencing psychic reality in borderline personality dis-
order and eating disorders.
Comorbidity of eating disorders and personality disorders is well recognized; how-
ever, it may not be as common as is often thought. For example, Godt (2008) examined
545 consecutive patients with DSM-IV-TR (American Psychiatric Association 2000)
eating disorders for personality disorder diagnoses on Axis II. Although 29.5% of the
sample met criteria for one or more personality disorders, avoidant personality disor-
der, rather than the dramatic Cluster B disorders, was the most common (12.1%). Only
in the group with bulimia nervosa was the prevalence of borderline personality disorder
significantly elevated (10.8%). If the proportion of eating-disordered patients with co-
morbid Cluster B personality disorders is not as large as is often assumed in clinical ac-
counts, then we may be better advised to consider a loosely coupled relationship
between the two diagnostic entities rather than a direct causal relation. For example,
personality types may create vulnerability for eating disorders via genetically deter-
mined personality traits (e.g., perfectionistic, obsessional, ineffective traits in anorexia
nervosa and impulsive, affectively unstable traits in bulimia nervosa). There may be
some mechanisms underlying personality disorders that create vulnerability for eating
disorders in such a way as to imply some common mechanisms, but in general there
seems little support for claiming a shared etiology.
In summary, it seems to us clinically more pertinent to make no assumptions about
the comorbidity of eating disorders and borderline personality disorder, but instead to
give attention to the particular psychopathological aspects of eating disorders from the
perspective of mentalization. It is tempting to state that severe forms of eating disor-
ders represent their own phenotype of personality disorders.
TABLE 14–1. Challenges in working with eating disorders
Patients
Patient’s lack of insight into illness
Restorative function of symptoms, contributing to lack of motivation for change
Physiological symptoms of malnutrition and chemical disturbances
Psychological symptoms of malnutrition and chemical disturbances
High risk of dropout and disrupted therapeutic relationship
Relational styles hindering therapeutic alliances
Therapists
Own difficulties with understanding the psychology of eating disorder
Inability to develop therapeutic alliances
Need for forbearance and self-questioning because of patient’s symptoms and behavior
High risk that patient’s symptoms and behavior will create strong countertransference reactions
Risk of overreactions (e.g., aggression or rejection) due to such intense emotional reactions
Risk of iatrogenic effects
Eating Disorders as Impaired Mentalizing

In this section, we link the conceptual model of mentalizing to the clinical phenome-
nology of eating disorders. We start with a description of eating disorders as disorders
of self- and affect regulation.
Eating Disorders as Self-Disorders

In early psychological and particularly psychoanalytic models of eating disorders,
symptoms were interpreted as messengers referring to specific psychological realities.
Symptoms were understood in a fairly precise and defined way. Conflict and object re-
lational models gave an impression of knowing what a symptom actually indicated in
terms of underlying psychodynamics. The symptom was representative of an internal
state of mind with specific meaning.
The mentalizing model is an example of a change in our understanding of the
mind’s function. Symptoms are still seen as conveying symbolic and dynamic meaning,
but their invocation derives more from an emergent need to drown out painful self-
states. Hence, when speaking of the mind’s symbolic or mentalizing function, it is with
far more emphasis on mental representations as processes and capacities than on the
meaning of symptoms and signs (Fonagy et al. 1993). This represents an increasing
interest in the how of representation—awareness of impaired symbolic or mentalizing

capacities—at the expense of the what of representation—literal interpretations of
meanings. Self-deficits are manifested in impairments of one’s own sense of cohesion, vi-
tality, self-soothing, sense of well-being and security, tension regulation, and self-
esteem regulation. Symptoms are then viewed as potentially restorative—as attempts at
recovering cohesion, vitality, and self-regulation (Goodsitt 1997; Skårderud 2007a,
2007b).
On the basis of phenomenological observation, sound evidence exists to support
categorizing eating disorders as disorders of regulation (e.g., Guarda 2008; Skårderud
and Sommerfeldt 2009). This view opens up the possibility of integrating different ex-
planatory and descriptive models in medicine and psychology. Advances in neurobiol-
ogy, developmental psychology, theories of affect, research on infant development,
trauma research, new concepts of personality development, and current concepts in
psychoanalysis have all contributed to conjectures concerning a new and distinct con-
ceptual entity: self-regulation in general and affect regulation in particular. The tradition
surrounding mentalizing is a prominent example of this general intellectual trend, with
an emphasis on how insecure attachment can contribute to impairment of regulation.
For a review of studies on eating disorders and attachment measured by the Adult At-
tachment Interview, see Zachrisson and Skårderud (2010). In general, the prevalence of
the “secure” attachment classification is low across all diagnostic subgroups of eating
disorders.
As well as individuals with such acquired deficits in affect regulation, however, there
are individuals with inherited deficits in their neurobiological functions that may predis-
pose them to affective dysregulation. Indeed, we are increasingly aware that a general vul-
nerability to environmental influence may have a genetic basis (Barry et al. 2008; Belsky
2006). Acquired and/or inherited deficits may be involved in the genesis of the problems
of emotion regulation underlying the eating disorders (Taylor et al. 1997).
Persons with eating disorders may attempt to drown out their anguished feelings
by frantic self-stimulatory activities. This could be seen as a common denominator to
such behaviors as starvation, bingeing, vomiting, and hyperactivity. The symptoms can
be seen as misguided attempts to organize emotions and other internal states more
meaningfully. The absence of reliable internal self-regulation may cause the eating-
disordered patient to feel inadequate, ineffective, and out of control. Realms of dysreg-
ulation are shown in Table 14–2.
Eating Disorders and Psychic Modes of Reality

In this section, we describe the prementalistic modes of reality that can be experienced and
described in eating disorders, with explicit reference to the tradition of mentalizing. We
also discuss corporealities: the ways in which different modes of realities involve bodily
experiences.
TABLE 14–2. Realms of dysregulation
• Food and body
• Emotions
• Relationships
• Therapeutic relationships
Psychic Equivalence
Psychic equivalence, as a construct, means equating the internal with the external
world (Fonagy et al. 2002a). Psychic equivalence covers one central aspect of the phe-
nomenological essence of embodiment in eating disorders, the bodily concretization of
inner reality. The concept is based on developmental psychology. The infant’s and the
young child’s early awareness of mental states is characterized by the equation of the in-
ternal with the external. What exists in the mind must exist out there, and what exists
out there must invariably also exist in the mind. Psychic equivalence, as a mode of ex-
periencing the internal world, can cause intense distress, since the projection of fantasy
to the outside world can be terrifying.
Eating disorders most often start during adolescence, which, for many, is a critical
phase characterized by both physiological changes and changes in identity. Body mod-
ifications such as controlling the appetite may then represent an effort to maintain in-
ner control and cohesion. There is psychic equivalence between the experience of body
shape and its concrete parameters: to be thinner is felt to be superior and therefore is
superior. Mental states, unable to achieve representation as ideas or feelings, come to
be represented in the bodily domain. “Physical attributes such as weight come to reflect
states such as internal well-being, control, sense of self-worth, and so on, far beyond the
normal tendency for this to happen in adolescence” (Fonagy et al. 2002a, p. 405).
Skårderud (2007a) gives numerous examples of psychic equivalence based on tran-
scripts from research interviews and therapy sessions with adults with anorexia nervosa.
Sensorimotor experiences and bodily qualities and sensations such as hunger, size,
weight, and shape are physical entities that function as sources for metaphors for non-
physical phenomena. In psychic equivalence, bodily metaphors do not function mainly
as representations, capable of containing an experience, but as presentations, experienced
as concrete facts here and now, and are difficult to negotiate with. The problem is to
distinguish between the metaphor and the object or phenomenon that is metaphorized.
The “as if” of the metaphor as a figure is turned into an “is.” Psychic equivalence is too
real. The psychic pain for the patient is that he or she is trapped in this harsh corpore-
ality, here and now, and does not satisfactorily mentalize how his or her body functions
as a metaphorical source for emotional life, and vice versa.
Clinical examples. In the opening paragraph of this section, we illustrated psychic

equivalence with reference to the clinical phenomenon of body image distortion.
Someone who is unable to control difficult emotions may experience a bodily expan-
sion, perceiving him- or herself as getting fatter and bigger. Here we bring other clin-
ical examples:
ELISABETH (anorexia for 20 years):

The idea of mixing different types of food scares me. The sight of too many types
of food on my plate and the idea of them mixed together in my stomach induce a
sense of chaos in me. I have to have control of my plate to have control in my life.
VERONICA (bulimia):
When I went home from work yesterday, I thought about bingeing. And when I had
thought about overeating, it was already a fact, as if I already had done it. So I rushed
home to do it.
SARAH (frequent vomiting and misuse of large doses of laxatives):
I’m so confused. It is simply too much for me. I have to reduce. I am completely
filled up. In some way or another, I do have to empty myself.
ANNA (frequent purging by vomiting):
Some days ago I should have had a meeting with my boss. I was anxious about this.
Then I decided to vomit. I couldn’t stand having the lunch in my stomach. I cannot
have anything in my stomach, because then I cannot concentrate. I need to be
empty to feel alert.
LISA (bingeing episodes for more than 20 years):
I was tempted the whole day to overeat, but fortunately I was able to resist. How-
ever, when I went to bed at night, the mere thought of eating gave me a feeling of
being oversized. Had I been eating all the same? No, but the sensation was over-
whelming.
Possible consequences for treatment. These examples demonstrate an impoverished

ability to symbolize. For the therapist, psychic equivalence may create a frustrating dif-
ficulty in the attempt to engage the patient and establish a fruitful working alliance.
The patient is caught up in her or his own reality of bodily concreteness, a prisoner of
“is,” while the therapist is trying to engage the patient in a meeting in a meta-language
of “as if,” about emotions, cognitions, and important relations.
To sum up, we maintain that the concept of psychic equivalence enriches our un-
derstanding of the psychopathology of eating disorders, particularly the phenomenon
of bodily concretization. And vice versa: eating disorders provide examples that give
body, literally, to the concept of psychic equivalence.
Pretend Mode
From a developmental perspective, “pretend” represents an alternative mode of expe-
riencing reality for the child. When the child is playing, it is “playing with reality”
(Fonagy and Target 1996a; Winnicott 1971). A wooden stick may be experienced as a
magic wand. It is a decoupling of internal from external reality (Fonagy et al. 2002a). In
a clinical perspective with adolescents and adults, this concept refers to dissociation be-
tween internal state and outside world. In psychotherapeutic work, words with refer-
ence to inner states are commonly used, and the therapist expects these to have a real
impact on the patient. But while the patient is in pretend mode, the words may be un-
derstood, but they do not have such real impact. Ideas do not form a satisfactory bridge
between inner and outer reality, and affects do not accompany thoughts. As Bateman
and Fonagy (2004, p. 70) write about therapy with borderline patients:
“Therapy” can go on for weeks, months, sometimes even years, in the pretend mode of
psychic reality, where internal states are discussed at length, sometimes with excessive
detail and complexity, yet no progress is made, and no real understanding is experienced.
Clinical example. The following example illustrates a patient operating in the pre-
tend mode:
Veronica is frustrated in the therapeutic sessions. She says that she is not moving forward.
During the sessions she is loquacious, but she sometimes describes situations inconse-
quentially, often contradicting herself. When the therapist stops her and invites her to
clear up the contradictions and also to describe her actual emotions, she becomes even
more frustrated. She has problems with connecting to actual emotions, and after a while
resorts to words like “confused,” “vague,” “opaque,” or “obscure.”
Of particular relevance for eating disorders are Veronica’s comparable difficulties in
describing her bodily sensations. On the one hand, she says that she detests her body; she
uses her index finger to point down to her thighs to indicate that her body is an inten-
sively negative object. But she also expresses that she does not experience it as “hers,” but
rather as “an alien shell on the outside of her.” In this case, the dissociative experiences in
pretend mode affect both her emotions and her bodily sensations.
Possible consequences for treatment. Pretend mode is a prementalistic mode often

covering feelings of emptiness and meaninglessness. Although the therapeutic dialogue
may appear to be relevant, given the topics of emotions and thoughts, it has minor ef-
fects when conducted in this mode. This represents pseudomentalizing. In the therapeu-
tic relationship, this may lead to endless inconsequential talk, and a probable counter-
transference reaction is the therapist feeling detached, confused, or tired. While
psychic equivalence is too real, pretend mode is too unreal.
To sum up, pretend mode is a highly useful conceptual tool to widen the understand-
ing of ineffective therapy. The alexithymic patient (see Alexithymia section later in this
chapter) may lack words for his or her inner life, while the patient in pretend mode has
words, but they are not yet his or her own. What has been described as outer-directedness,
with the patient trying to interpret and satisfy other persons’ needs (Buhl 2002; Skårderud
2007c), may also lead to hypermentalizing. The combination of pseudomentalizing and
hypermentalizing may contribute to confusion in the therapeutic relationship.
Teleological Stance
Telos in Greek means “goal” or “purpose.” The teleological stance refers to a develop-
mental phase in childhood during which expectations concerning the agency of the self
and the agency of the other are present, but are formulated in terms restricted to the
physical world (Fonagy et al. 2002a; Gergely 2001). There is a focus on understanding
actions in terms of their physical, as opposed to mental, outcomes: “I don’t believe it
unless I see it.” The teleological stance is a highly relevant concept that can deepen the
understanding of the physicalization of life and relationships.
Few clinical conditions illustrate this concept better than eating disorders. In the
world of psychiatric disorders, eating disorders represent a special case, insofar as one
can identify an initial active wish for change in the biographies of the patients: the pa-
tients want to change themselves in terms of self-esteem and social acceptance, and
they seek to achieve these changes physically, by modifying their bodies. Hence, the te-
leological stance may be a useful concept for understanding the bodily concretized am-
bitions for self-improvement in eating disorders.
Clinical examples: self-referent teleological stance. The patient has low self-esteem,
and his or her solution is to lose weight. In the personal psyche, and also, to a degree
that should not be underestimated, in the cultural context, losing weight teleologically
represents mastery and self-control. A general feeling of distrust is expressed as distrust
about something specific: for example, the accuracy of weighing scales and the true
number of calories or grams in food. The eating-disordered patient might also be a per-
son who practices self-harm, in which internal pain is concretized and regulated by
physical pain. We return to Elisabeth, who, in descriptive terms characteristic of psy-
chic equivalence, expressed how too many kinds of food on the plate provoked a sense
of chaos. She has a teleological solution to her chaos:
ELISABETH: I gradually understood that taking control over food was a way to take con-
trol over my overwhelming worries, my restlessness, all my anxieties about myself;
and simply my need to be somebody.
We have already postulated how such a statement represents poverty in symboliz-

ing, in the sense of an equivalence between inner and outer realities. But there is also a
kind of richness in what is being symbolized. It is striking how, for Elisabeth, emptying
and organizing her plate refers to mental control as well as to affect regulation and a
sense of identity. This is an example of the polysemy of the body. Polysemy means that the
sign refers to multiple meanings (Johnson 1987; Ricoeur 1976). In this chapter we pro-
pose that body rituals, such as self-starvation, may have a multitude of symbolic mean-
ings. In doing so, we oppose many of the psychological and psychodynamic traditions
that have stated that eating-disordered symptoms convey a specific meaning, such as
maturation anxiety or anti-sexuality (Skårderud 2007d; Skårderud and Nasser 2007).
The following quotes from patients elucidate these phenomena:
EMILY (speaks about self-starvation as a body ritual about purity):

My anorexia was there when everything else seemed unpredictable, excessive, in a
frantic state. Its austerity, its plain, straightforward, and concrete nature infused
the unsure with something safe—it served as a channel to something more basic,
minimalist, uncluttered, pure.
HANNAH (refers to her daily body checking):

When I don’t have access to my bones and skeleton, when there is something be-
tween what I feel when I touch myself and my inside, then I get scared. I don’t like
it. Things are blurred.
ANNA (has reduced her body weight by half):

When I was in the hospital, admitted because of my extremely low weight, I re-
membered thinking that this is good. The old, chaotic, unhappy me is gone, and
this is a new opportunity. Now I am down to a bedrock of stability. And this time
I will be another person.
Clinical examples: other-referent teleological stance. Anna regained most of her weight,
and “the old, chaotic unhappy me” reappeared on the mental scene. Eating-disordered
symptoms were reduced, but she was tormented by her anxiety. She felt calmer and
clearer in the encounters with her therapist:
ANNA: But when I leave this room, the effect vanishes. You are good for me, and I
have great trust in you. But I wish you were a book. Now you’re more like ra-
dio. The voice disappears in the air. If you were a book, I could carry you in my
bag and pick it up whenever I wanted, read and read again, and find support.
Hannah participated in an MBT program for eating disorders. She was in favor of
the written case formulation mentioned below. The text was about her and the defined
aims and approaches in treatment. It is a shared work developed by her and her therapist,
but for which the therapist has done the main component of the work:
HANNAH: Sometimes, in the evenings when I feel terrible, I pick it up and read
it. Then I get a sense of not being completely hopeless. I am not only bits
and pieces, but a kind of story. And I am not so alone.
The eating-disordered person’s feelings of distrust may also be expressed as dis-

trust of other people, including health personnel and helpers. The patient’s fear of not
being in psychological control can lead to controlling behavior, such as checking,
double-checking, and controlling behavior toward the therapist.
In group therapy, patients may define each other by their weight, body shape, and
reports about dieting, restriction, bingeing, purging, and physical activity. Insecure
identity generates patients’ tendency to compare themselves with others in terms of

their concrete achievements and bodily qualities:
Hannah was one of those who obsessively compared her own body with those of the
other patients in the group. The therapist asked her whether she compared herself with
the two female group therapists:
HANNAH: In the beginning, yes, but not any more.

THERAPIST: Do you have any idea why not?
HANNAH: I have started to trust you.
Possible consequences for treatment. The patients’ great dependence on comparing

themselves with others—therapist, co-patients, family members, partners—is a strik-
ing illustration of the role of teleology in eating disorders. Teleological stance as a the-
oretical and clinical construct is highly relevant to understanding relationships in
general and therapeutic relationships in particular, including battles about agreements,
appointments, contracts, time, money, and attention. To the patient in this stance, for
example, if the therapist really cares, he or she is expected to show a benign disposition
and a willingness to be helpful in concrete ways, such as availability on the telephone,
extra sessions at weekends, physical touching and holding, and acts “beyond the rules.”
Hence, this stance may contribute to violations of therapeutic boundaries (Bateman
and Fonagy 2004). The patient’s attempts to control the therapist will probably stim-
ulate negative countertransference reactions.
The therapist working with patients with eating disorders should be aware that his
or her own body is being assessed and judged; this judgment may impair therapeutic re-
lationships, particularly in the initial phases. Eating-disordered patients may think that
they cannot learn to gain weight when they think that their nutritional counselor is
thinner than they are. Or how can they learn control from an obese therapist?
To sum up, teleological stance conceptualizes important aspects of psychic func-
tion in eating disorders: “I don’t believe it unless it is physical.” Teleology may repre-
sent a hindrance to traditional psychotherapeutic work. Again, the patient is trapped in
physical realms of experience. Later we discuss how the teleological stance can be ad-
dressed in the psychotherapeutic encounter.
Minding the Minds of Others

Mentalizing as a concept overlaps with the concepts theory of mind and social cognition
(Sharp et al. 2008). Social cognition is a broad concept that underpins social behavior
and has been defined as “the mental operations underlying social interactions, which
include the human availability to perceive the intentions and dispositions of others”
(Brothers 1990). In a study, Russell et al. (2009) assessed social cognition in anorexia
nervosa by examining performance on two theory of mind (ToM) tasks: Baron-Cohen’s
“Reading the Mind in the Eyes” task and Happé’s cartoon task. These tasks probe the
affective and cognitive poles of mentalizing, respectively. Forty-four female partici-
pants were recruited and completed both tasks, with concurrent clinical and intellec-
tual functioning assessment. Compared to healthy control subjects (n=22), anorexia
nervosa patients (n = 22) performed significantly worse on both tasks. The findings
broadly replicate those of limited previous research (Tchanturia et al. 2004).
There are different ways to interpret such findings of “collapse” in social cogni-
tion. Eating-disordered patients may feel excessively dependent on others for their
well-being because they are deficient in self-regulatory structure. An increased aware-
ness of others should not be confused with the mentalizing capacity to understand oth-
ers’ minds. Such patients are obsessively interpreting others’ minds, but not in precise
ways. A supplementary interpretation may include an apparently active wish to stop
oneself from social thinking, to “decouple” mentalizing. A recovered anorexic patient
described this state as:
just being very focused on what I had to do during the day and not having to think about
the things that I would have to think about normally. I had been quite introspective be-
fore. I had to drive out any mental experience and just focus on what had to be done. Not
question things. My experience of everything was rather flat and empty.
Another recovered patient described the nonsocial drive that bodily preoccupation
entails:
The self-centeredness of it was remarkable. Rather than focusing on others and thinking
of finding them attractive, I got preoccupied with my own body and trying to control it.
So rather than thinking of people, I thought of my clothes being too tight or not.
A lack of understanding of or concern for others’ point of view is perhaps one of the
clearest indicators of mentalizing failure.
Embodied Mentalizing
We introduce the concept embodied mentalizing to emphasize the corporeal aspects of
the mentalizing process. By conceptually shifting from body to embodiment, the in-
tention is to open up wider perspectives on the many possible roles of the human body
in mental life and psychopathology. Moving from body to embodiment underscores
processes more than states, and it moves beyond the physical qualities of the human
body. Embodiment is a wide concept and has to be concretized with reference to dif-
ferent theoretical discourses and clinical or experiential domains.
In this chapter, we confine ourselves to discussing the ways in which the eating-
disordered person experiences his or her own body. What we call embodied mentaliz-
ing refers to a complex and confusing picture. There may be an unduly negative focus
on the body’s exterior, combined with an inability to distance oneself from this dissat-
isfaction. In this way, the eating-disordered person is hyperembodied. At the same time,
however, the person’s awareness of bodily sensations is impaired; in this way, he or she
is disembodied. The body is emotionally and cognitively experienced more via glances,
on the weight scales, in the mirror, by measuring circumferences of limbs and counting
skin folds on the stomach, and via fantasies about being looked at by others rather than
by feeling one’s own lived body (Merleau-Ponty 1962). Papezová et al. (2005) describe
elevated pain thresholds in eating disorders, and Pollatos et al. (2008) describe reduced
perception of bodily signals in anorexia nervosa. In the language of mentalization im-
pairment and prementalistic modes of reality: corporeality in eating disorders may in-
volve experiencing one’s body as both too real (psychic equivalence) and, at the same
time, too unreal (pretend mode).
Interoceptive Confusion and Self-Deficits

We want to develop the idea of impaired embodied mentalizing, that is, patients’ dif-
ficulties in perceiving and interpreting stimuli arising in their bodies, by referring to
the work of Hilde Bruch, a seminal figure in eating disorders. As a psychiatrist and psy-
choanalyst with an extensive authorship on eating disorders, particularly anorexia ner-
vosa, Bruch (1904–1984) developed new vistas in the understanding and conceptual-
ization of the psychopathology of eating disorders (Bruch 1970, 1973, 1988; Skårderud
2009). Her work demonstrates a willingness to experiment, to challenge established
truths, and to develop new knowledge and practices. Bruch was a pioneer in developing
the psychotherapeutic approach to such disorders, with emphasis on curiosity and a
not-knowing stance. In our words, she tailored her therapeutic stance to the mentaliz-
ing capacities of these patients.
Noting that treatment results from traditional insight-oriented psychotherapy
were rather poor, Bruch concluded that the classical psychoanalytic formulations of an-
orexia nervosa were based mainly on atypical cases involving conversion hysteria. Her
conclusions were subsequently supported by Garfinkel et al. (1983), who used psycho-
metric tests to document differences between patients with anorexia and patients with
conversion disorders. The latter showed fewer pervasive psychological deficits, and
they appeared better able to use fantasy and to respond to insight-oriented psychother-
apy. Bruch regarded the psychopathology of primary anorexia as different from the
Freudian understanding of psychoneurosis and more akin to what we today would de-
scribe as narcissistic, borderline, and schizoid personality disorders (Bruch 1982/1983,
1985). In her opinion, the core problem lies in a deficient sense of self and involves a
wide range of deficits in conceptual developments, body image and awareness, and in-
dividuation (Taylor et al. 1997).
Bruch (1962) observed that anorexic patients find it difficult to accurately perceive
or interpret stimuli arising in their bodies, such as hunger and satiety, and also the phys-
iological signs of malnutrition, such as fatigue and weakness. She observed that patients
with anorexia experience their emotions in a bewildering way. In addition, she noted
that the patients were often unable to describe their emotions, with disconnections be-
tween language and the physiological, subjective, feeling components of emotion (Tay-
lor et al. 1997):
HANNAH: Fuck! There are no words for how I feel. And since there are no words, it can-
not exist. And nobody can understand. I’m confused. And I hate it when you con-
tinue to ask questions about my feelings. I am not able to answer.
The lack of awareness of inner experiences and failure to rely on feelings, thoughts,
and bodily sensations to guide behavior may contribute to an overwhelming sense of
not living one’s own life (Bruch 1962, 1973). The clinical picture presented is the pa-
tient’s effort to compensate for these underlying deficits. Bruch (1973, p. 24) defines
anorexia nervosa as a “struggle for control, for a sense of identity, competence, and ef-
fectiveness.” She advanced a developmental model to explain the psychological deficits
in eating-disordered patients (Bruch 1973). In her opinion, interoceptive confusion is a
consequence of consistently poor attunement between the innate needs of the child and
the responses of the caregivers in the environment. The parents’ misinterpretation of
the infant’s nonverbal, presymbolic communications, and their “direct mislabeling of a
child’s feeling state, such as that he must be hungry (or cold, or tired), regardless of the
child’s own experience..., (leads) a child to mistrust the legitimacy of his own feelings
and experiences” (p. 62).
In the terminology of contemporary developmental psychology and psychoanaly-
sis, this parental misinterpretation could be described as “incongruent mirroring”
(Gergely and Watson 1996). For Bruch, the person with anorexia is therefore one who
does not know, because he or she is a person who has not learned to distinguish. The rela-
tionship between experience and category has not been established in a valid manner.
Bodily experiences are miscategorized. The child or patient who does not know his or
her own feelings and needs is close to experiencing loss of his or her own reality. The
child who does not know what he or she feels and needs can be close to what is called
impaired reality testing. Such descriptions of dissociation from mental states are close
to the concept of pretend mode.
Reconceptualizing Body Image Distortion

Bruch (1962) was also the pioneer who illuminated the phenomenon of body image
distortion. This is defined as a significant disturbance in the way in which one’s body
weight or shape is experienced (American Psychiatric Association 1994) and is an es-
sential diagnostic feature of anorexia nervosa. Although body image and its disturbance
in eating disorders has been the subject of a large number of studies, there is still no
consensus about the specific nature of the problem. To a great extent, body image dis-
turbance has been treated as a stable trait that can be studied outside the context in
which it occurs. However, Slade and Brodie (1994) concluded that anorexic patients do
not have a fixed and implacable distorted image of their own bodies; rather, they have
“uncertain, unstable and weak” body image (p. 41). There is also evidence that body ex-
periences fluctuate in real-life situations and contexts (Rudiger et al. 2007). In our own
research, we describe how body experiences can also fluctuate with affective states (Es-
peset et al., in press): for example, a person with anorexia may feel fatter when she is
frightened, as we illustrated in the opening paragraph of this chapter. With reference to
the paradigm of mentalizing, there is an interesting parallel between the impairment of
mentalizing caused by negative affects in borderline patients (Bateman and Fonagy
2004) and the impairment of embodied mentalizing caused by similar affects in eating-
disordered patients.
To sum up, Bruch’s clinical and theoretical descriptions of eating disorders antici-
pated later models of impaired mentalizing, not least by stressing how such compro-
mised competences affect both one’s own mental states (minding one’s own mind) and
somatic sensations (minding one’s own body). The mentalizing model allows a re-
conceptualization of body image distortion as a combination of psychic equivalence
(hyperembodied states in which inner life is experienced as too real and immediate in a
concrete way) and pretend mode (disembodied states disconnected from both affects
and somatic stimuli).
Mentalization-Based Therapy
for Eating Disorders
In this section, we outline a mentalization-based approach to eating disorders. The
main background for this part of the chapter is an ongoing treatment and research
project, “Minding the Body,” administered by one of the authors (F.S.) at Oslo Univer-
sity Hospital, Norway. Different centers in the Nordic countries are participating, and
all except one, an inpatient facility, deliver MBT for eating disorders as intensive out-
patient treatment. Here we present the structure of the treatment, describe some men-
talizing interventions more specifically designed for eating disorders, and discuss the
main clinical challenges. It is a basic assumption of MBT that interventions should be
tailored to the mentalizing capacities of the patient, but eating-disordered patients as a
group tend to highlight some particular issues.
Structure of Treatment
The aims of treatment are to stimulate mentalizing through a combination of
treatment models, strengthen therapeutic alliances, and prevent dropout. The mental-
TABLE 14–3. Treatment structure
• Individual therapy
• Group therapy (implicit mentalizing groups)
• Psychoeducational groups (explicit mentalizing groups)
• Case formulation
• Medical management
ization-based treatment program for eating disorders is structured as a combination of

individual therapy, group therapy, psychoeducational work in groups, the active use of
written case formulations, and medical management. Patients are offered a 2-year pro-
gram with weekly group therapy organized as a slow open group, initial weekly indi-
vidual therapy with a gradually lowered frequency, and a limited number of psychoed-
ucational group sessions. Table 14–3 shows the structure of treatment.
In addition to the traditional MBT format (Bateman and Fonagy 2004, 2006b), pa-
tients with eating disorders require regular somatic assessment. An agreement between
a medical doctor, most often external, and the treatment program about how to divide
responsibility is a precondition for participation. Depending on capacity and the pa-
tient’s wishes, nutritional counseling may be supported. In addition, family or relation-
ship crises may lead to a limited number of family or couples therapy sessions, and
other forms of crisis such as suicide attempts or increased frequency of self-harm may
lead to intensified contact for a limited time. All therapy sessions are videotaped.
Individual Therapy
Most patients prefer individual therapy; patients often describe the group as very chal-
lenging and the individual context as safer. Some, however, feel the group is safer, in a
negative sense, as a possible place to “hide” by means of silence, unwavering courtesy,
withdrawal, or passivity, and they experience individual therapy as more demanding be-
cause there are only two in the room. In individual sessions we base the work on MBT
principles in general and on those more specifically developed for eating disorders, as
we describe later. In the treatment model, we practice openness between the different
treatment contexts; for example, the individual therapist is informed about the patients’
ways of functioning in the group. In this way the individual sessions are also an oppor-
tunity for us to work with the patient on how to use the group in optimal ways.
Group Therapy
These weekly groups are also called implicit mentalizing groups. As indicated above,
many of the patients find the group sessions the most challenging part of the treatment
program. This makes sense in terms of some of the psychological traits frequently ob-
served in eating-disordered patients, such as outer-directedness with an obsessive pre-

occupation with others’ ideas about oneself and one’s body (Buhl 2002; Skårderud
2007c). Hence, the group treatment context inevitably activates the core pathology of
eating disorders as self-disorders. Thus, while groups are very useful, they are challeng-
ing to run. Some moderate modifications in therapeutic stance from the MBT model
for borderline patients (Bateman and Fonagy 2004, 2006b) are described later in this
chapter.
Psychoeducational Groups
These groups are also called explicit mentalizing groups. The number of sessions is lim-
ited (5–8), and the topics of each session are set and presented by the therapist. In the
Oslo University Hospital the first session is always about mentalizing, with emphasis
on communication, misunderstanding, difficulties in reading other people, and diffi-
culties in knowing oneself. The therapists present the topic briefly and with a simple
language and then ask the participants to contribute their own examples. For a pro-
posed list of topics, see Table 14–4.
There are various options for when in the treatment process to run these groups.
One is to use this context as a pretreatment, both to introduce the patients to the treat-
ment program and to further assess them. We have chosen to integrate these pedagog-
ical sessions in the first months of the treatment program so the patients can share
anxieties about treatment and consider challenges and difficulties of therapy. In these
groups we try to establish and maintain a playful atmosphere, not too “hot” or emo-
tionally intense. The emphasis is on a pedagogical stance (Csibra and Gergely 2006),
with the therapists taking an active role both in sharing ideas and involving all partic-
ipants. A concrete challenge for the therapists is to make these group sessions different
enough from the weekly group therapy, with the weekly group intentionally dealing
more with personally challenging (“hotter”) material. It is our experience that the pa-
tients are generally very supportive of this format.
Case Formulations
In the Oslo project we put great emphasis on the elaboration of a written formulation
at the beginning of the treatment. Case formulations have their historical roots in psy-
chodynamic short-term treatments, arising out of the need to create a sharp focus for
treatment. Gradually, the use of case formulations has been implemented in long-term
treatments, too, and has been incorporated into other psychotherapeutic traditions. In
essence, all types of treatments have a formulation, but it is most often implicit, form-
ing part of the therapist’s own way of understanding the patient. It becomes explicit
when it is written.
There is no agreed definition of a case formulation, and the literature has proposed
various definitions. But essentially, different approaches cover the same scope, which is
descriptive, prescriptive, and predictive aspects of the case. The formulation tries to orga-
TABLE 14–4. Psychoeducational groups: proposed themes
• Mentalizing
• The therapeutic model
• The why and how of group therapy
• Nutrition and somatic aspects of eating disorders
• Emotions
• Attachment
• Personality traits and eating disorders
• Embodied culture
nize the clinical material into an essence so that one can define goals and ways of reach-
ing these goals. It should answer the questions “Why does the patient go into therapy?”
and “What should change, and how?” Case formulation succinctly describes the chief
features of the case as well as encapsulating the diagnosis, etiology, and treatment op-
tions. This part of the treatment structure provides a framework for linking theory, the
assessment of the individuals’ needs and strengths, therapeutic approaches, change
processes, and desired outcome (Bateman and Fonagy 2006b).
In the MBT program for eating disorders, it is vital to share the written case for-
mulation with the patient. More than that, the formulation should be the product of
collaborative work between patient and therapist, put together in such a way that there
are “two minds in the formulation.” The formulation includes not only descriptions of
the patients, but also the perspectives of the therapist or the team. Hence, the case for-
mulation is not only our perspective on the patient as “a case,” but also a summary of
common perspectives about collaborative work in treatment. It may be better named a
working formulation or document of collaboration.
After the assessment interviews, the therapist writes the first outline of a formula-
tion, and the patient is invited to revise the text, either by written or verbal comments.
The formulation is written in simple language, referring to the patient by first name
and as she or he. In this way, we stimulate patients to see themselves from the outside.
The formulation aims to link historical experiences and attachment history to actual
problems, mentalizing impairments, symptoms, and relational style, and to address
how this linkage should be worked with in the different therapeutic contexts. In our
cases of eating disorders, we particularly emphasize impairments in embodied mental-
izing and the possible meanings and functions of symptoms, such as their role in affect
regulation. Here are two brief excerpts from Hannah’s case formulation:
Hannah describes feeling “bigger” in new situations where she is uncertain and/or when
she is with more than one person. How she feels about her body depends on her weight,
what she has eaten, or whom she is with. Thighs and stomach are the body parts that
Hannah feels change the most according to her emotions. She compares her own body
with the bodies of others. For Hannah it is important to “be thinnest.” If she feels bigger
than others, she has a tendency to withdraw and cancel appointments.
Hannah finds it difficult to be open and get close to people, including group members
and therapists. When she is more open about her feelings, she can afterwards worry
about what the others think of her. Then she can get anxious and withdraw by becoming
silent or stopping coming to sessions. Both group therapists and the individual therapist
should be aware of this, to prevent Hannah from dropping out of treatment. She has a
history of dropping out. Hannah will also be encouraged to express herself when she ex-
periences such reactions, so that they can be explored.
Medical Management
An MBT approach to eating disorders is an integrative practice that aims to reduce
symptoms via psychotherapeutic interventions but also through active work on behav-
ioral change. It is a misunderstanding that the approach is “psychotherapy only” with
the risk of the patient starving to death while well-meant interventions are delivered.
There is an explicit focus on symptom reduction. An eating disorder is an example of a
self-perpetuating negative cycle. The psychology of hunger refers to the way in which
the somatic state of being underweight and malnourished influences psychological
states, creating increased cognitive rigidity, obsessive traits, agitation, and depression.
Put simply: if you have not eaten for days, you will probably be dizzy, vertiginous, and
exhausted, or possibly in a state of euphoria. Being anorexic makes you more anorexic.
Correspondingly, the person who frequently vomits or abuses diuretics or laxatives
self-induces a loss of potassium, with the risk of hypokalemia. Pathologically low levels
of serum potassium will often lead to depression and affective instability. And the phys-
ical hard work of bingeing and purging leads to more exhaustion and bodily pain. Being
bulimic makes you more bulimic.
Hence, a part of the program involves medical assessment and management, with
concrete aims of symptom reduction. For patients who are underweight, this means agree-
ments on how and how fast to restore weight. For patients who binge and purge, it means
agreements about how to try to reduce the frequency. Because of the teleological stance
that those with eating disorders often display, we consider written agreements to be very
useful. They can assist in bringing about the mental attitude that “I believe it because I see
it, and I try to cooperate because I actually have signed.”
It is important for the professionals involved in the treatment process to establish
an agreement about who is responsible for what. In the Oslo project, the individual
therapist is responsible for this part of the structure. The therapist usually is not a med-
ical doctor, and there will therefore be a clear agreement about how to cooperate with
somatic services. In this respect, this is treatment for eating disorders as it is typically
administered. The contribution of the MBT approach is the strong emphasis on the
therapeutic interaction as such: how you and I can cooperate although you originally
demonstrated that you not were interested in cooperation. In order to have success in
symptom reduction, patient and therapist preferably work together on how to work to-
gether, particularly on “negotiating non-negotiables” (see the later section so titled).
Reflections on Structure of Treatment

The aim of the treatment structure is to organize different therapeutic components in
such a way that reflective competences are enhanced. A rationale for combining differ-
ent therapeutic modalities is that mentalizing is challenged in different ways and at dif-
ferent levels. In working with eating disorders, this is best done using a combination of
individual and group therapy.
In the Oslo-based project “Minding the Body,” we have met patients who have pre-
viously participated in group therapy and, according to their self-reports, have made
very little progress. It is tempting to state that historically the group therapy movement
has theorized a kind of omnipotence for group work, seeing group encounters as a pan-
acea for a vast array of suffering. A more in-depth understanding of eating disorders
makes it probable that such approaches alone, with the emotional and relational
complexity of intimate groups, will be too challenging for many patients. This is par-
ticularly relevant to the early phases of treatment. Many patients have described how
encounters in the group have triggered feelings of inferiority, shame, obsessive
comparison, and perfectionism. All of these emotional reactions can lead to impaired
mentalizing. This is illustrated by statements from patients such as, “My thinking col-
lapsed,” “I went blank,” “I sank into a deep hole of confusion,” “I am not worthy to
contribute here,” and “My preoccupation with the others’ negative view of me para-
lyzed me.”
Avoidant personality disorder is the personality disorder most frequently found to
be comorbid with eating disorders (e.g., Godt 2008), and perfectionist traits are com-
mon, leading many eating-disordered patients to be excessively concerned about how
they appear and perform in the group (Westen and Harnden-Fischer 2001). Such ex-
periences may lead to dropout. Individual sessions are therefore used as a context to
elaborate on mentalizing in different relational and emotional situations, particularly
the group, and to maintain motivation for continued participation.
The psychoeducational work represents another clinical context to stimulate curi-
osity, cultivate different perspectives on personal examples brought by the patients, and
question the absolute certainty of psychic equivalence. In this form of psychoeduca-
tional work the patients are not passive receivers of knowledge, but are encouraged to
be active contributors. The intentionally more relaxed atmosphere is meant to cultivate
positive relational experiences that may be brought back into the weekly group therapy
sessions.
With reference to the psychopathology of eating disorders, we also consider the
systematic use of case formulations to be highly relevant. This work can be seen as
directly addressing the teleology so prominent in eating disorders. As described earlier,

teleology refers to the need for physical proof of emotions and relations: “I don’t be-
lieve it until I see it.” The physical reality of the case formulation, written down on a
piece of paper, is positively described by some patients as a narrative supporting their
sense of coherence by linking past to present and future. It may help them to under-
stand the goals of treatment and the theoretical and therapeutic model underpinning
them. The co-creation of a text may stimulate symbolizing in the therapeutic processes.
This function of writing has been extensively researched by Pennebaker (2000; Pen-
nebaker and Seagal 1999). The text is also a physical product of the interactive work be-
tween the therapist and the patient and may, as such, stimulate the working alliance.
As a collaborative work, the making of the case formulation is mentalizing in prac-
tice. Making the formulation stimulates both the therapist and the patient to keep each
other’s mind in mind and their own mind in mind. Through the process of writing the
formulation, the therapist uses his or her capacity to mentalize (since the therapist has
to have the patient’s mind in mind) and then enables the patient to have his or her own
mind in mind and also the mind of the therapist (Allen 2008b). The therapist uses his or
her mentalizing capacities to draw the patient into the process, cultivating the patient’s
mentalizing capacities. Patterns of mentalizing impairments and success are identified
explicitly with the patients. The important issue is the stimulation of the interactional
mentalizing processes and not the accuracy of the formulation. Hence, unlike other
traditions that make use of case formulations, the process of collaborative work and
sharing is a sine qua non in an MBT context.
General Mentalizing Stance

Mentalization-based therapy for eating disorders is a development of the original MBT
model as it was developed for borderline personality by Anthony Bateman and Peter
Fonagy (2004, 2006b). Karterud and Bateman (2010) have recently identified 17 dif-
ferent items to define adherence to the model and competence. These items are listed
in Table 14–5. Some of these items are considered to be essential in defining MBT.
These include taking a not-knowing or inquisitive stance, adapting interventions to the
patient’s mentalizing level, and stimulating mentalization through the process.
The patient’s mentalizing activity will vary throughout the session. MBT for eating
disorders is an active approach in the sense that it continuously assesses and tries to re-
habilitate mentalizing capacities at any given moment. Enhancing mentalizing compe-
tencies implies working with current mental states; the main focus should be on the
present state and how it continues to be influenced by past events rather than on the
past itself. Past experiences are, of course, relevant, but they need to be emotionally
linked to the present situation, using bridging narratives and affects, and to the thera-
peutic situation.
When mentalizing is severely impaired, many interventions may be experienced as
invasive, too advanced, or irrelevant. If there is a high level of anxiety, cognition col-
TABLE 14–5. Adherence scale items for mentalizing interventions
1. Show engagement, interest, and warmth

2. Use exploration, curiosity, and a not-knowing stance
3. Challenge unwarranted beliefs
4. Adapt to patient’s level of mentalizing
5. Regulate level of tension
6. Stimulate mentalizing through the process
7. Reward positive mentalizing
8. Identify and challenge pretend mode
9. Identify and challenge psychic equivalence
10. Maintain affect focus
11. Link affects to interpersonal experiences
12. Stop and rewind
13. Validate emotional reactions
14. Understand how to relate to transference
15. Use countertransference
16. Check own understanding and correct misunderstandings
17. Integrate experiences from concurrent group therapy
lapses, and challenging interventions only increase the level of frustration. A mental-
izing-enhancing intervention in such a situation is “showing engagement, interest, and
warmth” rather than “relating the situation to transference.” The former is a common
factor for many forms of effective psychotherapy, but what is more specific for a men-
talization-based approach is the far more developed conceptualization of, and the
stronger emphasis on, working with the therapeutic relation itself: the emphasis on be-
ing in touch with the patient.
Mentalizing Stance for Eating Disorders

In this section, we describe ways to address forms of impaired mentalizing that are
more specific to eating-disordered patients. Exploration, curiosity, and a not-knowing
stance are essential in the therapeutic dialogue to stimulate reflective function. Both
one’s own and others’ emotions are opaque, but they can become clearer through in-
vestigation and elaboration in language, and the inquisitive stance is the recommended
approach. In the following paragraphs, we anchor this position in the history of eating
disorders.
Naïve Stance
Again, we refer to the work of Hilde Bruch. The not-knowing approach is more or less
identical to Bruch’s (1973, p. 336) approach, which also eschewed interpretations in fa-
vor of what she called a “fact-finding, non-interpretive approach.” Like Bateman and
Fonagy (2004, 2006b) three decades later, she emphasized how interpretations in the
classical psychoanalytical sense might be too advanced for patients with developmental
deficiencies. Classical interpretations might have no positive effect, or they might be
experienced negatively. Bruch (1985, p. 14) stated:
To these patients, “receiving interpretations”... represents in a painful way a re-experi-

ence of being told what to feel and think, confirming their sense of inadequacy and thus
interfering with the development of a true self-awareness and trust in their own psycho-
logical abilities.
The patient may respond with pseudocompliance, a hallmark of eating-disordered

functioning, or, if threatened enough, may simply bolt from treatment. Hence, like
Bateman and Fonagy, Bruch stressed the need to tailor interventions to the patients’
way of psychological functioning. In her posthumously published book Conversations
With Anorexics, Bruch (1988, p. 8) described what she called a naïve stance:
The therapeutic task is to help the anorexic patient in her search for autonomy and self-
directed identity by evoking awareness of impulses, feelings, and needs that originate
within herself. The therapeutic focus needs to be on her failure in self-experience, on her
defective tools and concepts for organizing and expressing needs, and on her bewilder-
ment when dealing with others. Therapy represents an attempt to repair the conceptual
defects and distortions, the deep-seated sense of dissatisfaction and helplessness, and the
conviction that her own self is empty and incomplete and that therefore she is con-
demned to compliance out of helplessness.
Following these same ideas, in mentalization-based psychotherapy for eating dis-

orders we recognize that the interchange between therapist and patient is impression-
istic at best. It is therefore essential for therapists to show humility and inquisitiveness
and acknowledge that they cannot know for sure what is actually happening in the pa-
tient’s mind. This is not the same as unconditional acceptance of the patient’s thoughts
and feelings, and the naïve stance includes respectful inquiry along the lines of: “I can
see how you arrived at that idea, but it occurs to me that there may have been other
things going on besides the idea you have alighted on; for example...,” or even: “I am
puzzled, and to be honest, I can’t really understand how on earth you got to this point.”
Although the therapist is instructed to identify difference, for this to work thera-
peutically it has to include a genuine acceptance of different perspectives. This includes
tolerance of a failure to understand. To quote Jon G. Allen (2008b, p. 175): “I would go
so far as to argue that mentalizing is not just a skill; at best, it is a virtue.” Mentalizing
virtuously means being authentically interested and curious in exploring the richness of
possible realities. The therapist’s desire to present herself or himself as able to under-
stand that which is not understandable is remarkably dangerous for the patient. Active
questioning expresses curiosity, but it should be expected to yield progress towards a
conceptualization of alternatives rather than an unequivocal answer. This attitude is
reminiscent of the leitmotif of Bruch’s work: to accept the fertility of insecurity. A fa-
vorite quote of Bruch’s was one of Maimonides: “Teach thy tongue to say I do not know
and thou shalt progress.”
Minding the Body

To further develop a mentalizing approach to eating disorders, let us return to the in-
troductory example with the emaciated anorexic patient who is feeling fat in the context
of emotional arousal. This, of course, is a situation that is likely to lead to severe non-
mentalizing. It might also result in anti-mentalizing, for example by denying that there
is any psyche involved: “I am fat. It’s just like that.” It also clearly illustrates the role of
the body. There is a concretization of mental life that is characteristic of both psychic
equivalence and teleology. Hence, a specific challenge in psychotherapy with eating
disorders is to stimulate and rehabilitate the mentalizing of the role of one’s own body
in mental life.
Mentalizing the body means stimulating the patient to investigate her or his con-
crete experiences with body and food and to connect them with emotional, cognitive,
and relational experiences, in order to translate them into a language that reflects them
both as physical reality and as metaphor for mind (Skårderud 2007a, 2007b).
In our experience, work with patients with eating disorders calls for specific types
of focus. For example, we pay more attention to triggers for bodily feelings than with
most other patient groups; identify small changes in mental states that can unsettle the
patient physically as well as psychologically; highlight the differences between the pa-
tient’s and therapist’s perceptions of the same physical events; bring awareness to the
intricacies of the relationship between action and meaning and their potential to gen-
erate changes in bodily experiences; and place the affects related to these into a causal
chain of concurrent mental experience.
Hence, a fundamental focus of the work with eating disorders is entering the con-
crete. It is expedient to enter the phenomenological world presented by the patient in
order to demonstrate an acceptance and understanding of the patient’s way of mental
functioning. From the perspective of therapeutic alliance, this is in order to meet the
patient where the patient is. From the perspective of mentalizing, it is to adjust to the
patient’s mentalizing level initially and from there try to stimulate more flexible forms
of reflective functioning.
Patients’ fears and anxieties are concretized as fears about food, weight, and other
aspects of eating; the therapist’s authentic interest, even in details, may be reassuring
and beneficial for the working alliance. The therapist shows interest in what engages
the patient, but uses this to bridge the gap between the primary affective experience and
its symbolic representation. Technically, this means an active focus on and elaboration
of the detail and context of experienced affects. The dialogue may begin with a concrete
situation such as the patient’s increased vomiting combined with a recent stressful sit-
uation:
Elisabeth equates control in her life with control of the plate, and the therapist com-
ments.
THERAPIST: I’m confused. It is like you are mixing realities, equating “control”
with “control.” But something here worries me. Do you really control
your emotions and your relations to others by minimizing the ingredients
on your platter? Do you follow me?”
Trying to intervene in such ways represents a de-concretization: opening up the

closed psychological experience of teleology and psychic equivalence. In the adherence
scale outlined in Table 14–5, this is an example of “Identify and challenge psychic
equivalence” (Karterud and Bateman 2010). With reference to the eating-disordered
patient’s loss of symbolic space, psychotherapy involves “re-metaphorization” (Carveth
1984): an exercise in becoming conscious and self-critical in our employment of the
metaphors we live and eat by (Lakoff and Johnson 1980; Skårderud 2007a, 2007b).
An alternative to getting the patient to enter the realm of the symbolic (the therapist’s
world), is the therapist instead entering the realm of the concrete (the patient’s world).
After all, the patient is usually looking for an ally. (Josephs 1989, p. 495)
Minding the body is a therapeutic activity to be used in the different contexts in the
therapeutic structure: in individual sessions, group therapy, psychoeducational work,
and case formulation, and not least when trying to develop a collaborative culture with
the patient on such concrete matters as weight restoration and behavioral change con-
nected to medical management.
Above we have described the general approach of minding bodily experiences. In
the following paragraphs we present examples of how this can be practiced in therapy.
These are just proposals. For more extensive background theoretically, empirically, and
clinically, see Duesund and Skårderud (2003).
Body Awareness
In some of the centers participating in the Oslo University Hospital project, we start
the group therapy sessions with a body awareness exercise, using the first 5 minutes of
the session to focus on how one senses one’s feet on the floor, one’s legs, one’s thighs on
the seat, one’s back against the back of the chair, and so on. This is a well-known exer-
cise. It is performed with a twofold intention. One aim is to stimulate the sensorimotor
awareness of one’s body. As we described earlier, eating-disordered patients experience
a split between body and mind: a Cartesian split between being hyperembodied (in their
obsessive preoccupation with bodily aspects of themselves) and disembodied at the same
time (Duesund and Skårderud 2003). Hence, we try to shift focus from the objectified
body to the lived body (Merleau-Ponty 1962; Skårderud 2007d). The other intention is
to stimulate affect. In general, the treatment of eating-disordered patients differs from
our work with borderline patients in that we more often want to increase the affective
“temperature” rather than reduce it (we later describe how to regulate tension in dif-
ferent treatment contexts in greater detail).
Approach to Meals
At one of the centers, the group therapy session starts with a lunch. In Norway, people
typically prepare their own simple lunch at home and bring it to work. Both patients
and therapists bring their food and eat together, and there are rules about what kinds of
food and what amounts of food are acceptable as a real meal. The intention is to stim-
ulate affects.
Use of the Body to Forget the Body

Programs for physical activity and concomitant physiotherapy can help psychotherapy.
Duesund and Skårderud (2003) describe the possible benefits of adapted physical ac-
tivity as a supplement to the psychotherapeutic dialogues. Social interaction in activi-
ties can move negative attention from the objectified eating-disordered body to a more
profound and subjective experience of one’s own body. This is intentionally using the
body, as in movement, social interactions, and physical challenges (the lived body) with
the intention to forget the body (the eating-disordered objectified body). Forgetting in
this context means shifting attention, not denial. Experiences of different kinds of ac-
tivities and the different perceptions of one’s body that arise in different contexts are of
utmost relevance in mentalizing psychotherapeutic dialogues. Patients need to reflect
on such experiences, positive and negative, and the impact on them of how different so-
cial, interpersonal, and affective contexts stimulate their embodied awareness of them-
selves.
For example, we have guided some of the patients to indoor wall-climbing, an ac-
tivity that incorporates relevant psychological and social messages. It has the flavor of
risk, which many patients like; it is a social activity where two climbers need to assist
and rely on each other; it requires physical strength, which may be a motivation for bet-
ter nutrition. We are skeptical of the general attitude of denying anorexic patients
physical activity. We find it more constructive to guide them toward medically safe
forms of adapted physical activity. It is likely that they will be active anyway, in secret,
so it is better to address the issue openly and try to harness their cooperation. This also
creates a background for common reflection about embodied experience. Inactivity in-
creases anxiety and symptoms. Accepting safe and social forms of physical activity can
also support the therapeutic alliance, particularly because anorexic patients are used to
many refusals of and few agreements to their demands.
Embodied Culture
Psychoeducational groups focus on cultural norms about health, appearance, and be-
havior—for example, moral and aesthetic norms about beauty, slimness, and fitness.
The individual is interacting with such cultural norms, and some eating-disordered pa-
tients feel highly driven by them. Eating disorders can often be understood as patho-
logical versions of ideal bodily and psychological norms in culture, such as slimness and
fitness. Such bodily norms function as teleological expressions of strong will, self-
control, and successful self-construction. Mentalizing interventions for eating disor-
ders are summarized in Table 14–6.
Minding the Symptoms

The patient with an eating disorder typically experiences both the advantages and dis-
advantages of symptoms (Table 14–7), experiencing the anorexic or bulimic way of liv-
ing as both a problem and a solution. In contrast to the borderline patient, who
experiences most of the symptoms of that disorder as painful, the eating-disordered
person experiences his or her symptoms as partly beneficial for identity, self-coherence,
and affect regulation (see Nordbø et al. 2006; Skårderud and Nasser 2007). A mental-
izing approach stimulates the open investigation of the different functions and mean-
ings of symptoms. This approach of opening up a dialogue—and, moreover, a dialogue
that can include exploration of the possible positive aspects of the disorder—may be ex-
perienced as liberating by the patient. The therapist demonstrates that the patient is al-
lowed to present ambivalence, doubt, and hesitation. Creating such an atmosphere of
open inquiry is beneficial for the therapeutic alliance, not least because the therapist
tries to understand the complexity of the disorder; genuine curiosity is vitalizing.
In practical terms, symptoms are discussed in individual and group sessions, in the
psychoeducational work, and in the collaborative development of a written case formu-
lation. Therapeutic focus on the function of symptoms is based on the therapist’s role as
an expert, from a knowing position of the patient’s expected ambivalence about giving
up the symptoms. But the symptoms are investigated using the inquisitive stance, from
a not-knowing position.
Meeting Other Challenges of

Eating Disorders
Malnourishment as a Metaphor for Mind
There are further challenging aspects of work with patients with eating disorders that
need consideration in tailoring the psychotherapeutic encounters. The predominance
TABLE 14–6. Specific mentalizing interventions for eating disorders
• Minding the body
• “Translating” to and fro between body and mind (as general stance)
• Stimulating the awareness of sensorimotor experiences
• Using affective activation through meals or exercises for bodily awareness
• Using adapted physical activity as an experiential basis for reflections
• Dealing with embodied culture and cultivated body
• Minding the symptoms
TABLE 14–7. Possible advantages and disadvantages of symptoms
Possible advantages
Feelings of mastery and control
Feelings of protection
Reduced complexity
Oblivion
Beauty
A sense of identity
Affect regulation through activity, hunger, and/or exhaustion
Attention from others
Care from others
Possible disadvantages
Destruction of self-esteem
Destruction of physical health
Destruction of relationship to parents and family
Destruction of relationship to friends and peers
Destruction of the future (school and work)
of the prementalistic modes of psychic equivalence and the teleological stance makes
eating disorders a particularly interesting but clinically challenging field. Inner and
outer realities are played out in concrete ways. It is tempting to state that the patients’
physical undernourishment or malnourishment functions as a rather precise metaphor
for emotional nourishment. As mentioned, Hilde Bruch described severe eating disor-
ders as expressions of a deficient sense of self, and these deficits of knowing, expressing,
and regulating are embodied. It may be hard to establish lively and healthy interactions,
in which both participants give and take, in clinical work with patients with severe eat-
ing disorders. The patient may be very anxious about accepting something from others.
She or he may also demonstrate stinginess and a hesitance to give things away and share
with others. The patient often experiences a sense of deficit.
Examples of Specific Challenges

In this section, we give different examples of how the sense of deficit may be clinically
expressed and how to meet it. Eating disorders call for active treatment approaches.
The examples we present will also contribute to an understanding of the dramatic
countertransference enactments that may occur in work with severe eating disorders.
Death as a Living Theme

Bruch (1973) uses the term a sense of ineffectiveness to describe the subjective experiences
of many of her patients. In our terms, this refers to impaired self-agency. In the mental-
ization paradigm, the birth of the agentive self is rooted in the attribution of mental
states, and this capacity emerges through interactions with the caregiver, in the context
of an attachment relationship, via a process of contingent mirroring (Fonagy et al.
2002a). The child finds him- or herself in the attention he or she receives from care-
givers: “I am, because you think of me.”
Clinical presentation. Temporary, contextual, or more extensive impairment of the

agentive self can be expressed as an outer-directedness: a searching and longing to be
confirmed, attended to, and psychologically nurtured by others. It can also be ex-
pressed as a form of deadness, in the sense of depression, and a lack of vitality and fan-
tasy. Of course, physical death may be a threatening reality; the focus here is on the
psychological experience of deadness, which “lives in” the patient and is “lived out” in
the moment-to-moment encounter in therapy, especially early in treatment This un-
settling phenomenon is important for countertransference, according to Ewen (2009,
p. 4), as “a gap between the self and a never to be satisfied self.” Ogden (1995) describes
lifelessness in the patient enacted as lifelessness in the therapy, as an “entombed” ex-
perience. Goss (2006) describes this phenomenon as an “internal waiting.” Both de-
scriptions might be associated with Bruch’s (1978) description of the person with
anorexia living in “the golden cage,” deprived of the freedom to be and do as she truly
wants (Ewen 2009).
Therapeutic approach. A fundamental premise of mentalization-based therapy is

that there are “two minds in the room.” The therapeutic enterprise moves in a direc-
tion from deadness to aliveness by explicitly demonstrating to the patient that she or he
is in our minds. In MBT we often use the pronoun “I” instead of “you.” The intention
behind such a form of self-disclosure is to stimulate the patient to mentalize about the
therapist’s active mentalizing mind. And we say things like “I have been thinking about
you since our last meeting,” partly because it is true, but also to elucidate that their
minds live in our minds. We are trying to stimulate their self-development through at-
tending to them, parallel to the interactions between infant and caregivers. In milieu
therapeutic contexts, particularly with children and the youngest adolescents, we often
meet “the silent patient.” Withdrawal, regression, and silence strongly challenge our
therapeutic ability. We advise the professionals to talk openly with each other about the
patients and how they might feel when faced with silence in groups or during joint
meals. This often relieves the tension during the exhaustingly silent meals in the anor-
exia ward, and gradually the patients begin to take part in these dialogues.
Therapy as a vitalizing activity, as an experience of aliveness, is a valuable experi-
ence in itself, quite apart from its usefulness in facilitating symptom reduction and en-
hanced self-understanding (Ogden 1995; Winnicott 1971). For many of the patients,
the therapists’ passive or reticent approach may be threatening for different reasons: it
may stimulate the sense of deadness and “entombed” interaction; activate shame and
negative self-evaluation; nurture the perfectionistic fear of not performing well
enough; or induce stress as the patient feels responsible for the well-being of the ther-
apist. All this will impair mentalizing. It is a frequent experience in successful psycho-
therapy with eating disorders that it is useful, or rather necessary, for the therapist to
engage actively during the initial phases and later gradually give more of the initiative
to the patient. But this requires caution. Too much activity on the therapist’s behalf may
be experienced as invading and threatening, activating memories of caregivers over-
whelming the child’s psychological capacities. “Taking up space” is yet another inter-
esting and prevalent example of teleology in eating disorders. The anorexic patient may
try to bodily minimize herself (concretizing) because she occupies too much room (so-
cial interaction) while the therapist inadvertently becomes increasingly directive and
active.
An active mentalizing approach includes open-mindedness. In mentalization-based
therapy, open-mindedness refers to how we stimulate and validate alternative perspec-
tives. It also requires the therapist to support the development of the patient’s fragile in-
quisitiveness by “thinking out loud,” intriguing the patient with the therapist’s
thoughts and feelings, and sharing ideas and reflections. The therapist uses him- or
herself as a model to demonstrate to patients how their mind is working in relation to
them. The therapists’ security about themselves should ensure that they will be able to
share doubts, ambivalence, and uncertainties.
Alexithymia
Bruch (1962) describes how a number of patients with severe eating disorders are un-
able to describe their emotions, exhibiting disconnections between subjective feeling
components of emotion and language.
Clinical presentation. Alexithymia refers to “lacking words for feeling” and is docu-
mented as a significant trait in eating disorders, as in substance abuse (Söderström and
Skårderud 2009; Taylor et al. 1997). The concept is problematic, because it does not
distinguish between this deficit as a constant trait and as a characteristic dependent on
context. The concept of mentalizing covers some of the same ground as alexithymia but
elaborates the idea to include the dependence of impaired thinking and expression on
affective states. A patient may answer “I don’t know” to a question about feelings be-
cause he or she lacks the ability to symbolize inner experiences in language. This may
contribute to an overwhelming sense of chaos that further compromises mentalizing
and stimulates the search for bodily practices to regulate his or her bewildered feelings.
Therapeutic approach. When alexithymia is prominent, the therapist may “fill the
room” with a language of possible feelings. This is explicit mentalizing in the thera-
peutic encounter. At first sight, it is counter to the normal exhortation in MBT not to
tell the patient how he or she feels. But it is a cognitive activity, thinking about felt feel-
ings, and good thinking presupposes valid concepts and categories that the patient does
not possess, so we contribute with some possible tools in language. It is useful to think
aloud, referring to possible ideas, perspectives, meanings, and feelings, but always re-
ferring to those as our ideas. This is particularly relevant when working with the silent
preadolescents and adolescents. The obvious challenge is to avoid thinking and feeling
on behalf of our patients and thereby stimulating pretend mode.
Covert Feelings
An interesting challenge is the dilemma of emotions in disguise: pseudocooperation
and pseudocompliance. Such phenomena indicate the presence of pretend mode.
Clinical presentation. In general, eating-disordered patients evoke attention, tokens

of esteem, praise, and comparison. They stimulate others to compensate for their neg-
ative self-evaluation by excelling in performance, achievement, and skills. Sensitivity
and a drive to satisfy other peoples’ needs are also well-known traits. This may be ex-
pressed as high compliance toward people in general and toward therapists. “The clever
child” also tends to aspire to be “the clever patient.” The preoccupation with getting
things “right” undermines getting things “true.” What may look like a real working al-
liance is mainly an ambiguous form of polite compliance. Inner experiences such as
sadness, agitation, and aggression may all be disguised by a smile.
Therapeutic approach. A mentalizing-based approach means being active in elabo-

rating on current mental states. The patient may say she is “okay.” We question this.
When we challenge her, she may after a while clarify that her saying “okay” actually
means “not okay.” The demand on the therapist is hence to elaborate on the real sub-
jective experiences of mental states. This is often done through active use of the coun-
tertransference (e.g., of becoming tired or restless, losing concentration, or having a

sense of meaningless dialogue), through which therapists often notice the effects of
concealment. The countertransference is an excellent starting point from which to en-
gage the patient in what is going on in the immediacy of the therapeutic encounter. The
aim is, of course, to try to establish the therapeutic room as a safe enough environment
for the patient to be more clear and honest about his or her feelings.
On the basis of such active clarification and challenge, patients gradually become
more open about their position and in doing so become more trusting that the therapist
is able to see things from their perspective. Many describe an ambivalence about dis-
closure or openness: they are afraid of being revealed, and yet they hope to be revealed.
To be revealed in this way is often a revealing experience. If patients get away with their
concealment, they are often disappointed.
Regulating Tension
In any therapeutic enterprise, we aim to modulate the affective climate. This approach
is based in part on neuropsychological evidence that “too warm” affective arousal im-
pairs mentalizing and that “too cold” affect may indicate detachment (Hatch et al.
2010). The aim in therapy of patients with borderline personality disorder is to strike
while the iron is “warm”—and to do so, we often need to calm down affects. But in pa-
tients with eating disorders, it is more common to have to “upregulate” affects.
Clinical presentation. Patients with eating disorders commonly present with an in-
difference to their situation and no obvious anxiety about their plight. Initially it is nec-
essary to be supportive and empathic, but it is important to begin gently activating
affects, making “cold warmer.” We aim to turn detachment into attachment and to pass
beyond the coldness of concealment, pseudocompliance, and pseudomentalizing.
Therapeutic approach. Challenging the patient’s statements and introducing doubt

and disagreement in emphatic but appropriate ways is the main technique for stimu-
lating affect. The therapist’s metacommunication to patients is that we help them to
regulate affects by showing them that we are able to endure and regulate the difficult af-
fects played out in the therapeutic encounter.
Negotiating the Non-Negotiables

A particular challenge in working with patients with anorexia nervosa is “negotiating
the non-negotiables” in treatment.
Clinical presentation. The major non-negotiable is that the patient has to eat more and
more healthily simply in order to survive. Iatrogenic effects are commonly a consequence of
therapists’ presenting basic non-negotiables in a harsh and authoritarian manner and in-
troducing more non-negotiables than are necessary (Geller and Srikameswaran 2006).
Therapeutic approach. Non-negotiables present an excellent opportunity to demon-

strate the mentalizing ambition of treatment by understanding different and opposite views
and negotiating about non-negotiables. A basic approach could be something like this:
THERAPIST: Are both of us—you as a patient and I as a therapist—able and willing to try
to understand the position of the other?
If so, can we agree on the fact that both of us are “forced” into a position: me as
an agent of health—that is, working for your eating healthier—and you trying to
manage your fear of eating?
If so, are we willing to try to explore and resolve that dilemma together, in the
sense of give-and-take?
Dealing with non-negotiables is at the very heart of treating anorexia. Often great
challenges are not given the necessary careful consideration. Basic conflicts are often
complicated by therapists failing to mentalize their patients and unwittingly enacting
the conflict in a way that attacks the patients’ sense of autonomy. It is unlikely that many
patients have benefited from aggressive statements such as, “If you don’t eat, you will
die!” Moralistic and threatening approaches often produce fear, protest, and stubborn-
ness, decoupling mentalizing and reducing therapeutic progress.
Most patients with eating disorders are looking for a way out of their confusing and
destructive obsession and are searching for allies. Although the somatic and psycho-
logical situation undermines traditional psychotherapy, most patients also “retain the
capacity for human connection” (Strober 2004, p. 230). Much may have been achieved
if the patient is moved from a “no” to any weight gain to accepting a minimal increase
over months. The latter represents the beginning of a “yes.” From that position it may
be possible to negotiate the frames and limits. For the therapist, this represents a key
situation to demonstrate both firmness and flexibility (not one or the other).
Group Therapy
In working with eating disorders, group therapy sessions are often the most challeng-
ing, and potentially ineffective or iatrogenic, component of any program.
Clinical presentation. A major phenomenon is the participants’ lack of contribution. In-

troversion and deadness are experienced in groups through silence and flight to agreement.
This tendency presents challenges to the therapist’s ability to develop a group process, and
there is the risk of group therapy deteriorating into individual therapy for each patient in
turn. A particular challenge in groups is teleology in the form of patients comparing their
own bodies with those of others in the group, and also with the therapists’.
Therapeutic approach. Working with eating-disordered patients in groups means

being more active than in traditional group analytic work, trying to engage the patients
in minding the minds of the others, and allowing less silence.
When there are two therapists in the group sessions, we recommend that they ac-
tively use each other, modeling mentalizing:
THERAPIST [addressing the other therapist]: I wonder what is going on in your head when
the group is so silent today. I get anxious that I am not doing my job well enough.
What about you?
More specifically, we recommend that the topic of comparison of bodily shape be

addressed early in treatment. When this is discussed openly, it may contribute to cre-
ative group processes in the sense of the patients sharing their obsession with compar-
ing themselves with others. If it is not addressed, it may be enacted in indirect and
destructive ways unrecognized by the therapists. This open and partly pedagogic dis-
cussion generates an understanding of the psychology and psychopathology of eating
disorders. Not having a clear sense of themselves from within, individuals with eating
disorder need to find a sense of the self through comparison with the others in a way
that demonstrates their deep and profound dependence on surfaces.
Combining patients with restrictive and bingeing symptomatology may help
group processes, with the latter bringing more vitality into group encounters.
Conclusion
In this chapter we have described the psychopathology of eating disorders through the
lens of the mentalizing paradigm. We have presented examples of clinical approaches
to symptom reduction and restoration of general mentalizing from an embodied
mentalizing. In sum, we recommend the further development of mentalization-based
interventions for eating disorders, which in turn can be the subject of empirical inves-
tigation. This proposal is based on the following rationales.
To make therapy more effective, treatment innovations should be informed by un-
derstanding of specific psychopathologies (Fonagy and Bateman 2006a; Kazdin 2004).
Patients who have eating disorders are heterogeneous in terms of background, clinical
features, comorbidity, and personality functioning. But we suggest here that impaired
reflective function is central to the psychopathology, either contextually or more com-
prehensively. The mentalizing approach specifically addresses competencies of reflec-
tive function: “In sum, mentalizing in the emotionally charged context of a psychother-
apeutic relationship is not just hard work; it is the work” (Allen 2008b, p. 180).
One of the major challenges in the work with patients with eating disorders is estab-
lishing therapeutic alliances. Surprisingly few studies have paid attention to aspects of the
therapeutic relationship. Factors reported by patients in a study of Vandereycken and
Devidt (2010) as important include treatment being too difficult, inappropriate ap-
proaches, lack of freedom and lack of trust. Mentalization-based therapy has an explicit
and systematic focus on improving and utilizing the therapeutic alliance by generating
trust and engendering autonomy while repairing ruptures through regaining mentaliz-
ing. Psychotherapy provides the opportunity to experience and learn from failures in
mentalizing and to repair ruptures in bonds, such as occur in enactments during therapy.
Mentalizing is a new paradigm, in the sense that it integrates evolutionary science,
psychology, and neurosciences. There is particular emphasis on how early attachment
interacts with brain development. This emphasis has consequences for the therapeutic
stance. One important aspect of psychotherapy is that it activates the attachment sys-
tem. Where therapeutic alliances are established and attachment bonds are formed,
neurobiological changes may follow, particularly if therapy acts as a secure base that
fosters mentalizing. Insecurity, affective arousal, and attachment traumas impair men-
talization, while a secure base represents open-mindedness.
Mentalizing as an intellectual framework can be helpful in organizing the confusing
and challenging phenomenology presented by the patients; hence, it can help us to tolerate
the patient’s symptoms better. The therapist’s focus on mentalizing of the patient’s impaired
mentalizing makes it easier to empathize with the patient and enhance the latter’s “negative
capability,” or capacity to tolerate doubt and to “stay with” the material (Holmes 2001).
All forms of psychotherapy foster mentalizing. As an intellectual model, mentaliz-
ing is a meta-language for effective treatment. As a specific aspect of therapy, it is the
systematic focus on the enhancement of mentalizing competencies. The mentalizing
approach has its roots in psychodynamic traditions, but with the emphasis on both cog-
nitive and emotional processes, this young tradition bridges psychoeducative, cogni-
tive, and psychoanalytical techniques.
The model of mentalizing is relevant not only to the patient with eating disorder,
but also to the therapist’s experience of working with such patients. In the face of great
therapeutic challenges, such as severe anorexia nervosa, our own reflective function
may collapse. There is not only a practical but also an ethical aspect to this. Patients can
get worse through treatment. Hence, we need models to understand and prevent our
own collapses in thinking, curiosity, open-mindedness, and decent behavior.
Mentalizing is a therapeutic virtue in that it entails a deep respect for the multitude
of different possible perspectives on oneself, the other, and the rest of the world. We
need to know that we are not able to read our patients’ minds, that we have separate
minds, that emotional states are opaque and can be deliberately concealed. Mentalizing
well for both patients and therapist is liberating, in the sense of allowing more flexibil-
ity in understanding others and ourselves. It is playing with reality. In working with pa-
tients with eating disorders, it also means playing with their embodied realities, trying
to help them to free themselves from the harsh realities of body and embodiment.
Suggested Readings
Bruch H: Conversations With Anorexics. London, Jason Aronson, 1988
Fox JRE: A qualitative exploration of the perception of emotions in anorexia nervosa: a basic
emotion and developmental perspective. Clin Psychol Psychother 16:276–302, 2009
Fox JRE, Froom K: Eating disorders: a basic emotion perspective. Clin Psychol Psychother
16:328–335, 2009
Harrison A, Sullivan S, Tchanturia K, et al: Emotion recognition and regulation in anorexia ner-
vosa. Clin Psychol Psychother 16:348–356, 2009
Hatch A, Madden S, Kohn M, et al: Anorexia nervosa: towards an integrative neuroscience
model. Eur Eat Disord Rev 18:165–179, 2010
Rothschild-Yakar L, Levy-Schiff R, Fridman-Balaban R, et al: Mentalization and relationships
with parents as predictors of eating disordered behavior. J Nerv Ment Dis 198:501–507, 2010
CHAPTER 15
Depression
Alessandra Lemma, B.Sc., M.A., M.Phil.
(Cantab.), D.Clin.Psych.
Mary Target, Ph.D.
D epression is among the most prevalent disorders worldwide. Population-based stud-

ies suggest a lifetime prevalence for unipolar depression of approximately 15%, with fig-
ures up to 25% in women (Alonso et al. 2004; Blazer et al. 1994; Kessler et al. 2003).
Depression is not only a very prevalent disorder but also a very serious one, affecting in-
trapersonal and interpersonal functioning both for individuals with the condition and
those in their immediate environment. Mood disorders are the chief cause of suicide and
suicide attempts (Bernal et al. 2007), and major depression and bipolar disorder are, re-
spectively, the first and fifth leading causes of years lived with disability (World Health
Organization 2001). Moreover, by the year 2020 depression is expected to be the second
most serious disorder with respect to global disease burden (Murray and Lopez 1996).
Depression is therefore also associated with serious economic costs (Donohue and Alan
2007). Furthermore, its negative effects are not limited to discrete episodes. Studies
385
suggest that relapse rates in unipolar depression are 20%–30% within 3 years following
a first episode and 70%–80% within the same time period in subjects who have had three
depressive episodes or more (Segal et al. 2003). The probability of at least one other ep-
isode after a first episode is estimated to be almost 90% (Kupfer and Frank 2001), and
the average depressed patient will experience four episodes during his or her lifetime,
each of about 20 weeks’ duration (Judd 1997). One of the most dramatic illustrations of
the long-term negative impact of mood disorders is the finding that children of parents
with mood disorders are at elevated risk for psychopathology in later life (Gibb et al.
2009), with both internalizing and externalizing disorders being more common in the
children of parents with mood disorders (Alloy et al. 2006).
Recent studies have shown that current pharmaceutical and psychotherapeutic treat-
ments have limited effects for a considerable subgroup of depressed individuals, with only
about 50% of depressed patients responding to such treatments (Cuijpers et al. 2010;
Luyten and Blatt 2007; Luyten et al. 2006). Consequently, current treatment guidelines
have emphasized the need for a long-term vision in depression management, stressing
continuation and maintenance treatment, with a focus on relapse prevention (Cuijpers et
al. 2010). As we will discuss in more detail below, prevention of relapse is one of the main
aims of the mentalization-based approach to depression. We believe that fostering men-
talizing capacities enables individuals vulnerable to depression to cope better with the
stresses of life when faced with adversity, thereby decreasing the probability of relapse.
Moreover, decreasing the probability of relapse and enhancing mentalizing skills may
also reduce the probability of the intergenerational transmission of depression.
In this chapter, we first spell out the rationale for applying the concept of mental-
ization to depression. We then present a discussion of the basic assumptions of the
mentalization-based approach to depression and a review of relevant empirical re-
search. Next, we discuss the relationship between mood and mentalizing and the roles
that individual differences in attachment history play in specific mentalization impair-
ments, as well as particular nonmentalizing modes. Finally, we discuss the treatment
implications of these views.
The Case for a Mentalization-Based

Approach to Depression
Interpersonal problems in people with depression are well documented (Luyten et al.
2005), and a focus on mentalization may therefore be particularly apt in the treatment
of these individuals. More specifically, as discussed in more detail below, depression has
been associated with so-called dysfunctional interpersonal transactional cycles (Kiesler
1983), implying that the individual’s interpersonal style leads to exactly those behaviors
and reactions in others that the individual fears and attempts to avoid, and that this in
turn confirms negative expectations about others and the self. Hence, it has been shown
Depression 387
that not only does depressed mood influence relationships negatively, but also individ-
uals who are vulnerable to depression actively select and evoke maladaptive interper-
sonal environments, leading to much conflict and ambivalence in relationships and
potentially to social exclusion and isolation. This has been emphasized historically in
Lewinsohn’s (1974) negative social reinforcement theory of depression and more re-
cently in stress generation models of depression (Hammen 2005; Luyten et al. 2006).
These latter models assert that vulnerability for depression is associated with the active,
although involuntary, generation of stress—particularly of interpersonal stress. This
view of the interpersonal nature of depression is further reinforced by findings that in-
terpersonal factors play an important role in explaining the outcome of current evi-
dence-based treatments of depression (Blatt et al. 2010). In the light of these findings,
it is fair to say that depression is as much an interpersonal disorder as it is an intraper-
sonal disorder (Hammen 2005).
A large body of research has documented the central role of impairments in social
cognition in depressed individuals that may underlie these interpersonal deficits and
conflicts. Cognitive-behavioral researchers, for instance, have identified impairments
at various stages of social information processing associated with depression and vul-
nerability to depression, including the following:
• The famous “cognitive triad” of negative attitudes about the self, others, and the fu-
ture (Beck et al. 1979)
• Mood-congruent attention and recall bias (Bower 1981)
• A depressogenic attribution style with regard to the causes of positive and negative ex-
periences, resulting in learned helplessness and hopelessness (Abramson et al. 1978)
• Negative self-focused rumination and poor social problem solving, leading to vi-
cious cycles characterized by increased negative thinking about the self and others,
which further lowers mood (Kyte and Goodyer 2008)
More recently, mindfulness-based cognitive approaches have stressed distortions

in social cognition with regard to the self and have emphasized techniques aimed at
“mindful awareness” (i.e., self-awareness without critical judgment or self-focused ru-
mination) in treating depression, and recurrent depression in particular (Watkins and
Teasdale 2004).
These findings concerning distorted social information processing are paralleled
by more direct studies of impairments in mentalizing in patients with mood disorders.
For instance, studies have found impairments in theory of mind (ToM), based on both
internally and externally based tasks, in patients with both unipolar and bipolar disor-
der (Inoue et al. 2004, 2006; Kerr et al. 2003; Lee et al. 2005; Montag et al. 2010). Im-
portantly, ToM deficits have been found to predict relapse in major depression (Inoue
et al. 2006) and have been demonstrated in euthymic bipolar patients, even when basic
cognitive dysfunctions associated with depressed mood were controlled for (Montag et
al. 2010). This finding clearly suggests that ToM impairments continue to exist outside
depressive episodes and thus may be involved in the onset and recurrence of mood dis-
orders. Similarly, a number of studies using the Reflective Functioning (RF) scale (Fon-
agy et al. 1998), as scored on the Adult Attachment Interview (AAI; George et al. 1985),
have found that depressed individuals are characterized by impaired mentalization. Fis-
cher-Kern et al. (2008), for instance, reported that inpatients with major depressive dis-
orders had even lower scores on the RF scale than patients with borderline personality
disorder. Müller et al. (2006), in turn, reported that pretreatment RF predicted symp-
tom improvement as measured with the Symptom Checklist–90—Revised (Derogatis
1994) in a 3-month inpatient treatment in a mixed in-patient sample consisting of pa-
tients with eating and depressive disorders. In contrast, it must be noted that Taubner
et al. (2009) found no pretreatment differences between chronically depressed patients
and healthy control subjects on RF as scored on the AAI. However, control subjects
scored extremely low on RF in this study (mean=3.6), well below average levels of RF
in normal controls in other studies.
Importantly, as we discuss in more detail below, we are not arguing that impairments
in depressed individuals are necessarily global and traitlike. Mentalization in depressed
patients may be context dependent (e.g., may be particularly pronounced with regard to
experiences of loss, separation, or failure rather than reflecting a general impairment in
social cognition) and may also be heavily influenced by current mood, particularly in se-
verely depressed patients or patients with strong mood reactivity to either positive or
negative events. Moreover, some depressed patients may also show hypersensitivity to
mental states and may be highly attuned to the mental states of others. For instance,
Montag et al. (2010) found that euthymic bipolar patients were impaired in cognitive, but
not emotional, ToM, a pattern that mimics findings in borderline personality disorder
(Fonagy and Luyten 2009). Similarly, depressed patients may show hypermentalization
(i.e., excessive concern with the mental states of self and/or others), discussed in more de-
tail below. There may be qualitative differences in the nature of impairments in mental-
izing between clinically depressed and subclinically depressed individuals. For example,
Harkness and colleagues found that whereas clinically depressed patients showed impair-
ments on a ToM task when compared to nondepressed control subjects, dysphoric stu-
dents and remitted depressed patients displayed the opposite pattern, showing enhanced
mental-state decoding abilities (Harkness et al. 2005, 2010).
A final and important reason the mentalizing approach may be relevant for the
conceptualization and treatment of depression is that depression shows high comor-
bidity with other disorders that are characterized by marked interpersonal problems
and pathology of the self, most notably borderline personality disorder (Zanarini et al.
2009, 2010). Hence, many depressed patients present with borderline features, and vice
versa. Not surprisingly, therefore, some models of borderline personality disorder have
emphasized affect dysregulation, and depression in particular, as a key feature (Linehan
1993a). Others have even advanced the hypothesis that borderline personality disorder
and mood disorders, including depression and bipolar disorder, belong to the same af-
fective spectrum of disorders (Akiskal 2004; Gunderson and Elliott 1985).
Depression 389
Although the precise nature of the relationship between depression and borderline
personality disorder requires further elucidation, from a clinical perspective the rela-
tionship is too important to neglect. Comorbidity of depression with borderline per-
sonality disorder has been related to longer time to achieve remission (Grilo et al.
2005), and comorbidity may negatively influence treatment outcome (Hilsenroth et al.
2007), particularly when therapists do not adapt their treatment to the presence of bor-
derline pathology. Hilsenroth et al. (2007) found that although short-term psychody-
namic psychotherapy was equally effective for depressed patients with and without
comorbid borderline pathology, therapists who treated depressed patients with comor-
bid borderline pathology tended to use a range of more structured techniques com-
pared to therapists who treated depressed patients without comorbid borderline
pathology, including providing structure at the outset of therapy, suggesting specific
activities or tasks to be done between sessions, maintaining an active focus on treatment
topics, supportively exploring difficult topics and shifts in mood, and examining cycli-
cal relational patterns. This more active and structured approach parallels mentaliza-
tion-based techniques in important ways, as we will see.
Depression and Mentalization:

Theoretical Perspectives
Basic Assumptions of the Mentalizing Approach

The basic assumption of the mentalization-based approach to depression is that de-
pressive symptoms reflect responses to threats to attachment relations, and thus threats
to the self, either because of (impending) separation, rejection, or loss; (impending)
failure experiences; or a combination of both. It is further assumed that these responses
result in impaired and/or distorted mentalization with regard to both one’s own and
other people’s motivations and desires (Lemma et al. 2011). Moreover, depressed mood
leads to further increases in arousal and stress levels, resulting in further impairments
and distortions in mentalization, which in turn lead to a loss of resilience in the face of
stress and to a vicious cycle of increasing depressed mood (see Figure 15–1).
The preceding assumptions provide a comprehensive explanation for 1) the central
role of interpersonal distress as a predisposing and precipitating factor, as well as a per-
petuating factor, in depression; 2) the importance of attachment and interpersonal issues
in the developmental origins of depression, including the intergenerational transmission
of depression; 3) the relationship between depression and decreased resilience in the face
of stress and adversity; 4) the central importance of interpersonal factors in the treatment
of depression; and 5) the evolutionary advantages and risks associated with the capacity
for mentalization. In what follows, we review the evidence for these assumptions.
Attachment, Stress Regulation, and Depression

Insecure attachment has been related to vulnerability to depression in children, adoles-
cents, and adults (Grunebaum et al. 2010; Lee and Hankin 2009). Likewise, research in-
dicates that vulnerability to depression is associated with personality traits or cognitive-
affective schemas (notably, interpersonal dependency and self-critical perfectionism) that
are rooted in disruptive attachment experiences (Blatt and Homann 1992; Blatt and
Luyten 2009). Moreover, insecure attachment has also been prospectively related to re-
current depression, greater number of depressive episodes and residual symptoms,
longer use of antidepressants, and impaired social functioning (Conradi and de Jonge
2009), as well as suicide (Grunebaum et al. 2010). More specifically, as discussed below,
vulnerability to depression has been related to both preoccupied and avoidant attachment
strategies (Bifulco et al. 2002b, 2002c): the preoccupied strategy has been shown to over-
lap theoretically with dependent perfectionism, the avoidant attachment strategy to over-
lap empirically with self-critical perfectionism (Blatt and Luyten 2009).
The central role of attachment experiences in the causation of depression is further
emphasized by findings of the central importance of the role of early adversity and disrup-
tive attachment experiences (in particular, abuse and neglect) in the etiology of depression,
with profound effects on the developing stress system (Heim et al. 2008a, 2008b). Indeed,
studies in animals and a growing body of research in higher primates and humans suggest
that attachment experiences play a key role in the developing stress system (Champagne
and Curley 2009; Lupien et al. 2009; Luyten et al. 2009). These studies of adversity and at-
tachment have shown that secure attachment experiences buffer the effects of stress in early
development, leading to a so-called adaptive hypoactivity of the hypothalamic-pituitary-
adrenal (HPA) axis in early development, and to resilience in the face of adversity in later life
(Gunnar and Quevedo 2007). By contrast, research in animals (Champagne and Curley
2009; DeVries et al. 2007; Neumann 2008) and humans (Bakermans-Kranenburg et al.
2008; Gunnar and Quevedo 2007) has shown that insecure attachment experiences are as-
sociated with increased vulnerability to stress, as expressed in dysfunctions of the HPA axis.
For example, in a study of adults who had reported low-quality parental relationships, there
was a significant elevation of dopamine in the ventral striatum and a higher increase in sal-
ivary cortisol during stressful events compared to levels in individuals who reported good-
quality parental relations (Pruessner et al. 2004).
Together, these findings may at least partially explain the mounting evidence that
vulnerability to depression is associated with an increased stress response to both daily
and major life stressors (Heim et al. 2008a; Wichers et al. 2009). In line with these as-
sumptions, insecure attachment has been shown to mediate the relationship between
early adversity and vulnerability to depression in later life through impaired affect reg-
ulation, stress responsivity, and social problem-solving skills (Bifulco et al. 2006; Styron
and Janoff-Bulman 1997).
Moreover, although the evidence is still somewhat equivocal (Risch et al. 2009), there
is some evidence that increased stress responsivity as a result of early or later adversity is
Depression 391
Threat to
attachment
Depressed Depressed
mood MIO
mood
PEP
• Increase of arousal
• Loss of mentalization
• Loss of resilience
FIGURE 15–1. Relation of threats to attachments, mood, and mentalization.
particularly pronounced in individuals with genetic liability. For instance, studies suggest
that a polymorphism of the 5-hydroxytryptamine transporter gene may be associated with
increased stress sensitivity, resulting in increased vulnerability to depression (Risch et al.
2009) and very probably a wide range of other stress-related disorders as well, including
functional somatic disorders such as chronic fatigue syndrome and fibromyalgia. This may
partially explain the high comorbidity among depression, pain, and fatigue (Luyten et al.
2008). Conversely, a haplotype in the corticotropin-releasing hormone receptor 1
(CRHR1) gene may protect against depression in individuals who have experienced early
adversity (Polanczyk et al. 2009). The CRHR1, a G-protein-coupled receptor, plays a cen-
tral role in the regulation of the HPA axis in response to stress and is located in frontal cor-
tical areas, forebrain, anterior pituitary, brain stem, and amygdala. CRHR1 also plays a
central role in emotional memory consolidation, and those individuals with two copies of
the TAT haplotype may have relatively unemotional cognitive processing of early adverse
experiences, protecting them against later vulnerability for depression.
Furthermore, there is now mounting evidence, from both animal (Carter et al.
2008; DeVries et al. 2007; Neumann 2008) and human (Gordon et al. 2008; Heinrichs
and Domes 2008; Levine et al. 2007) research, that the neuropeptides oxytocin and va-
sopressin, which are involved in neural systems underlying attachment, such as the
amygdala and the hypothalamic paraventricular nucleus (Insel and Young 2001; Neu-
mann 2008), play a key role in stress regulation. In particular, oxytocin is involved not
only in affiliative behavior—such as pair bonding, maternal care, and sexual behavior—
but also in social memory and social support (Feldman et al. 2007; Levine et al. 2007),
and at the same time, it reduces behavioral and neuroendocrinological responses to (so-
cial) stress (Neumann 2008). Furthermore, both oxytocin and vasopressin are involved
in affiliative behavior and have anxiolytic and antistress effects directly, by acting on the
HPA axis system, and indirectly, by enhancing social cognition and trust in particular.
For instance, in humans, administration of oxytocin has been shown to lead to positive
mood states, reduced anxiety, increased calmness, and reduced emotional responses to
psychological stressors in nursing mothers (Heinrichs et al. 2001); reduced levels of
anxiety and stress in an experimental stress task (Heinrichs et al. 2003); reduced
amygdala activation in response to stress (Baumgartner et al. 2008; Kirsch et al. 2005);
increased levels of trust in others by modulating activity in the amygdala and caudate
nucleus, which are involved in fear learning and reward-related processing (Baumgart-
ner et al. 2008; Kosfeld et al. 2005); and higher levels of mentalization as expressed in
increased ability to read the mind of others on the basis of facial expressions (Domes et
al. 2007). Moreover, oxytocin has been related to maternal bonding behaviors, includ-
ing gaze, vocalizations, affectionate touch, and positive affect, as well as attachment-
related thoughts and higher levels of parental mentalization as expressed in frequent
checking of the child (Feldman et al. 2007; Levine et al. 2007). Hence, oxytocin plays a
central role in the initiation of attachment behavior in mothers, facilitated by its stress-
attenuating effect and its positive effects on empathy and trust (Ross and Young 2009),
and thus may play an important role in the intergenerational transmission of emotion
regulation and vulnerability for stress. This assumption is further supported by studies
showing that parental care is associated with oxytocin levels in offspring (Gordon et al.
2008). Early adverse attachment experiences are associated with decreased oxytocin
levels and increased cortisol response (E. Fries et al. 2005; Heim et al. 2008b;
Meinlschmidt and Heim 2007). Moreover, increased levels of attachment anxiety and
avoidance have been associated with several polymorphisms in the oxytocin receptor
gene in patients with unipolar depression (Costa et al. 2009). This finding is consistent
with studies showing dysregulated peripheral oxytocin release in depressed women
(Cyranowski et al. 2008). Some evidence suggests that these dysregulations in oxytocin
are a vulnerability factor for depression. Gotlib et al. (2010), in a neuroimaging study,
found that adolescent girls who were at risk for depression showed decreased activation
in the reward processing system, most notably striatal areas, suggesting a marked re-
duced sensitivity to reward. Yet given the heterogeneous nature of depression, the small
sample sizes, and the many methodological problems associated with these studies
(Cyranowski et al. 2008), further research is clearly needed.
Despite their limitations, taken together these studies lend strong support to the no-
tion that there are intimate ties between attachment experiences, stress, and mentaliza-
tion in depression (Heim et al. 2008a; Luyten et al. 2009). Research in this area suggests
that the attachment system is an evolutionarily developed system that is closely associated
with the brain systems that reward affiliative behavior and regulate stress, and that it has
stress-attenuating features that reinforce the interpersonal regulation of stress, increase
trust in others, and reinforce the capacity for metacognition and mentalization.
Depression 393
Further support for these assumptions comes from research showing that the abil-
ity to continue to mentalize, even under considerable stress, leads to so-called broaden-
and-build (Fredrickson 2001) cycles of attachment security, which reinforce feelings of
secure attachment, personal agency, and affect regulation (“build”) and lead to an in-
dividual’s being drawn into different and more adaptive environments (“broaden”)
(Mikulincer and Shaver 2007). Indeed, studies on resilience have shown that positive
attachment experiences are related to resilience in part through relationship recruiting—
the capacity of resilient individuals to become attached to caring others (Hauser et al.
2006). Hence, high levels of mentalization and the associated use of security-based at-
tachment strategies when faced with stress can explain the effect of relationship recruit-
ing on resilience in the face of stress.
In contrast, the attachment hyperactivation and deactivation strategies that are as-
sociated with insecure attachment have been shown to limit the ability to “broaden and
build” in the face of stress. Moreover, they have also been shown to inhibit other be-
havioral systems that are involved in resilience, such as exploration, affiliation, and
caregiving (Insel and Young 2001; Mikulincer and Shaver 2007; Neumann 2008).
These findings might explain the key role of interpersonal distress and problems in de-
pression, as well as findings concerning the high rates of intergenerational transmission
of depression. Fonagy et al. (1994), for instance, found that mothers who had a history
of adversity but had high levels of mentalization all had secure infants, as measured by
the Strange Situation Procedure, whereas only 6% of mothers with a history of early
adversity and low mentalizing levels had infants with secure attachment. As noted,
mentalization may underlie characteristics that have been associated with resilience,
such as feelings of autonomy (willingness and capacity to plan, higher sense of self-
worth, feelings of self-efficacy, good problem-solving capacities) and relatedness (in-
cluding interpersonal awareness and empathy) (Fonagy et al. 1994), as well capacities
for relationship recruiting and for drawing benefit from social support (Hauser et al.
2006). The capacity for mentalization when faced with adversity may also be partially
responsible for the sense of humor that has been associated with resilience. Many de-
pressed individuals, particularly dysthymic individuals, possess a dark and sometimes
even morbid sense of humor despite their chronic feelings of depression. From a men-
talizing perspective, humor can be considered to be a coping strategy and a positive in-
dication of mentalizing abilities; it attests a person’s ability to “play with ideas,” a key
feature of genuine mentalizing. For a therapist to recognize, and where appropriate
also playfully respond to, the ability for humor not only supports the patient’s capacity
for mentalizing but also provides a sense of mutual recognition and understanding.
Moreover, the interpersonal nature of humor may reflect an attempt to co-regulate
stress and arousal in the relationship with the therapist; that is, it reflects a mentalizing
stance, or at least an attempt at mentalizing. Yet humor may be deployed to undermine
the therapist rather than representing a constructive attempt to subtly adjust the levels
of intimacy in the therapeutic dyad or a capacity to take up the position of observer to
the self (Lemma 2000). Despite this potential, the absence of humor altogether often
indicates seriously impaired and distorted mentalization. Congruent with this assump-
tion, studies have found a negative relationship between impairments in mentalizing in
depressed patients and the appreciation of humor (Uekermann et al. 2008).
Mentalizing and Resilience in

Different Treatment Approaches to Depression
Findings concerning the relationships among mentalizing, attachment, stress regulation,
and depression may also help to explain the central role of interpersonal experiences in
the treatment of depression, and not least the role of a positive therapeutic alliance.
These findings may also partially explain why evidence-based psychotherapies have been
found to be associated with greater resilience in the face of adversity, whereas no rela-
tionship has been found between the duration of antidepressant medication treatment
and the probability of relapse/recurrence after discontinuation (Luyten et al. 2006).
Based on these findings, it is tempting to speculate that one of the common mecha-
nisms through which effective psychotherapies lead to reduced relapse rates in depression is
mentalization—that is, the metacognitive ability to reflect on the experiences and feelings
of oneself and others, even when faced with adversity, leading to enhanced adaptive capac-
ities to deal with life stress in the long run. In a reanalysis of the National Institute of Mental
Health Treatment of Depression Collaborative Research Program data, it was found that
both interpersonal psychotherapy and cognitive-behavioral psychotherapy, but not phar-
macotherapy, were associated with decreased stress sensitivity (Hawley et al. 2007) and an
increase in adaptive abilities to deal with stress and thus enhanced resilience (Zuroff and
Blatt 2003), which in turn predicted decreased levels of depression over an 18-month fol-
low-up period. Importantly, in this study, a positive therapeutic alliance was associated with
enhanced adaptive capacities to deal with stress (Zuroff and Blatt 2006).
Traditional cognitive-behavioral approaches, for instance, may systematically promote
mentalizing by drawing attention to automatic thoughts and dysfunctional attitudes, thus
fostering mentalization about the self and others (Bjorgvinsson and Hart 2006). The recent
focus within the cognitive-behavioral therapy movement on metacognition, or “thinking
about thinking,” is congruent with our emphasis on the importance of mentalization (Wells
2000). Mindfulness-based approaches may be particularly effective in fostering mentaliza-
tion about inner mental states and their effects on how one perceives and interprets the
world, including social relationships. Mindfulness-based approaches furthermore resemble
the mentalization-based approach to depression, as they also prioritize a focus on the process
of thinking and reflecting, rather than the content, and aim to foster awareness of inner
mental states and their impact on perception and interpretation.
Interpersonal psychotherapy, because of its focus on interpersonal relationships,
almost by definition prompts mentalizing with regard to the self-in-relation-to-others
(Klerman et al. 1984). Traditional psychodynamic treatments’ use of clarification, con-
frontation and interpretation, and examination of maladaptive representations of self
Depression 395
and others in the context of the therapeutic relationship (Leichsenring and Leibing
2007) are equally likely to foster mentalization. Moreover, as psychodynamic treat-
ments focus on the transference relationship, encouraging patients to discuss feelings
about the therapist and the treatment, working with the transference provides ample
opportunity to foster mentalization with regard to both self and others (elaborating,
then challenging, assumptions about the other’s attitudes and intentions; probing the
meanings and functions of these assumptions with respect to the therapist and in im-
portant external relationships). However, excessive use of confrontation or interpreta-
tion, especially in the early stages of treatment and with severely depressed and/or
traumatized patients, may be inadvisable and even harmful. Interventions that prema-
turely link current experiences with past experiences—or any intervention, regardless
of theoretical orientation, that overestimates depressed individuals’ ability for mental-
ization, whether the deficit stems from global impairments and distortions due to de-
pressed mood or from high arousal levels and resulting decoupling (taking “offline”) of
mentalization—may be counterproductive. Such interventions are only likely to evoke
more feelings of guilt and shame (“It’s all my fault. I already thought I was bad, but now
I’m even to blame for my husband leaving me. I deserve to be left”), defensive exter-
nalization (“I feel bad, and now you’re telling me that it’s all my fault! How is this pos-
sible? I can’t believe my ears”), and/or the feeling that one is not understood (“I really
can’t follow you; what do you mean by that?”). Likewise, overly supportive interven-
tions (e.g., “I see you feel really sad, perhaps now is not the time to talk about it, it may
be too difficult for you”), although sometimes necessary, may be equally counterpro-
ductive, as they tend to confirm depressogenic states of mind by making the person feel
beyond help when mood is low. By contrast, supportive interventions may actively
communicate an attempt at understanding and engender interest in the minds of others
and one’s own mind (e.g., “I see that you are really sad that your husband left you, but
I’m here and would like to understand what it is that makes you feel so sad”).
Experiential therapies, by their focus on affect states in the here and now in the
context of a positive therapeutic alliance communicating empathy and understanding,
may equally foster mentalization. For example, Greenberg and Watson’s (Greenberg et
al. 1998) emotion-focused therapy for depression, with its focus on empathic under-
standing and experiential processing of core emotion-linked depressogenic schemes, is
likely to promote mentalization.
Mentalizing and Depression

From an Evolutionary Perspective
From an evolutionary point of view, the ability to predict one’s own and someone else’s
responses, and to use that prediction to successfully navigate the social world, has prob-
ably acquired substantial survival value (Humphrey 1988). To predict one’s own re-
sponses and those of others requires an understanding of mental states. Mentalizing
not only has substantial survival value for the individual but also has been argued to ac-
count for other major differences between humans and animals that lack the ability to
mentalize—such as, in humans: 1) self-awareness and self-consciousness; 2) a striving
to live beyond one’s body, to aspire to a spirit that transcends physical reality and to step
beyond one’s own existence; and 3) the social origin of a sense of selfhood in the rec-
ognition of oneself in the mental state of the other (see Allen et al. 2008).
It is notable, however, that these core features of mentalizing also seem to be related
to the core features of depression. Thus, alongside the major evolutionary advantages,
there is a potential shadow side to mentalization. First, self-awareness and self-conscious-
ness bring with them social emotions such as embarrassment, shame, and guilt. Such
emotions are important for regulating interpersonal relations, but in the extreme, these
self-conscious emotions may become maladaptive (Fontaine et al. 2006). Moreover,
awareness of being unable to achieve one’s aspirations may lead to feelings of depression,
loss, pain, and fatigue. Finally, the social origin of selfhood carries with it the risk (in the
case of insufficient or chronically unmarked mirroring of one’s self-states and aspirations)
of feelings of not being recognized as someone worthy of love, care, respect, and admi-
ration; and this can lead, in turn, to feelings of depression, anxiety, anger, and pain.
Hence, because of its broad and developmental focus on attachment-related pro-
cesses and the associated evolutionary advantages and risks of the capacity for mental-
ization, the mentalization-based approach to depression may be applied to a wide range
of mood disturbances. These may span from normal feelings of dysphoria and subclin-
ical depression to chronic and/or severe depressive states (e.g., dysthymia, major de-
pression, bipolar disorder, depressive personality disorder) or other disorders in which
mood disturbances are involved (e.g., personality disorders, somatoform disorders).
Impaired and Distorted Mentalization

in Depression
Both clinical experience and a growing body of research suggest that disturbed mood
impairs individuals’ ability to mentalize. Moreover, when depressed individuals at-
tempt to mentalize, mentalizing is likely to be distorted, as expressed in the reemer-
gence—either temporarily or more chronically—of modes of thinking that antedate
full mentalizing.
Impairments and distortions of mentalizing because of depressed mood are most
likely to be encountered in severely depressed patients. Hence, for therapists working
with these patients, discussions of etiological issues (e.g., trauma, dysfunctional atti-
tudes) that presume a capacity for insight and reflectiveness are contraindicated in the
early stages of treatment. Such discussions may be counterproductive because they are
likely to exceed the depressed patient’s ability to mentalize effectively about these issues.
Early introduction of these topics can create a vicious cycle of increasing self-criticism,
Depression 397
rumination, helplessness, and suicidal thoughts, which also tends to make the therapist
feel helpless and superfluous. Every clinician is familiar with the often extremely painful
sequence of self-accusations and expressions of helplessness and hopelessness that fol-
low from interventions that ask patients to dwell on their past relationships or current
mood. Such interventions more often than not lead patients to further pessimistic
thoughts about their own motives and those of others, in which the patients depict
themselves as victims of cruel or loveless significant others, or alternatively, by either
omission or commission, as guilty perpetrators.
From a mentalization-based perspective, depressed mood is likely to be associated
not only reduced with mentalizing but also with the emergence of distorted modes of
mentalizing. Foremost among these nonmentalizing modes is the reemergence of the
psychic equivalence mode, in which inner and outer reality are equated. From a phenom-
enological perspective, indeed, perhaps one of the best descriptions of depressed mood
is that it reflects a state of psychic equivalence, in which there is little or no room for
“pretend,” “play,” symbolization, or inner security of mental exploration (Allen et al.
2008), expressed in a lack of desire and/or inability to explore inner mental states. As is
well known, security of mental exploration also entails the freedom and willingness to
call for and accept help (Grossman et al. 1999), a tendency that is often notably absent
in severely depressed patients, especially melancholically depressed patients.
Importantly, psychic equivalence leads to equating psychological and physical pain
and emotional and physical exhaustion, which may explain the high comorbidity be-
tween pain, fatigue, and depression (Hudson et al. 2004; Van Houdenhove and Luyten
2008). Psychological experiences are felt as too real; there is a return to concrete think-
ing where psychological pain means bodily pain, worries feel like a painful weight on
one’s shoulders, and depressive thoughts literally press down on the self. Criticism by
others is felt as an attack on the integrity of the self, often experienced as physical pain,
threatening the integrity of the embodied self. Findings concerning the common neu-
ral circuits underlying psychological and physical pain further underline the close in-
tertwining of these experiences: rejection literally hurts (Eisenberger et al. 2003).
Hence, in psychic equivalence mode, a prereflective or “physical” self-experience re-
emerges in place of a psychological self-experience, with marked impairments to reflect
on psychological experiences. A state of hyperembodiment ensues, in which subjective
experiences are experienced as too real. As the phenomenologist Van den Berg stated,
“Whereas we are able to rid ourselves of the spell of a depressing landscape, the patient
is unable to liberate himself from his gloomy scenery” (Van den Berg 1972, p. 20).
Not surprisingly, therefore, phenomenological psychiatry has linked depression to
a disturbance in the experience of time (for a review, see Ey 1954): past, present, and fu-
ture do not have the same differentiated meaning for the depressed patient, but all feel
equally painful and immovable, leading to feelings of helplessness, hopelessness, and
anhormia (lack of drive) and disturbances in the experience of both objective and sub-
jective (autobiographical memory) time. The depressed patient often appears to be
locked in the “specious present” (James 1890), unable to free himself or herself from
rumination and worry and afraid of looking ahead or back. Hence, clinically, it is im-
portant to determine the extent to which depressed mood, versus more stable and pre-
morbid impairments in mentalizing, impairs a perhaps otherwise relatively intact
capacity for mentalizing. Moreover, as depicted in Figure 15–1 (p. 391), depressed
mood is likely to further increase arousal and stress levels, leading to a further decou-
pling of controlled mentalization.
In line with these assumptions, converging evidence from neuroimaging, neuro-
pathological, and lesion studies, as well as from stimulation and treatment studies in both
animals and humans, suggests that depression is associated with impairments in neural
circuits implicated in mentalizing (Fonagy and Luyten 2009; Luyten et al., submitted
2011a), including the medial prefrontal cortex, amygdala, hippocampus, and ventrome-
dial parts of the basal ganglia (Drevets et al. 2008; Johnson et al. 2009; Savitz and Drevets
2009). Moreover, these dysfunctions have been linked to failure of top-down regulation
and/or impairments in bottom-up input reflecting hypersensitivity of limbic structures,
which in concert may be responsible for the impairments in autonomic regulation, emo-
tion regulation, and neuroendocrine stress responses typically observed in mood disorder
(Drevets et al. 2008; Johnson et al. 2009; Savitz and Drevets 2009). Although much more
research is needed, interestingly, contemporary models of neural circuitry in depression
more specifically suggest that depression may be associated with an imbalance between
activity in the ventromedial prefrontal cortex and dorsolateral prefrontal cortex, with the
former subserving more affective functions (including projections to the ventral striatum
and the reward system more generally) and the latter subserving more cognitive or exec-
utive functions (Koenigs and Grafman 2009). More specifically, studies suggest that de-
pression is associated with hyperactivity of the ventromedial prefrontal cortex and
hypoactivity of the dorsolateral prefrontal cortex.
This pattern in depression is reminiscent of impairments in automatic/affective
versus controlled/cognitive mentalizing and the neural circuits underpinning these as-
pects of mentalizing (Fonagy and Luyten 2009; Luyten et al., submitted 2011c; see also
Chapter 1 in this volume). It suggests that depression is characterized by a failure of re-
appraisal and suppression of negative affect—that is, a failure of controlled mentaliz-
ing, resulting in a predominance of automatic, affect-dominated mentalizing. This
primacy of affect may help to explain the biased, nonreflective assumptions about the
self and others and the regression to prementalizing modes that characteristically dom-
inate depressive states. The imbalance between cognitive and affective aspects of men-
talizing would also be congruent with findings of diminished ability to recruit the
dorsal anterior cingulate cortex, which is involved in the integration of reinforcement
history during reward outcomes by girls at risk for depression (Gotlib et al. 2010) and
the failure of depressed patients to disengage from self-reflection when appropriate and
to activate the anterior medial areas associated with positively valenced thoughts
(Johnson et al. 2009). Similarly, disturbances in the experience of time have been re-
lated to disturbances in prefrontal cortex functioning in areas that are also involved in
mentalizing, such as the medial prefrontal cortex (Vogeley and Kupke 2007), and may
Depression 399
be related to the impairments in the attachment system through the dopaminergic sys-
tem, as dopamine type 2 receptor antagonists have been shown to lead to an impair-
ment of time estimation (Lalonde and Hannequin 1999).
Although these findings concerning the neural substrates of depression clearly
need further replication, they are consistent with the view that severely depressed in-
dividuals have lost the “self-righting tendency” that is associated with the capacity for
controlled mentalization. Yet, congruent with our view that depressed symptoms re-
flect responses to threats to attachment relations and thus threats to the self, rumina-
tion and self-criticism often also have an interpersonal function—as a cry for attention
and help, but also as an attempt to regulate internal mental states in the presence of
another. From the mentalizing perspective, these interpersonal functions, particularly
attempts to co-regulate arousal and stress in the context of a secure therapeutic rela-
tionship (see also Chapter 2 in this volume, on assessment), can be a primary target for
interventions aimed at fostering mentalization.
Because depressed mood first and foremost impairs the process of mentalizing, in-
terventions should be primarily focused on the recovery of the capacity for mentalizing.
This may start with basic containing interventions. Although merely being there—
being with the patient and recognizing his or her suffering—may not fully contain such
experiences, it at least provides a holding function. More specifically, the therapist’s
recognition of the intensity of the patient’s negative affective experiences and inability
to exercise an agentive response to them may paradoxically empower the patient to feel
that his or her “unbearable” emotional experiences constitute a mental as opposed to a
physical state, an imagined as opposed to a concrete reality, something that can be en-
gaged with mentally as opposed to dissociated from. As reviewed above, research has
amply demonstrated the positive, stress-attenuating effects of the mere presence of se-
cure attachment figures. Psychoeducational interventions explaining the influence of
depressed states on thinking and feeling may also be helpful in restoring mentalization
when done in a supportive manner. For instance, for many patients it is helpful to point
out that it is “their depression, not they, that is speaking.” Medication may be equally
helpful, particularly in severely depressed patients. Furthermore, restoring sleep and, if
possible, encouraging physical activity are further measures that may be helpful in the
recovery of mentalizing. Exercise in particular may not only distract depressed pa-
tients, but also reinstill a sense of efficacy and control, lead to a libidinal reinvestment
of the body, and probably have a stress-attenuating effect through its effects on the
dopaminergic reward system. These factors may explain the positive results of behav-
ioral activation in the treatment of depression (Cuijpers et al. 2010).
One particular characteristic that requires special attention in this context relates to
the high prevalence of suicidal thoughts in depressed individuals. Many different factors
have been involved in explaining suicidal thoughts, ranging from feelings of helplessness
and hopelessness to more complex explanations involving anger turned toward the self,
fantasies about killing hated parts of the self, and omnipotent fantasies about reunion
with lost loved ones. We do not deny the value of such explanations. However, from a
mentalization-based perspective, we suggest that it may be the too-realness of painful in-

ner states (feelings and emotions) that leads patients to ideas or acts of suicide in a last and
often dramatic attempt to silence inner feelings of pain. Suicidal thoughts, particularly
when intense, are precisely characterized by the absence of a self-correcting tendency.
There seems to be only one truth, a tunnel vision. Clinically, it is often when one is able
to open up a different perspective that suicidal thoughts disappear and mood lifts, which
patients often experience as a relief. This conceptualization is reminiscent of the views
propounded by Maltsberger and Weinberg (2006), who have proposed that suicidal
thought involves the following sequence of states: 1) a precipitating event, 2) the escala-
tion of intolerable painful affect that the patient cannot moderate, 3) the self-perception
of helplessness, 4) the evolution of hopelessness as a secondary affect, 5) increasing fan-
tasies of suicide as a means of escape, and 6) self-deconstruction, fragmentation, or dis-
integration of the self. Similarly, substance and drug abuse in depression can be partly
understood, congruent with self-medication theory (Khantzian 1997) and alcohol myo-
pia theory (Steele and Josephs 1990), as a means of silencing painful thoughts. These as-
sumptions are also congruent with Parker’s suggestion to differentiate between core
symptoms of depression and other symptoms that rather reflect coping strategies aimed
at restoring homeostasis (Parker 2007).
A second nonmentalizing mode that can be typically observed in depressed indi-
viduals is the teleological mode or stance, in which desires and feelings are equated with
observable behavior and/or material causes. Many depressed patients can feel loved
only if their partner, or any other significant other, also physically expresses his or her
love (e.g., by being present, buying gifts, staying home with the patient rather than go-
ing out with friends). This stance may lead to often frantic attempts to induce attach-
ment figures, including the therapist, to show that they care about, like, and love the
patient. Hence, patients may demand longer or more sessions and, in more extreme
cases, demand to be touched, caressed, or hugged by the therapist, which may lead to
boundary violations. Alternatively, many depressed patients are desperately looking for
“objective proof” of their illness. Therapists may find themselves in a discussion about
the biological or environmental causes of depression with patients who are often des-
perately trying to explain—and explain away—their depression by referring either to
biological causes (“It’s probably genetic; my father was also depressed”) or environ-
mental causes (“It’s because my father never loved me”). Although these latter expla-
nations often contain references to mental states and may be expressed with some
uncertainty, they are in essence nonmentalizing in nature because they are rigid and
self-serving attempts to explain one’s feelings of depression and hinder genuine men-
talization (e.g., about one’s own role in shaping one’s life).
Yet, although depressed patients often show clear impairments and distortions in
mentalizing, it is also well known that apart from the long list of cognitive biases and
distorted cognitions that depressed individuals are prone to, they may also show so-
called depressive realism, meaning that their perceptions, including perceptions of self
and others, sometimes may be more accurate than those of nondepressed individuals.
Depression 401
Depressed individuals sometimes seem to look at the world less with “rose-colored
glasses” than nondepressed individuals (Moore and Fresco 2007; Yeh and Liu 2007).
Hence, deficits in mentalizing may be context- or relationship-specific, so that de-
pressed individuals may primarily show mentalizing impairments with regard to
themes of loss, separation, or failure; with regard to specific attachment figures (e.g.,
mother or partners); and/or only with increasing levels of arousal or stress. As reviewed
in Chapters 1 and 2 of this volume and elsewhere (Luyten et al., submitted 2011c),
there is now considerable evidence for the assumption that mentalizing is to a large ex-
tent context - and relationship-specific and is closely related to stress and arousal levels.
Hence, whereas perceptions of the self and others may be quite accurate in low arousal
conditions, when arousal levels rise, mentalization deficits may become more pro-
nounced. Congruent with this assumption, studies have shown that depressed patients’
accounts of their attachment history are not necessarily distorted, but rather appear to
reflect the adverse circumstances in which many depressed patients grew up (Hardt and
Rutter 2004). Yet this depressive realism is not invariably “realistic,” being often ac-
companied by hypomentalizing: that is, the grim reality “is what it is” for the depressed
patient, and no alternatives can be envisioned.
This hypomentalizing phase is often followed by extreme pretend mode or hypermen-
talizing accounts in which the relation to reality is severed. Clinicians may be led astray
by what seem to be elaborate, differentiated, and largely accurate narratives involving
the self and others that depressed patients often provide during assessment. These re-
ports may strike clinicians—on first impression—as signs of genuine mentalization.
Yet, on closer listening, several features may distinguish such pretend mode accounts
from genuinely high levels of mentalizing, including 1) the often overly analytical, re-
petitive, and lengthy nature of such narratives, which are permeated by depressive
themes such as guilt and shame; 2) the self-serving function of such accounts (e.g., to
receive attention or compassion, or to control or coerce others); 3) the overly cognitive
nature of some accounts, out of touch with the underlying affective core of the experi-
ences, or the affectively overwhelming nature of interpersonal accounts; 4) the total ab-
sence, however illusory, of feelings of self-worth, self-liking, and perceived control
(“excessive depressive realism”); and 5) the inability to “switch perspectives” (e.g., from
a focus on the self to what could have motivated others in a specific situation: “I really
have no idea; probably because she hates me”). From this perspective, research that has
used interview methods such as the Life Events and Difficulties Schedule (LEDS)
(Brown and Harris 1989) to determine the impact of life events on the onset of depres-
sion has been wise to take account of individuals’ subjective perceptions in calculating
the contextual threat associated with specific life events in the prediction of depression.
Yet, on the other hand, these measures also, as a result, may overlook an important facet
of vulnerability for depression, namely impairments in mentalizing capacities. Genuine
mentalization should thus not be confused with hypermentalization or with rumina-
tion. Whereas rumination leads to exacerbations of depressive cognitions, effective
mentalization normally leads to lifting of depressed mood (Allen et al. 2008). This
assumption is borne out by studies showing a distinction between reflection and brood-
ing or rumination, with the former being related to improved mood, the latter to
worsened mood and suicidal ideation (Mathew et al. 2010; Miranda and Nolen-
Hoeksema 2007).
In summary, mentalizing impairments in depressed patients may primarily show
themselves in terms of hypermentalization-hypomentalization cycles. These cycles,
and the often subtle distortions in mentalizing with which they are associated, may par-
tially explain the inconsistent findings with regard to social cognition and depressive
realism in depression, particularly in mildly depressed patients and dysthymic patients
(Vogeley and Kupke 2007).
Mentalization and the

Phenomenology of Depression
The features described above suggest that the mentalization model of depression may
be thought of as integrating cognitive-behavioral, interpersonal, and psychodynamic
models. Whereas cognitive-behavioral models mostly start by exploring the patient’s
behavior, the focus of mentalization-based treatment of depression is interpersonal re-
lationships and the distortions in interpersonal understanding of mental states, both in
relation to the self and others, that underpin enduring and recurring interpersonal
problems. To some degree, distorted mentalization is captured in cognitive-behavioral
formulations of depression. For example, a depressed individual may “automatically”
interpret a friend’s failure to send texts or e-mails as an indication that this person no
longer likes her. This may make her think that a separate occasion when she was crit-
icized was more serious than it might have appeared, that the critics were correct in
identifying the patient as “useless,” and that she has no real friends. She then begins to
feel isolated and lonely and unable to contemplate facing her critics at work ever again.
In preference to going to work, she stays at home engaged in intense self-criticism, se-
lectively focusing on memories where she and others could see her as being inadequate.
These ruminations end up dominating her day.
Seeing these experiences in terms of problems in mentalizing, we can see the initial
misinterpretation of the friend’s failure to contact our patient as the trigger that leads to
a cascade of nonmentalizing reactions primed by the stress of an intense experience of
rejection. The failure of mentalization, which brings with it a reactivation of psychic
equivalence, makes her fleeting thoughts about not being likable become very con-
crete, endowed with a quality of physical reality. So that she can avoid the unbearable
distress associated with this way of thinking, a quality of pretense enters her thinking.
The ruminative quality of her contemplations of failure suggests a dissociation between
her thinking and her life situation. While this reaction is disproportionate in quantity
and highly selective in quality, it is also experienced as lacking in genuine meaning as a
Depression 403
consequence of mentation within the pretend mode. The physical disengaging from
friends and work colleagues is a teleological mode of response to the feeling of being
disliked. She cuts herself off physically as she feels cut off in a psychological sense from
her friends. The (social) world becomes imbued with hostility and failure and is felt to
be permeated with negative emotional experience.
A similar failure of mentalization can apply to thoughts about the future. Let us as-
sume that our patient not only ruminates about unpleasant experiences in the past but
anticipates even worse outcomes in the future. She anticipates negative reactions from
her work colleagues should she return to work, expects further failures and criticisms in
relation to the challenges immediately facing her, contemplates with dread the requests
that are piling up on her desk, and feels overwhelmed by the knowledge that she will
miss out on a key training event that might have enabled her to perform better in the
future. All around her, everyone is struck by how someone who had been confident,
competent, and assertive can now manifest such excessive concerns about her future
prospects. The failure of mentalization is pervasive in that she feels quite incapable of
constructing a realistic image of the feelings and thoughts of her work colleagues. She
is unable to separate her thoughts about herself from those of others, and this failure
generates a sense of certainty that her ruminative self-critical feelings are shared by ev-
eryone who has contact with her. However, her perception of her own capacities suffers
from the failure of mentalization and thus she is unable to assess accurately what she
might or might not be capable of, leaving her feeling grossly deficient in relation to the
backlog that she anticipates facing. Just as she undervalues her resources, she overval-
ues the training event from which she absented herself. Her metacognitive capacity (in
other words, her ability to make judgments about mental processes such as learning,
understanding, and remembering) has become dysfunctional, and therefore she is un-
able accurately to anticipate the realistic likely benefits of a brief training experience.
The continuity in the sense of self that mentalizing provides has receded, creating a
manifest discontinuity between memories of past experiences of competence and ex-
pectations of future success, simply because the protagonist in the memories of success
can be felt to be a different person from the agent in current awareness and the actor pro-
jected into the future.
In brief, we are suggesting here that the cognitive anomalies noted by cognitive-
behavioral practitioners can equally well be seen as dysfunctions in mentalizing. Our
patient is making “cognitive errors” in relation to making predictions about others’ re-
actions when these involve anticipating thoughts and feelings that others might expe-
rience in relation to particular circumstances. “Negative automatic thoughts” in
relation to the self, others, and the future may be seen as consequences of mentalization
failures and in particular teleological modes of thinking. The depressed individual’s
failure to challenge these and tendency to give them excessive importance is of course
a feature of the psychic equivalence mode of cognition.
We have already noted the somatic features that often accompany depression.
Elsewhere, we have suggested that the failure of mentalization brings about an inap-
propriate prioritization of bodily experience (Fonagy and Target 2007b; Moran and
Fonagy 1987; Moran et al. 1991). Of course, this view is in line with a long-established
tradition within psychoanalysis that sees somatization as linked with the failure of sym-
bolic thought (e.g., de M’Uzan 1974; Marty 1991; Sifneos 1973; Taylor 1987). In this
way, sadness becomes embodied. A feeling of hopelessness is translated into a bodily
posture, and the anticipated failure of agentive acts is palpable as psychomotor retar-
dation. The mentalizing approach makes no attribution of the direction of causality.
The collapse of symbolic mentalizing thought makes emotional experience less acces-
sible and less possible to reflect on as a physical state; but equally, physical inactivity can
undermine mentalization. Therapies that prioritize exercise and physical activity rely
on the assumption that changing physical state has a positive impact on mental func-
tioning. Regardless of the direction of causality, we claim that in a state of poor or in-
adequate mentalizing, the individual with depression experiences his or her bodily state
in mental state terms, which we regard as an extension of the teleological mode of
thinking to the body. After all, there can be little doubt that the first experiences of re-
flective thinking are somatic in nature. They are linked to the caregiver’s reactions to
changes in the infant’s physical state, hypothesizing underlying psychological changes
and communicating this understanding through alterations of her or his physical treat-
ment of the infant. Elsewhere we have suggested that this developmental history, which
in itself may be a quasi-repetition of the evolutionary origins of symbolic thoughts in
physical gestures (Fonagy 2000), leaves us open to attempting to identify intentional
states in bodily attitudes, hand gestures, and gross body movements, as well in prosodic
characteristics of language such as intonation and stress patterns. We suggest that in
nonmentalizing modes, this physical (externally focused) mode of envisioning inten-
tional states becomes dominant (see, e.g., Bateman and Fonagy 2004; Fonagy and Tar-
get 2006; Luyten et al., submitted 2011a). This mode applies not only to sensory
sensitivity to emotional states but also to its expression through bodily experience. By a
similar set of mechanisms, states of mind related to attachment may be thought of as te-
leological expressions of relatively stable relational attitudes.
Cognitive-behavioral models and the mentalization model would probably both
consider the origin of the predisposition to this kind of thinking to lie in early (child-
hood) life experiences. Yet, within the mentalizing approach, we consider early attach-
ment experiences, in particular, to be formative in relation to the generalized
expectations that an individual brings to a (social) situation and his or her capacity to
appropriately apprehend these. Moreover, we do not assume that depression necessar-
ily results from preexisting maladaptive expectations about the self and others that are
triggered by certain events, which is commonly assumed in diathesis-stress models
within the cognitive approach. Although the research we summarize below suggests
that generalized expectations rooted in disruptive attachment experiences confer vul-
nerability to depression, we suggest that depression is also, and perhaps primarily,
rooted in impairments in mentalizing capacity (in turn rooted in faulty attachment
experiences) that are commonly triggered when the individual is faced with stress and
Depression 405
adversity. Once triggered, mentalizing impairments result in the resurgence of non-

mentalizing modes, leading to distortions in the perception of the self, others, and the
future. Hence, such distorted perceptions may be thought of as the consequence, rather
than the cause, of depressive states—that is, the consequence of impairments in men-
talizing. Particularly in severely depressed states, as we discuss below, the two factors
(i.e., mentalizing impairments and maladaptive internal working models of self and
other) reciprocally reinforce each other.
Attachment in adulthood consists of characteristic patterns of cognitions (Hesse
1999; Main and Goldwyn 1995). As we have suggested, these do indeed originate in in-
fancy. They are characteristic of infancy in a visual metaphoric sense. The most striking
aspect of an individual whose history of attachment is one of avoidance, and who be-
comes dismissing of attachment relationships, is not just the apparent carelessness with
which he or she describes attachment relationships. What is most striking in dismiss-
ively toned AAI transcripts is the attitude toward mental life, the derogation of thinking
and feeling itself. Insecurity is embodied in the way in which thoughts are treated. It is
the embodied gestures expressed through thought processes that reveal this type of at-
tachment. At the metaphoric level, there is a physical gesture of avoidance that is em-
bodied in reaching out and finding nothing substantive (no meaning behind thoughts),
just as there is in the experience of not being able to retrieve an idea or of not being able
to get hold of a feeling or thought from the past. The gesture of the dismissive thought
is one of not needing and of turning away. The overvaluing of one’s unsubstantiated
thoughts and opinions is the hallmark of the narcissistic structure of idealization in Ds1
“dismissing of attachment” AAI transcripts (Main and Goldwyn, unpublished manu-
script, 1998). Failing to resolve contradictions in a narrative (talking about one’s
mother as caring, yet using her explicitly neglectful behavior as evidence) is a gesture of
deliberately failing to connect two things that belong together. Similarly, the resistant-
preoccupied pattern of attachment characterized in our coding systems as involving an-
ger or passivity shows itself in unfinished, run-on, entangled sentences. The gesture
that is expressed is one of needing to hold on, yet not being satisfied. Losing track of the
interview question and rambling on about irrelevant topics is a mental gesture that ex-
presses a feeling of being lost, or perhaps the very act of losing. In sum, we suggest that
the infantile attachment experience is also reflected in adult narratives through the
metaphoric structure of language. At that level, the experiences of infancy are depicted
by the way we manipulate our minds to create mental gestures that recall the formative
moments of infancy.
States of mind associated with security of attachment are believed to be rooted in
early interpersonal experience. Both cognitive therapies and mentalization-based
treatments consider the expectations created by such early experiences to be crucial in
creating lifelong vulnerabilities to depression. However, although within both cogni-
tive and interpersonal therapy this is thought of rather concretely as a maladaptive set
of expectations (dysfunctional assumptions), we assume within the mentalizing ap-
proach that early (attachment) experiences disrupt the robustness with which second-
order representations are established. More specifically, we assume that the secure ma-
ternal attachment that is associated with greater maternal sensitivity toward the child
leads to more robust, second-order representations of self-states, generating improved
affect regulation that enhances the quality of interpersonal interactions. Interpersonal
interactions that are relatively problem free will contribute to generating a social en-
vironment that is conducive to the development of improved mentalization. This type
of “virtuous cycle” generates a social background for resilience which arguably protects
individuals from their adversity associated with family history and life events frequently
found in the history of depressed individuals. By contrast, insecure early attachment
associated with nonmentalizing responses to the infant’s distress creates enduring
problems for the child in terms of insufficient opportunities for generating robust rep-
resentations of his or her subjective states that would normally be created through the
internalization of marked contingent interactions. For individuals with this attachment
history, mentalizing goes awry more frequently, particularly under conditions of high
arousal and the activation of the attachment system, generating teleological (control-
ling) behaviors. These behaviors have a destructive impact on social interaction, un-
dermining further social opportunities for the development of mentalizing. In contrast
to the virtuous cycle of the social facilitation of mentalizing associated with maternal
sensitivity toward the child, this pattern generates a vulnerability to adverse life expe-
riences such as negative life events and attachment trauma.
It should be noted, as we suggest elsewhere (see Chapter 16), that in individuals vul-
nerable to trauma as a consequence of less robust affect regulation and mentalizing ca-
pacity, traumatic experiences may themselves have destructive effects on mentalizing.
Such experiences undermine the social situations in which a dysfunction in mentalization
could be addressed in the context of a benign attachment relationship. Further, the
trauma itself can create patterns of biological reactivity that limit the capacity to think in
mental state terms. Consequently, adverse affective experiences associated with contem-
plating the mental states of those who harbor frankly hostile thoughts and feelings toward
the maltreated individual are generated. Thus, within the mentalization model, it is not
the prevalence of negative experiences that is seen as the cause of vulnerability to depres-
sion, but rather the impact that these experiences have on mentalizing.
Individual Differences in Attachment

History and Mentalization in Depression
Heterogeneity of Depression and
the Importance of Tallying Interventions
Depression is a notably heterogeneous condition with regard to etiology, symptom ex-
pression, course, and treatment response (Luyten and Blatt 2007). As a result, there is also
Depression 407
considerable heterogeneity in mentalizing deficits in patients with depression. This hetero-

geneity renders it extremely unlikely that a “one size fits all” approach to the treatment of
depression will be particularly effective. To help clinicians match their interventions to spe-
cific depressed patients, in this section, we will focus on the role of individual differences in
depression and their effects on mentalizing. In keeping with the general approach of this
chapter, we focus on the role of differences in attachment history. As noted, there is sub-
stantial evidence that vulnerability to depression is associated with attachment anxiety and
attachment avoidance and with the use of hyperactivating and deactivating attachment
strategies, respectively (Mikulincer and Shaver 2007). Attachment hyperactivating strate-
gies, which are typically used by anxious attached individuals (i.e., those with a preoccupied
attachment style), involve strategies that are aimed at finding security, leading to frantic
efforts to find support and relief, often expressed in demanding, clinging, and claiming
behavior. Attachment deactivation strategies, typically observed in avoidant individuals
(i.e., those with fearful-avoidant and, in particular, dismissive attachment), involve denying
attachment needs and asserting one’s own autonomy, independence, and strength in an
attempt to downregulate stress. Moreover, as outlined in Chapters 1 and 2 of this volume
(see also Fonagy and Luyten 2009; Luyten et al., submitted 2011a), these attachment strat-
egies have been shown to influence the neurobiological switch from cortical to subcortical
systems, and hence a switch from controlled to automatic mentalizing and subsequently
nonmentalizing modes as a result of stress.
Similarly, almost three decades of research have provided empirical support for
both psychodynamic and cognitive-behavioral approaches to depression that have pro-
posed a relationship between vulnerability to depression and the cognitive-affective
schemas of dependency or sociotropy and self-critical perfectionism or autonomy, par-
ticularly in interaction with life stress (Beck 1983; Blatt 2004; Blatt and Luyten 2009). As
noted, these dimensions overlap theoretically and empirically with attachment anxiety
and avoidance (Blatt and Luyten 2009; Luyten and Blatt 2011). Importantly, there is
good evidence to suggest that these two fundamental psychological dimensions in de-
pression are associated with relatively distinct dysfunctional interpersonal transactional
cycles (Luyten et al. 2006). Whereas dependent/sociotropic individuals may be able to
generate a positive social environment, their claiming, clinging relational style also
seems to elicit annoyance, resentment, and eventually rejection and abandonment, con-
firming their underlying fears of rejection and abandonment. By contrast, self-critical/
autonomous individuals have been found to be more ambivalent, critical, and distrustful
in relationships, criticizing other people while constantly fearing their criticism and dis-
approval. Accordingly, they are perceived by others as cold and distant and are less liked
by them. Thus, self-critical/autonomous individuals are likely to have not only few, but
also very ambivalent relationships, confirming their conviction that others do not like
them and criticize and disapprove of them. Moreover, they are unable to generate pos-
itive experiences in relationships and have also been found to continue to solicit social
comparisons, particularly when these comparisons are unfavorable (Santor and Yazbek
2006), which is likely to further confirm their negative self-views.
The implications of these findings for treatment, especially with regard to the na-
ture of the therapeutic relationship, are readily apparent. As both Blatt (2004) and Beck
(1983) have emphasized, dependent/sociotropic and self-critical/autonomous individ-
uals not only bring very different needs and expectations to treatment, they will also
perceive the therapeutic relationship differently, as they are prone to construct that re-
lationship in congruent ways so that their initial perceptions and experiences of the
therapeutic relationship match their beliefs and expectations. Hence, the therapeutic
process should aim to identify these typical dysfunctional transactional cycles or dom-
inant interpersonal narratives, explore and articulate them, then link these themes to
the presenting symptoms and work through the patient’s transference reactions (“men-
talizing the transference”).
Although this schematic model represents a huge oversimplification, in the follow-
ing sections we briefly describe prototypical impairments in mentalizing associated
with these different dysfunctional interpersonal cycles, which are linked to attachment
anxiety and avoidance (or to cognitive-affective schemas related to dependency/socio-
tropy and self-criticism/autonomy dimensions, respectively). Figures 15–2 and 15–3
schematically depict the hierarchy of relationships associated with these dimensions so
as to help identify dominant interpersonal narratives in patients’ accounts.
Attachment Deactivating Strategies and Mentalizing

Depressed individuals in general, and those who primarily use attachment deactivating
strategies in response to threats to attachment relationships in particular, typically have
a tendency to defensively inhibit mentalizing by the use of cognitive hypermentaliza-
tion, a pattern of overactivity, or a combination of both. Activity and work function as
avoidance strategies that enable the depressed individual to avoid reflecting on his or
her past or current life, because such reflection would be too painful and threatening.
Mentalizing in these individuals has been defensively inhibited because of underlying
feelings of sadness, emptiness, or rage that are developmentally linked to attachment
experiences. In addition, this deactivating strategy often serves to compensate for feel-
ings of failure or worthlessness, as a means of proving that they are “good” or “capable
of achieving important things in life.” Arieti and Bemporad (1978) characterized these
individuals as “dominant-goal oriented,” as they seem to live entirely for a very limited
number of often lofty goals, which they are determined to reach at all costs, primarily
at the cost of cultivating satisfying interpersonal relationships. But behind these dom-
inant goals lie attachment needs that are defended against, namely the wish to be loved
and cared for.
These individuals also often seem to be “disconnected” from their emotions and
their bodies, congruent with findings that attachment avoidance is associated with a
dissociation between subjective and bodily stress (Luyten et al. 2009). This may explain
the alexithymic-like features of some of these individuals and the high comorbidity be-
tween mood disturbances and functional somatic complaints in these patients (Van
Depression 409
Best friend
Partner
Colleague
Most involved
self
selff
Least involved
Intensity of emotional
investment
Mother
Daughter
Teacher
FIGURE 15–2. Hierarchy of relationships associated with high attachment anxiety

in dependent/sociotropic depressed individuals.
Best friend
Partner
Most involved
Colleague
Least involved
self
selff
Intensity of emotional
investment
Mother
Daughter
Teacher
FIGURE 15–3. Hierarchy of relationships associated with attachment avoidance in

self-critical/autonomous depressed individuals.
Houdenhove and Luyten 2008). As noted, attachment deactivation strategies are often
associated with a derogation of mental life as such and with a dominance of the teleo-
logical model, leading to a prioritization of “objective” knowledge. These patients may
also show gross “mindblindness” to the internal states of others, and sometimes also to
their own mental states. For instance, they may either be unaware of the fact that others
do not like them or, alternatively, exaggerate dislike by others.
However, in some patients who have a tendency toward intellectualization and ra-
tionalization, this mindblindness may alternate with a kind of “cognitive mentaliza-
tion” involving highly detailed, typically self-centered narratives, particularly when
they are asked to provide such accounts. Such accounts may sometimes be difficult to
distinguish from genuine mentalizing. The overly detailed, self-centered, and self-
serving focus of such accounts, combined with their overly cognitive nature which
seems decoupled from reality, and the inability to shift perspectives (e.g., from self to
others or vice versa), may lead to the identification of these accounts as pseudomental-
ization. Yet, even then, it may be difficult to distinguish such pseudomentalization from
genuine mentalization, particularly in patients who are highly educated or very verbally
gifted, as they may be able to give high-level mentalizing-like accounts even when un-
der stress, making it hard to distinguish them from more securely attached individuals
(Luyten et al., submitted 2011c). Yet, under increasing stress, mentalizing typically
breaks down, leading to the reemergence of strong feelings of dependency and feelings
of helplessness and hopelessness. Much easier to identify as failures of mentalization
are the highly dismissive accounts in which some of these individuals almost completely
deny the problematic nature of their complaints and relationships, or the highly ideal-
izing accounts in which some may minimize problems in or exaggerate positive aspects
of their attachment history—usually without being able to give any concrete examples.
Thus, although attachment deactivating strategies may be quite productive in the
short run, in the long run they may collapse as a result of increasing stress, such as a missed
promotion, a painful separation, the realization that life may involve more than achieve-
ment, or physical exhaustion, often associated with feelings of burnout, pain, and fatigue.
Because of their emphasis on cognition and their need for control, these individ-
uals are particularly prone to a combination of teleological reasoning and hypermen-
talizing, which may lead to a frantic search for an “objective,” often biological, cause for
their symptoms and complaints. This leads to further decoupling of mentalizing, often
accompanied by a plain rejection of psychological explanations. Indeed, any attempt to
focus on the possible role of psychological factors may be met with fierce resistance.
Therefore, the first task in working with these patients is to foster a mentalizing
stance before addressing underlying psychological issues, thus focusing on mentalizing
as a process and a capacity rather than on content. Hence, again, the linking of symp-
toms and mentalizing impairments to (current) interpersonal relationships, with a fo-
cus on the process of mentalizing, takes precedence over addressing the underlying
dynamics of these impairments.
This focus requires considerable effort on the part of the therapist, who has to
adopt not only an active and empathic stance but also a nondefensive and not-knowing
attitude, particularly because these patients often need considerable time to develop a
positive therapeutic alliance (Blatt et al. 2010). Only subsequently does there begin to
be room for identifying and linking typical interpersonal cycles and their associated
Depression 411
coping strategies (such as a pattern of overactivity and defensive compensation) to un-

derlying feelings of inferiority and worthlessness and the desire to be recognized,
loved, and cared for. Likewise, although mentalizing the transference plays an impor-
tant role in the treatment of these patients, they may feel attacked, shamed, or embar-
rassed by such interventions, particularly in the early stages; hence, the therapist has to
find a difficult balance between fostering a mentalizing stance effectively and being
overly intrusive. Indeed, in the early stages of treatment it is best to focus mentalization
interventions on issues that these patients typically prefer at this stage, such as auton-
omy, identity, power, guilt, shame, and worthlessness, and gradually link these issues to
their symptoms and relationships, rather than directly focusing on emotions and rela-
tionship issues involved.
Again, fostering mentalizing may not always be easy, as these patients may have little
capacity for adaptive pretend functioning and may be quite restricted and constricted in
their thinking. Yet, on the other hand, they often show marked cognitive abilities (e.g., as
expressed in a distinct dissociation between mentalizing in professional and in intimate
relationships) and will gradually begin to enjoy “playing with ideas.” This is an important
achievement—which they often also experience as such, because of their focus on
achievement and recognition—that signals a turning point in the treatment.
Attachment Hyperactivating Strategies and Mentalizing

Individuals who primarily use attachment hyperactivating strategies in response to
threats to attachment relationships often show a paradoxical pattern of hypersensitivity
to the mental states of others yet simultaneous defensive inhibition of mentalization,
because they are easily overwhelmed by emotions related to threats to attachment re-
lationships in the present and past (e.g., related to memories of abuse or neglect). More
specifically, they are easily overwhelmed by fear of rejection and abandonment and
fears about their own aggression and rage. Hence, in contrast to those who primarily
use attachment deactivating strategies, these individuals tend to have a low threshold
for decoupling of mentalization, and they typically also need considerable time to re-
cover from this decoupling. Particularly in situations of acute stress, or when they are
severely depressed, depressed mood seems to overwhelm them completely, which can
lead to a total inhibition of the capacity for mentalization. Moreover, attempts at gen-
uine mentalization are also often short-circuited because of hypersensitivity to the
mental states of others, including the therapist (Blatt 2004). Hence, in the early stages
of treatment, these patients will often try very hard to please the therapist and to say
what the therapist “wants to hear.” Moreover, they may be vulnerable to emotional
contagion, leading to confusion of their own mental states with those of others—
a tendency that is often quite pronounced in patients with comorbid borderline fea-
tures (Fonagy and Luyten 2009). Because of their attachment history, which is often
characterized by emotional neglect or abuse and/or conflicts over loss and separation
(Blatt and Homann 1992), they have become hypersensitive to the minds of others and
have often developed a hypersensitivity to signs of rejection, leading to strongly affect-

driven, hypermentalized accounts of their interpersonal relationships and/or defensive
decoupling of mentalization as a result of being overwhelmed by emotions linked to
these experiences. Hence, whereas security of attachment is associated with a relaxation
of mentalization, attachment hyperactivation strategies are typically associated with a
constant anxious preoccupation with other people’s mental states (Mikulincer and
Shaver 2007). This preoccupation is expressed not only in hypersensitivity to rejection,
separation, and loss, but also in a bias toward interpreting the behavior of others in
terms of rejection that can be very difficult to correct. For instance, when the therapist
yawns, he or she is bored; or when the therapist announces a holiday break, the patient
feels completely rejected and fears that the therapist would like to get rid of the patient.
Such a teleological stance is also expressed in a strong need to be liked, loved, and
cared for, which may show itself in demands for the (constant) physical presence of at-
tachment figures and strong demands for “objective proof” of love and care, related to
impairments in object constancy (Blatt 2004). This pattern may be accompanied by
hypermentalizing as expressed in extremely detailed and often confusing accounts and
fantasies about perfect or unrequited love, or by attachment narratives that betray a con-
tinuing enmeshment with attachment figures (e.g., mother or father) that can be further
exacerbated by self-other confusion. Particularly in higher-functioning patients (e.g.,
those with histrionic or hysterical features), such accounts may be quite elaborate and
dominated by a seemingly endless series of possible scenarios about relationships in the
past, present, or future, in which the self is often depicted as the helpless victim of the bad
intentions of others. This almost complete severance from reality is an indication of ex-
treme pretend mode functioning, which often becomes particularly obvious when the
therapist meets one of the significant others of the patient (e.g., partner or parent) and is
struck by the difference between this person and the patient’s accounts of this person.
Hence, although patients who rely on attachment hyperactivating strategies may
readily accept an interpersonal focus, their hypersensitivity to the mental states of oth-
ers, their difficulty with differentiating between their own and others’ mental states,
and their low threshold for the decoupling of mentalization may make it particularly
challenging to foster a genuinely mentalizing stance. Their dependent features, partic-
ularly their hypersensitivity to mental states, may be a two-edged sword. Because of
their developmental history and their hypersensitivity to mental states, they may show
genuine interest in the mental states of others, particularly the therapist, or they may at
least be open to the suggestion that mental states and attachment relationships may in-
fluence one’s attitudes and behavior. Fischer-Kern et al. (2008), for instance, found
higher levels of mentalization in depressed patients with dependent personality disor-
der, whereas there was a negative correlation between mentalization and features of
schizoid personality disorder (which are associated with attachment deactivating strat-
egies). These findings are consistent with studies showing that dependency is not only
related to ambivalence and conflict in intimate relationships, but also associated with
the ability to generate social support and to benefit from the support others offer
Depression 413
(Luyten et al. 2006). Yet while dependent/sociotropic individuals may be able to show
and receive care and affection, and may be concerned about others, effective mentaliz-
ing goes beyond showing affection and concern; it is the capacity to envisage different
states of mind of others. Hence, whereas these individuals may show concern for others
and may believe they are good mind readers, they often are not, and their concern for
others is frequently self-oriented.
Particularly in the early stages of treatment, therefore, while therapists must acti-
vate the attachment system in order to engage these patients in treatment, as in patients
who predominantly use deactivating strategies, there is a constant risk of the decou-
pling of mentalization, particularly if interventions are aimed at clarifying links be-
tween symptoms and interpersonal conflict and ambivalence. In lower-functioning
patients, such interventions may lead to a rapid decoupling of mentalization, with en-
suing rage, and thus be a threat to the therapeutic alliance. In higher-functioning pa-
tients, such interventions may lead to denial, rage that threatens to “bite the hand that
feeds it,” decoupling of mentalization, and disengagement from the treatment.
As Arieti and Bemporad (1978) have pointed out, the lives of these patients are of-
ten almost completely dominated by one or a limited number of “dominant others”
(e.g., mother, father, and partner). Mentalizing interventions that link current symp-
toms with relationship patterns, particularly with underlying feelings of dissatisfaction,
anger, and ambivalence, threaten the relationship with this “dominant other” and may
lead to disengagement not only on the part of the patient, but also on the part of the pa-
tient’s attachment figures, who may, in some circumstances, actively attempt to under-
mine the treatment.
Thus, with these patients, on the one hand there is a constant risk of premature ter-
mination, while on the other, there is the risk that the patient may unwittingly replicate a
dependent relationship, with the therapist becoming a new “dominant other.” Mentaliz-
ing the transference—that is, first identifying the patient’s responses to the therapist in
the here and now of the therapeutic situation, then linking these responses to other re-
lationships—counteracts this tendency. The therapeutic relationship may thus become
an interpersonal laboratory for the patient to experiment with new and different ways of
relating to others, which can often lead to mentalizing (initially hesitant, but as treatment
progresses, increasingly active) with regard to feelings of aggression, anger, and auton-
omy. This requires the therapist to acknowledge mistakes and feelings of loss, separation,
aggression, and frustration on his or her own part, thereby modeling a mentalizing
stance. Only then can the therapeutic relationship become a secure base to explore men-
tal states and their associations with current symptoms and attachment relationships.
Dysfunctions of the Attachment System and Mentalization

Patients with dysfunctions of the attachment system may show a sequence, moving
from deactivating strategies to hyperactivating strategies if the former fail, or may show
marked oscillations between the two strategies. In these patients, hypomentalization-
hypermentalization cycles may be particularly pronounced. At lower levels of person-

ality functioning, depressed individuals with these features often show many borderline
features and thus show mentalization deficits that have been documented in borderline
personality disorder (Fonagy and Luyten 2009). At higher levels of personality func-
tioning, these patients may show a pattern of fearful-avoidant attachment, and thus a
typical approach-avoidance conflict with regard to attachment relationships. This con-
flict is typically expressed either in very brief and barren accounts of attachment rela-
tionships, as in patients with schizoid and schizotypal features, or in hypermentalizing
accounts revealing both their desire for and their fear of relationships, as in patients
with hysterical features.
It is our impression that in individuals at lower levels of personality functioning,
disorganized attachment is related to identity diffusion, while individuals at higher lev-
els of personality functioning seem to be characterized by marked rigidity. Hence,
whereas the former group may be particularly responsive to mentalization interven-
tions, the latter may show high levels of pseudomentalizing, which is not only difficult
to distinguish from genuine mentalization, but also perhaps more difficult to treat. Al-
though there is some evidence to support these assumptions (Shahar et al. 2003), more
research is definitely needed to address this issue.
Treatment Implications
In this section, we briefly summarize the main treatment implications of the mental-
ization-based approach to depression. Although the overall strategy and background of
this approach differ from those of other treatments for depression, the techniques used
in this approach are by no means exclusive, and they can be flexibly integrated with
other treatments. (For a more detailed overview and a treatment manual that incorpo-
rates these views, see Lemma et al. 2011).
Briefly, the mentalization-based approach to the treatment of depression distin-
guishes three phases in treatment. Each phase has characteristic aims and strategies.
The core feature throughout is an unwavering focus on the patient’s mind, not his or
her behavior. The therapist’s interventions are primarily directed at linking interper-
sonal processes with the patient’s mental states.
The first phase of treatment aims at:
1. Engaging the patient in treatment by adopting an active, supportive, and empathic

therapeutic stance and by providing hope and structure.
2. Attaining recovery of mentalization, particularly in severely depressed patients, by us-
ing different interventions depending on the particular patient and situation (e.g.,
using supportive techniques aimed at holding and containment; using psychoedu-
cation to provide a different perspective on symptoms and complaints; prescribing
medication; restoring sleep; encouraging activity).
Depression 415
3. Identifying and exploring typical maladaptive interpersonal cycles or interpersonal narra-

tives, the typical attachment strategies used to cope with interpersonal issues, and
linking these to symptoms and complaints using both unstructured methods (e.g.,
in the context of a clinical interview or intake sessions) and structured methods
(e.g., the use of attachment descriptors).
The second phase mainly aims at:
1. Working through interpersonal issues and conflicts by fostering mentalization with re-
gard to self and others, particularly the therapeutic relationship. The extent to
which the patient is able to mentalize effectively about these issues as treatment
progresses is important in this regard, and especially so in the transference, as the
transference provides the therapist with a real-time assessment of mentalizing in
high-arousal conditions. Patient and therapist may agree to limit this focus to one
dominant interpersonal cycle or narrative that reflects the activation in the patient’s
mind of an affectively charged representation of self-in-relation-to-another, and
the defensive function of this configuration, as in Dynamic Interpersonal Therapy
(Lemma et al., in press). Attending to this more circumscribed focus nevertheless
aims to enhance and extend more broadly the patient’s awareness of how his or her
behavior is driven by mental states; it thus supports a mentalizing process that po-
tentially can be generalized beyond the particulars of the specific interpersonal dy-
namics that are worked through during the therapy.
2. Fostering resilience in the face of past, present, and future adversity by actively encour-
aging patients to reflect on and try out new ways of dealing with adversity, partic-
ularly new ways of relating to others and the self.
The third and final phase aims at the following:
1. Working through issues of loss, separation, autonomy, and identity that are triggered by the
impending end of the treatment (e.g., fears of losing the therapist, fears of relapse, fear
of failure when resuming work) by encouraging patients to express their fears and
wishes related to the prospect of the termination of treatment.
2. Consolidating changes and preventing future relapse by reviewing the treatment pro-
cess, exploring what has been achieved, and actively exploring how the patient is
going to use these achievements in the future.
Whereas the mentalizing-focused approach to depression may be implemented as

a brief, time-limited treatment with more modest aims, focusing on improvements in
mentalizing with regard to current relationships (Lemma et al., in press), a substantial
proportion of depressed patients, particularly those with marked comorbid personality
pathology, may need a longer, open-ended treatment approach focused in more detail
on the connection between current and past relationships and functioning, with the
aim of attaining more profound characterological changes. In this context, there is ev-
idence to suggest that patients who primarily use attachment deactivating strategies do
not respond well to brief treatments for depression, for several reasons: the typically
time-limited nature of these treatments may interfere with their need for autonomy
and control (Reis and Grenyer 2004), they may have more difficulty accepting an in-
terpersonal focus (McBride et al. 2006), and they may be unable to form a positive ther-
apeutic alliance within such a short time frame (Blatt et al. 2010).
As noted, many techniques used in the mentalization-based approach to the treat-
ment of depression are also used in other treatments (e.g., see Driessen et al. 2007).
What is specific to the mentalization-based approach is the unwavering focus on the pa-
tient’s mind in the context of a relationship with another person (i.e., the therapist) who
is interested in thinking with the patient about mental states and how they influence
symptoms and complaints, as well as attachment relationships, with the aim of fostering
mentalizing. Again, the emphasis is on the process of mentalizing; any intervention is
evaluated against the criterion of whether it helps the patient to mentalize more effec-
tively (e.g., by moving from impaired and/or implicit mentalization to explicit and con-
trolled mentalization). This aim implies not only an active and empathic stance from the
therapist, but also a “not-knowing” and curious attitude towards mental states, thus
modeling a mentalizing or pedagogical stance (Fonagy et al. 2007).
In addition, these techniques are evaluated against the criterion of whether they
contribute to enhanced resilience in patients—that is, whether they are likely to foster
adaptive feelings of autonomy and relatedness, thereby allowing patients to create, in-
sofar as possible, a more adaptive interpersonal environment characterized by relation-
ship recruiting and enabling them to cope better with the calamities of life. By fostering
mentalization, the therapist aims to reduce the patient’s vulnerability to relapse.
Finally, as noted, treatment techniques should be tailored to individual patients at each
stage of the treatment, and thus therapists must be able to use a range of supportive and ex-
pressive techniques flexibly. In the early stages of treatment, attachment-congruent themes
(e.g., loss, separation, and abandonment for patients using hyperactivating attachment
strategies; autonomy for patients using deactivating strategies) tend to dominate, but as
treatment progresses, attachment-incongruent issues tend to emerge, and the emergence
of this “other voice” requires therapists to move flexibly between the two voices, so as to fa-
cilitate adaptive flexibility in moving between different attachment issues in patients.
The therapist must find an optimal balance between attachment activation and men-
talization (Fonagy and Bateman 2006b). Reflecting on oneself and one’s autobiographical
past and self-concept is associated with activation of the neural areas that are involved in
mentalization, such as the medial prefrontal cortex (Gilboa et al. 2004; Lieberman 2007),
but these areas are deactivated when arousal increases (Lieberman 2007). Interventions
that focus prematurely on the patient’s past, particularly aspects of the past that were trau-
matic and are therefore likely to trigger high levels of stress, might be counterproductive
in patients with serious impairments in mentalization, particularly in the early stages of
treatment with severely depressed and traumatized patients.
Depression 417
Conclusion
The mentalization-based approach to depression starts from the assumption that symp-
toms of depression are reactions to threat to attachment, and thus to the self. From a
mentalizing perspective, individual differences in attachment history and the resulting
internal working models of self and others determine only in part how individuals deal
with such threats. It is primarily the capacity to mentalize that influences the extent to
which such threats have more lasting effects on mood. If this capacity is impaired, the
patient is likely to experience the world in a teleological or psychic equivalence mode, in
which he or she remains stuck in the painful present. Alternatively, impaired mentaliz-
ing capacity may lead to extreme pretend mode functioning, leading to (further) distor-
tions in representations of self and other, which in turn lead to further mentalizing
impairments. In this mode, what is causing depressive states remains unreflected upon,
unintegrated, and sometimes plainly dissociated.
Future research should investigate these assumptions further and should address
the efficacy and effectiveness of mentalization-based interventions in the treatment of
depression compared to other treatments with recent empirical support (Cuijpers et al.
2010). Currently, such studies are under way.
Suggested Readings
Besser A, Vliegen N, Luyten P, et al: Systematic empirical investigation of vulnerability to post-
partum depression from a psychodynamic perspective: commentary on issues raised by
Blum (2007). Psychoanal Psychol 25:392–410, 2008
Blatt SJ: Experiences of Depression: Theoretical, Clinical and Research Perspectives. Washing-
ton, DC, American Psychological Association, 2004
Lemma A, Target M, Fonagy P: Dynamic Interpersonal Therapy (DIT). Oxford, UK, Oxford
University Press (in press)
Luyten P, Corveleyn J, Blatt SJ: The convergence among psychodynamic and cognitive-behav-
ioral theories of depression: a critical overview of empirical research, in The Theory and
Treatment of Depression: Towards a Dynamic Interactionism Model. Edited by Corveleyn
J, Luyten P, Blatt SJ. Mahwah, NJ, Lawrence Erlbaum Associates, 2005, pp 107–147
Luyten P, Blatt SJ, Van Houdenhove B, et al: Depression research and treatment: are we skating
to where the puck is going to be? Clin Psychol Rev 26:985–999, 2006
CHAPTER 16
Trauma
Jon G. Allen, Ph.D.
Alessandra Lemma, B.Sc., M.A., M.Phil.
(Cantab.), D.Clin.Psych.
Cognitive-behavioral therapies for posttraumatic stress disorder (PTSD) dominate

the field of empirically supported treatments for trauma (Foa et al. 2009). Clinicians
struggle to help patients with long-standing and multifaceted problems who do not fit
this narrow conception. In this chapter, we use the concept of mentalizing to broaden
the perspective on trauma treatment in a way that integrates cognitive-behavioral and
psychodynamic approaches within the context of attachment theory and research.
We begin by rethinking the concept of trauma and the diagnosis of PTSD, arguing
that multifaceted trauma-related psychopathology requires a fundamental shift in per-
spective from a disorder-centered to a person-centered approach to treatment (Luyten
et al. 2008). An adequate understanding of trauma requires a developmental psycho-
pathology perspective that takes into account complex developmental trajectories
(Sroufe et al. 2005). We outline a theoretical model of the impact of attachment trauma
on the capacity for emotion regulation and mentalizing, emphasizing the dual liability
stemming from traumatic childhood attachments: these relationships not only evoke
extreme distress but also impair the development of capacities to regulate emotional
419
distress—in part through compromising the development of mentalizing. We describe

symptoms of traumatized patients that can best be understood as the consequence of
trauma-triggered hyperactivation of the attachment system coupled with failure of
mentalizing in the context of preexisting developmental vulnerabilities; this cascade
leads to the reemergence of developmentally more primitive modes of thought. We
propose that the overall aim of trauma treatment is to help patients establish a more ro-
bust mentalizing self so that they can be better equipped to mentalize trauma and re-
lationship conflicts and thus able to develop more secure attachments. We discuss some
of the special challenges of working with such patients stemming from the fears and
anxieties stimulated by becoming involved in a new attachment relationship with the
therapist. Finally, we review some therapeutic strategies in working with traumatized
patients, illustrating with clinical material.
What Is a Trauma and

How Do We Know It When We See It?
PTSD is merely one of many disorders for which traumatized patients seek treatment;
comorbidity is the rule (Keane et al. 2007; Magruder et al. 2005; Najavits et al. 2009).
Common co-occurring disorders and symptoms include other anxiety disorders, depres-
sion, substance abuse, dissociative disorders, suicidal states, nonsuicidal self-injury, eating
disorders, and personality disorders. Such multifaceted problems are particularly prom-
inent among patients who have endured extreme, repeated, and prolonged trauma—
especially early in life (Herman 1992b; Sroufe et al. 2005). Alongside a long-standing psy-
chodynamic tradition, increasingly eclectic cognitive-behavioral approaches have been
developed to treat trauma that extends beyond PTSD to include pervasive problems with
emotion regulation, identity, and relationships (Courtois and Ford 2009).
Diagnostic Issues Concerning

Posttraumatic Stress Disorder
Trauma is a fuzzy target for treatment. The term trauma is used ambiguously to refer to
exposure to potentially traumatic (i.e., extremely stressful) events and to the traumatic
effects of such exposure (i.e., in the sense of having been traumatized). Plainly, we treat
effects, not events. Yet exposure to events is included in the current diagnostic criteria
for PTSD, and ample room exists for disagreement about what level of stress counts as
being potentially traumatic. In DSM-IV-TR (American Psychiatric Association 2000,
p. 467), the potentially traumatic stressors are defined objectively and subjectively. Ob-
jectively, in Criterion A1, traumatic stress is defined as “the person experienced, wit-
nessed, or was confronted with an event or events that involved actual or threatened
Trauma 421
death or serious injury, or a threat to the physical integrity of self or others.” Subjec-
tively, Criterion A2 specifies that “the person’s response involved intense fear, helpless-
ness, or horror.”
Both objective and subjective stressor criteria have been substantially criticized
(O’Donnell et al. 2010). The objective definitions of trauma exposure (Criterion A1)
change with various iterations of DSM, and debate continues as to whether they should
be broadened or narrowed (Friedman and Karam 2009; Spitzer et al. 2007). On the one
hand, the focus on physical injury is too narrow: psychological abuse (e.g., being sadis-
tically tormented, terrorized, humiliated) can be profoundly damaging (Bifulco et al.
2002a), as can psychological neglect (Erickson and Egeland 1996). On the other hand,
the criteria might be too broad. Being “confronted with” a traumatic event, for exam-
ple, could include watching it on television. In addition, the subjective criterion (A2)
has been criticized for focusing too narrowly on fear to the exclusion of a host of emo-
tions that also contribute to PTSD, including shame, guilt, anger, and disgust (Brewin
2003; Friedman et al. 2007). Moreover, some persons develop PTSD without experi-
encing extreme distress at the time of trauma; furthermore, subjective distress is a weak
predictor of PTSD and has little bearing on prevalence estimates (Friedman and
Karam 2009). Accordingly, Criterion A2 does not appear in the DSM-5 draft criteria
for PTSD (www.dsm5.org).
Ironically, although PTSD (along with acute stress disorder) is unique among psy-
chiatric diagnoses in specifying a traumatic etiology, the etiological role of trauma in
PTSD is anything but simple. First, ample evidence indicates that exposure to objec-
tively defined traumatic events is not sufficient to produce PTSD; the vast majority of
exposed persons do not develop PTSD (Rosen and Lilienfeld 2008), although some
types of trauma carry a far higher risk than others (e.g., sexual assaults compared with
automobile accidents). Second, the symptom cluster of PTSD is occasionally evident in
the absence of objectively defined (i.e., Criterion A1) traumatic events (O’Donnell et
al. 2010). For example, gauged by responses to symptom checklists—which admittedly
lend themselves to overreporting (McHugh and Treisman 2007)—the PTSD syn-
drome has been observed in relation to common stressors such as family or romantic
relationship problems, occupational stress, parental divorce, and serious illness or
death of a loved one (Gold et al. 2005; Mol et al. 2005). Strong evidence indicates a glo-
bal dose-response relationship: the more severe the stressor, the greater the likelihood
of developing PTSD (Friedman et al. 2007; Vogt et al. 2007). Yet as the foregoing im-
plies, the relation between severity of stress and illness is by no means monotonic
(Rosen and Lilienfeld 2008), raising important questions about the precise etiological
role of the trauma event (the “T”) in PTSD.
In summary, objectively defined traumatic stress exposure is neither necessary nor
sufficient for the development of PTSD. Accordingly, serious consideration is being
given to dropping the stress-exposure criteria altogether (Friedman and Karam 2009;
Rosen and Lilienfeld 2008). Arguing that diagnosis of disorder should be based on de-
monstrable pathophysiology, Yehuda (2009) proposed: “It is important that we do not
consider events, even those that result in fear responses, as pathogens and, moreover,
that the expected fear and stress responses to such events are not conceptualized as
pathology” (p. 262). Sroufe et al. (2005) made a more general point in criticizing the
specific-pathogen/specific-disorder model of disease. They pointed out that discrete
causal influences and discrete resulting categories are no longer presumed in general
medicine, which recognizes that multiple interacting factors of various kinds can lead
to disorders such as heart disease, and they suggested that simple links should not be
taken for granted in psychiatry and psychology. Sroufe et al. advocate a developmental-
organizational approach within which early patterns of maladaptation and adversity
can be seen as creating vulnerabilities that may interact with later factors to result in
various psychopathological manifestations.
These considerations are very much in line with the critique of phenomenological
diagnoses that Thomas Insel and colleagues (Insel and Wang 2010; Insel et al. 2010)
have directed at DSM from the perspective of value for scientific discovery. From a re-
searcher’s standpoint, heterogeneous groups meeting relatively arbitrary diagnostic cri-
teria will not suffice. Such criteria cannot support the progress of science. Those seeking
National Institutes of Health funding will have to make their case in terms of inquiry
aimed at disease mechanisms rather than disorders. Taking the perspective of mecha-
nism rather than stimulus (event) or response (PTSD), we might define this group of
disorders simply as conditions caused by the effect of a salient social event on the psy-
chobiological capacities available to the individual for processing that event. In other
words, the mechanism of the disease is to be found in the event-processing systems of
the brain. Diagnosis depends on the extent to which the event was able to disrupt the
normal functioning of this neural network. This “Inselian” approach to defining the
subject matter should help us to move beyond trying to draw arbitrary lines around
symptoms that have a multitude of causes, many of which are unrelated to the effect of
events on the capacity to process the event, or around the nature of the events them-
selves, which, although retrospectively readily defined, have so far resisted non–
a posteriori delineation.1
The loose coupling between severity of stress and extent of traumatization indi-
cates the need for a complex causal model to account for PTSD. First, attesting to de-
1
From a psychodynamic perspective, it may be worth noting a curious echo of the distinguished
psychoanalyst Joseph Sandler’s struggle with the same conceptual conundrum. Prompted in part
by the difficulty of defining trauma in absolute terms either as an intrapsychic experience of
being overwhelmed or as a particular category of external events, Sandler et al. (1991) revised
the concept. In an important theoretical advance, they specified that the pathological sequelae
of trauma do not depend on the child’s initial experience of helplessness in the face of the event
but rather on the child’s posttraumatic condition. They suggested that the clinical sequelae of
trauma may be a result of the continuing strain on the ego, determined principally by the degree
of inner conflict that remains after the trauma, crippling personality growth and leading to the
development of borderline, delinquent, or psychotic pathology.
Trauma 423
velopmental vulnerability, a multitude of pretrauma factors are significant. Genetic risk

is twofold: risk for exposure to potentially traumatic events (e.g., participation in com-
bat) and risk for developing PTSD after exposure (Segman et al. 2007). The former
type of risk, so-called gene-environment correlations (Plomin and Bergeman 1991),
raises complex issues of causality because behavior genetic studies have confirmed that
even events such as divorce carry a highly significant heritability component (O’Con-
nor et al. 1998). Ultimately, it will only be possible to disentangle the importance of
trauma relative to constitutional factors in the context of genetically informed longi-
tudinal studies such as the UK E-risk study (Polanczyk et al. 2009). Gender also bears
a complex relation to PTSD as a conditional risk factor (Kimerling et al. 2007). Men are
more likely to be exposed to traumatic events, but women are more likely to develop
PTSD after exposure. Yet gender and type of trauma exposure are confounded: women
are more likely to be exposed to high-risk traumas such as sexual abuse and assault;
moreover, such trauma often occurs repeatedly in attachment relationships—namely,
in childhood sexual abuse or in violent relationships with an intimate partner in adult-
hood. Other developmental factors predisposing to PTSD include young age at expo-
sure, lower socioeconomic and educational level, low IQ, personal and family
psychiatric history, impaired family functioning, and prior trauma exposure—most no-
tably, child abuse (Vogt et al. 2007). In a longitudinal study of vulnerability to child-
hood PTSD, MacDonald et al. (2008) used laboratory assessments of mother-infant
security and found that disorganized infant attachment predicted PTSD symptoms at
age 8.5 years for those children exposed subsequently to traumatic events. Hence, in-
fant attachment, presumed to bear on emotion regulation capacities, proved to be a sig-
nificant pretrauma risk factor for later childhood PTSD.
Prospective developmental studies of etiological factors in adulthood PTSD are
extremely rare, such that the Dunedin longitudinal study, in which participants were
carefully assessed at multiple intervals from birth to age 32, is particularly valuable
(Koenen et al. 2007). One set of risk factors is associated with the likelihood of being
exposed to trauma; these include difficult temperament, antisocial behavior, hyperac-
tivity, maternal distress, and loss of a parent in childhood. A second set of risk factors is
associated with the likelihood of developing PTSD after exposure; these include low
IQ, difficult temperament, antisocial behavior, being unpopular, changing parental fig-
ures, multiple changes of residency, and maternal distress. Consistent with extensive
developmental research, a cascade is plainly apparent: an accumulation of different cat-
egories of risk factors most powerfully predicts PTSD.
In addition to pretrauma factors, experiences at around the time of the trauma—
peritraumatic factors—play a role in the development of PTSD. As stated earlier, sub-
jective response (Criterion A2) relates weakly to the likelihood of developing PTSD,
although the fact that women report substantially more distress than men in the midst
of traumatic events may contribute to the gender difference in PTSD (Kimerling et al.
2007). Dissociative responses in the midst of trauma exposure have been identified as
a significant risk factor for subsequent PTSD in numerous studies (Allen 2001). Yet
surprisingly, Brewin (2003) concluded that “What happens after a trauma has been
shown consistently to have the biggest impact on whether a person develops PTSD”
(p. 56, emphasis added). Indeed, the most powerful posttrauma factor is lack of social
support (e.g., coldness, lack of sympathy, and criticism). Of course, the PTSD syn-
drome itself can contribute to negative social support (e.g., in others’ negative reactions
to emotional volatility or in injunctions such as “Just put the past behind you!”). Hence,
from our perspective, such unempathic and nonmentalizing responses in attachment
relationships, which might resonate with earlier adverse attachment experiences, po-
tentially play a significant role in vulnerability. Finally, it is not surprising that another
prominent posttrauma risk factor is ongoing stress in the aftermath of the ostensible
traumatic event (Vogt et al. 2007). Thus, from a developmental perspective, we con-
clude that reducing “the trauma” to any single event is arbitrary.
In addition to concerns about the specificity of traumatic etiology, numerous ques-
tions have been raised about the syndromal integrity of PTSD. First, as extensive co-
morbidity implies, many PTSD symptoms are relatively nonspecific (e.g., sleep
disturbance, irritability, concentration problems), and they overlap extensively with
those of other anxiety disorders and depression (McHugh and Treisman 2007; Spitzer
et al. 2007). Yet Elhai et al. (2008) found that removing these nonspecific, overlapping
symptoms from the diagnosis makes only a modest difference in prevalence estimates
and does not have an appreciable effect on rates of comorbidity or disability. These au-
thors concluded that although the reexperiencing symptoms are most specific to
PTSD, the intermingling of disorders implies PTSD’s lack of distinctness; hence, for
example, PTSD and depression may not represent distinct disorders but rather an in-
tegrated reaction to a traumatic stressor. Consistent with this last point, comorbid
PTSD and major depression could be construed as “a depressive subtype of PTSD or a
posttraumatic subtype of major depressive disorder” (Friedman et al. 2007, p. 548).
Syndromal integrity also is called into question by the extensive heterogeneity
among patients with PTSD. For example, externalizing and internalizing subtypes
have been distinguished (Keane et al. 2007). “Externalizers” are characterized by im-
pulsivity, antagonism and aggression, substance abuse, and Cluster B personality dis-
orders, whereas “internalizers” are prone to shame, anxiety, depression, avoidance, and
withdrawal. In addition, neuroimaging research has distinguished a dissociative sub-
type of PTSD (Lanius et al. 2006). Moreover, factor analyses of symptom clusters
rarely confirm the three main criteria sets in DSM-IV-TR (i.e., reexperiencing, avoid-
ance, and hyperarousal; American Psychiatric Association 2000); rather, a common,
four-factor solution includes reexperiencing and hyperarousal but separates effortful
avoidance from numbing (Rosen and Lilienfeld 2008). In addition, consistent findings
of substantial functional impairment associated with subsyndromal symptoms of
PTSD argue for a dimensional approach (Friedman et al. 2007), in which PTSD might
best be conceptualized as the upper end of a stress-response spectrum (Rosen and Lil-
ienfeld 2008). Ideally, severity of stress, severity of symptoms, and extent of impairment
would all be dimensionalized independently (Friedman and Karam 2009).
Trauma 425
Complex Posttraumatic Stress Disorder

Several clinicians have proposed diagnosing a broader pattern of trauma-related psy-
chopathology than PTSD. Herman (1992a, 1992b) initially formulated the concept of
complex PTSD to include a multitude of symptoms, relationship and identity distur-
bance, and patterns of suicidal behavior and nonsuicidal self-injury that can stem from
repeated and severe trauma, including childhood abuse and neglect. She proposed that
this amalgam of symptoms and personality disturbance be diagnosed as disorders of ex-
treme stress not otherwise specified (Herman 1993). More recently, van der Kolk
(2005; van der Kolk and d’Andrea 2010) proposed a childhood counterpart of complex
PTSD: developmental trauma disorder. Trauma that occurs in the context of attach-
ment relationships plays a significant role in the etiological component of these formu-
lations. Building on prior conceptualizations, Ford and Courtois (2009) reviewed the
range of proposals for characterizing complex PTSD, and their formulation is repre-
sentative. They defined complex psychological trauma as “resulting from exposure to se-
vere stressors that (1) are repetitive or prolonged, (2) involve harm or abandonment by
caregivers or other ostensibly responsible adults, and (3) occur at developmentally vul-
nerable times in the victim’s life, such as early childhood or adolescence” (p. 13). They
construed the multifaceted sequelae as complex traumatic stress disorders—namely,
“the changes in mind, emotions, body, and relationships experienced following com-
plex psychological trauma, including severe problems with dissociation, emotion dys-
regulation, somatic distress, or relational or spiritual alienation” (p. 13). Hence complex
traumatic stress disorders potentially entail extensive comorbidity, including a range of
symptoms and clinical syndromes as well as personality disorders—not to mention ex-
istential-spiritual concerns that transcend psychiatry (Allen 2005).
When we refer to “trauma-related disorders,” it is important to avoid the single-
pathogen/single-disorder mode of thinking. Rather, we must view these as disorders to
which traumatic stress makes some substantial, albeit individually variable, contribu-
tion in conjunction with a host of other etiological factors. This multifaceted etiology
often is true for “simple” PTSD as well as complex PTSD. Correspondingly, although
evidence-based, cognitive-behavioral approaches to treating PTSD have made an
enormous clinical contribution, the sheer complexity of trauma-related disorders indi-
cates that treatment involves far more than processing traumatic memories. Taking the
perspective suggested earlier—that PTSD is partly defined in terms of the interference
of a psychosocial event with the mechanisms available to the human mind to process
that event effectively—in principle opens the field to all cognitive and emotional ca-
pacities that are involved in the processing of salient social experience (Fonagy and
Target 1997). Attentiveness to strengthening emotion-regulation capacities in all the
cognitive-behavioral interventions respects some of this thinking because impaired
emotion-regulation is central to this domain of developmental psychopathology (Allen
2005; Sroufe 2005; Sroufe and Waters 1977). In reviewing the developmental lit-
erature on attachment and maltreatment, one repeatedly encounters a puzzling and
paradoxical aspect of adaptation (in humans and in other species) to traumatic events,
which includes a disruption of some of the neural processes essential to adequate future
adaptation (see, e.g., Alter and Hen 2009; Coan 2008).
In reviewing PTSD, we have been setting the stage for a more extensive consideration
of attachment. Attachment is highly pertinent at each stage in the development of PTSD:
before, during, and after exposure to potentially traumatic stressors. As noted earlier, pre-
traumatic risk factors for adulthood PTSD include not only earlier attachment trauma but
also the quality of the family environment (Koenen et al. 2007), and the family environment
context plays a significant role in attachment security (Belsky 2005; Sroufe et al. 2005).
High-risk traumatic stressors in adulthood often take place in attachment relationships—
as noted earlier, especially for women (Kimerling et al. 2007). In addition, social support is
a potent posttrauma risk factor (Brewin 2003); mentalizing responses in secure attachment
relationships are a key source of positive social support, whereas nonmentalizing responses
in the context of insecure attachment are a prime source of negative support.
Attachment Trauma and

Developmental Psychopathology
Attachment theory and research offer a useful starting point for understanding the ef-
fect of trauma. Trauma triggers the attachment system and, concomitantly, inhibits ex-
ploration (Bowlby 1982). We feel distressed, and we want to be hugged. The July 7,
2005, London bombings triggered the need in Londoners to belong to a community, as
the September 11, 2001, attacks did in New Yorkers and the March 11, 2004, train
bombings did in residents of Madrid. Crisis most challenges those whose capacity for
relationships is weakest, whereas a history of secure attachments increases the chances
of responding to trauma in relatively adaptive ways. Why?
Classical attachment theory and some object relations theories contend that tem-
plates of relationships are established in infancy and are enacted in later development
(Bretherton and Munholland 1999; Crittenden 1994; Fonagy 2001a; Sroufe 1996).
Early traumatic experiences establish corresponding early relationship expectations,
and later traumas activate and interact with these previous expectations. Children ex-
posed to parental conflict, whose attachments have been disrupted and sense of security
undermined, are likely to anticipate rejection. Such children might dismiss a helper
in much the same way that avoidant infants in Ainsworth’s (Ainsworth et al. 1978)
“Strange Situation” feel they cannot risk turning to the caregiver for comfort.
Yet this model is still too simplistic. For example, to understand adult violence as a
mere repetition of attachment trauma fails to reflect the extent of the devastation that
attachment trauma causes to a child’s psychological integrity. To understand this dev-
astation, we must consider early development. In our usage, attachment trauma has two
senses: 1) referring to trauma that occurs in the context of an attachment relationship
Trauma 427
and 2) encompassing the ensuing disruption of the capacity to develop secure attach-
ments, with the concomitant impairment of mentalizing and emotion regulation ca-
pacities. We recognize that attachment relationships can be traumatic in adulthood as
well as childhood, as battering relationships exemplify (Walker 1979). Yet because of
their potentially shaping effects on development, traumatic attachments in childhood
merit particular attention. To reiterate, Fonagy and Target (1997) proposed a dual
liability stemming from childhood traumatic attachments: these relationships not only
evoke extreme distress but also impair the development of capacities to regulate emo-
tional distress—in part through compromising the development of mentalizing.
Coan (2008) elegantly conceptualized the role of attachment in emotion regu-
lation. He argued that the attachment system is “primarily concerned with the social
regulation of emotion responding” (p. 251). As Luyten et al. (submitted 2011a) also de-
lineated, social contact provides powerful positive reinforcement (in its reward value)
and, concomitantly, negative reinforcement (in reducing distress). The reinforcing
value of social contact in the context of heightened distress hinges on security of
attachment. Coan (2008) maintains:
[T]he brain’s first and most powerful approach to affect regulation is via social proximity
and interaction. This is most obvious in infancy.... Because the PFC [prefrontal cortex]
(Drevets et al. 1997) is underdeveloped in infancy, the caregiver effectively serves as a
kind of “surrogate PFC”—a function that attachment figures probably continue to serve
for each other to varying degrees throughout life. (p. 255)
Animal research has dramatically documented that disruption and trauma in early
attachment relationships compound the challenges of stress regulation. Polan and
Hofer (2008) focused on research with rats and noted that the adaptive function of at-
tachment goes far beyond providing protection from predators, as Bowlby (1982) ini-
tially proposed: attachment processes influence neurobiological development in ways
that shape basic emotion regulation and adaptive strategies. Specifically, high levels of
maternal stimulation immediately after birth, including licking and grooming, lead to
toned-down stress reactivity into adulthood, coupled with a proclivity toward explora-
tion and learning. Conversely, low levels of stimulation and interaction (e.g., as associ-
ated with prolonged separations) are associated with high levels of fear, defensiveness,
and avoidance, along with lower levels of exploratory activity. Simpson and Belsky
(2008) have spelled out the putative evolutionary function of these contrasting adaptive
patterns: the fearful-defensive (insecure) pattern prepares the animal for a harsh envi-
ronment with few resources, whereas the converse (secure) pattern prepares the animal
for exploratory learning in a stable, resource-rich environment. In effect, these early
rearing experiences are predictive of future environmental conditions to which the an-
imal’s stress response systems and behavior will be adapted. These adaptive patterns,
mediated by epigenetic mechanisms, constitute a form of “soft inheritance” (Polan and
Hofer 2008, p. 167) because they are passed on intergenerationally from mothers
through their daughters—an animal model of reenactment in attachment relation-
ships. Ford and Courtois (2009) reviewed literature consistent with that of animal
models suggesting that brain development can be skewed toward a focus on either sur-
vival or learning; of particular concern is the possibility of adverse effects on brain de-
velopment during sensitive periods (Alter and Hen 2009).
This sketch of developmental research is intended merely to draw attention to the
neurobiological side of the dual liability of attachment trauma that we noted earlier—
namely, the combination of evoking extreme distress while simultaneously undermin-
ing the development of the capacity to regulate that distress (Fonagy and Target 1997).
Notwithstanding inevitable inconsistencies in research findings, there is considerable
convergence on an “amygdalocentric” model of PTSD (Rauch and Drevets 2009).
With its emphasis on the prominent role of the prefrontal cortex (PFC), this model is
highly pertinent to our concern with trauma-related impairments to mentalizing. Al-
though the circuitry is extremely complex, a broad reciprocity exists between activity of
the amygdala (which is activated in response to threat, mediates fear conditioning, and
orchestrates many components of the fear response) and that of the medial PFC
(mPFC), which plays a role in extinction and “top-down” regulation of fear responses:
“individuals with anxiety disorders exhibit intrinsically exaggerated amygdala hyper-
responsiveness and/or deficient top-down modulation of the amygdala response due to
deficiencies in function within mPFC (Gusnard et al. 2001) and/or the hippocampus”
(p. 219). Rauch and Drevets (2009) summarized the circuitry in PTSD as follows:
This model hypothesizes hyperresponsivity within the amygdala to threat-related stim-

uli, with inadequate top-down governance over the amygdala by the mPFC and the hip-
pocampus. Amygdala hyperresponsivity mediates symptoms of hyperarousal and
explains the indelible quality of the emotional memory for the traumatic event: dysfunc-
tion involving the pACC [pregenual anterior cingulate cortex] underlies deficits in sup-
pressing attention/response to trauma-related stimuli; deficient vmPFC [ventromedial
PFC; Zald et al. 2002] influence underlies deficits in extinction retention; and decreased
hippocampal function underlies deficits in identifying safe contexts as well as accompa-
nying explicit memory difficulties. (p. 226)
This view of PTSD corresponds to the neurochemical switch hypothesis that we

have postulated (Arnsten et al. 1999; Mayes 2000; see Fonagy et al., Chapter 1 in this
volume). In effect, mentalizing goes offline when defensive (fight-flight-freeze) re-
sponses come online. Although this reciprocity has the adaptive value of promoting
rapid responses to imminent danger (e.g., traumatic events), it is maladaptive in less
dire interpersonal situations such as ordinary conflicts in attachment relationships that
call for complex social problem solving (i.e., mentalizing). As Mayes (2000) pointed
out, the thresholds for switching from flexible to automatic defensive responding may
be permanently altered by exposure to early stress and trauma. It is notable that the
mPFC has been identified as the mentalizing region (Frith and Frith 2006), and recent
research shows that childhood maltreatment, including emotional abuse alone, is asso-
ciated with substantial reduction of mPFC volumes (van Harmelen et al. 2010).
Trauma 429
Although limbic system hyperactivation coupled with prefrontal cortical hypoacti-

vation is commonly observed in trauma research, not all findings are consistent with this
model (Rosen and Lilienfeld 2008). Lanius et al. (2006, 2010) discovered one reason for
this inconsistency: a substantial minority of persons with PTSD shows the reverse pat-
tern. Specifically, in response to script-driven imagery, about 70% of participants have
the experience of reliving the trauma, concomitant with failed prefrontal inhibition
of limbic activity. Yet 30% report a dissociative response (e.g., feeling “zoned out” or
detached from their body), and this subgroup shows abnormally high prefrontal activa-
tion in conjunction with inhibited limbic activation. Hence, emotional dysregulation
has contrasting patterns: undermodulation and overmodulation of limbic regions by
medial prefrontal regions. The authors proposed that the dissociative subtype of PTSD
might reflect pathological emotional underengagement (Hopper et al. 2007) that might
undermine extinction processes normally mediated by the mPFC. This dissociative
subtype is especially likely to be associated with childhood trauma (Lanius et al. 2010).
The Traumatized Patient

The difficulties that traumatized patients have in understanding themselves and others
struck us forcibly more than 15 years ago while treating borderline personality disorder
in women and violent men (Fonagy 1989). Research has shown that the capacity for
mentalizing is undermined in most people who have experienced trauma. Traumatized
children have difficulty learning words for feelings (Beeghly and Cicchetti 1994), and
traumatized adults are more impaired in recognizing the intent behind facial expres-
sions (Fonagy et al. 2003).
The collapse of mentalizing in the face of trauma entails a loss of awareness of the
relation between internal and external reality (Fonagy 2000). Modes of representing
the internal world reemerge that developmentally precede awareness that thoughts,
feelings, and wishes are part of the mind (Fonagy et al. 2002a). Posttraumatic flash-
backs, like dreams, dramatically demonstrate psychic equivalence: reliving the trauma as
if it were happening again in the present takes the place of remembering the trauma.
Often, survivors of trauma simply refuse to think about their experience because think-
ing about it means reliving it.
The intrusion of the pretend mode, particularly in dissociative experiences, is another
means of dealing with the terrors of psychic equivalence. In dissociated thinking, nothing
can be linked to anything; the principle of the pretend mode, in which fantasy is cut off
from the real world, is extended so that nothing has emotional implications anchored in
a sense of self (Fonagy 2000). The return of the pretend mode generates a sense of emp-
tiness and disconnection. Patients report “blanking out,” “clamming up,” or remember-
ing their traumatic experiences as if in a trance or a dream. The oscillation between
psychic equivalence and pretend modes of experiencing the internal world is a hallmark
of traumatization.
Traumatized persons also may protect themselves against terrifying flashbacks

through negatively reinforcing (i.e., distress-reducing) actions such as substance abuse,
nonsuicidal self-injury, and bingeing and purging (Nock 2009; Roemer and Orsillo
2009). Such actions exemplify the third nonmentalizing mode of experience (Fonagy et
al. 2002a)—namely, the teleological mode—wherein mental states are expressed in con-
crete goal-directed actions instead of explicit mental representations such as words
(e.g., the patient who communicates emotional pain through scars on her arms). The
return of this teleological mode of thought (“I believe it when I see it”) is perhaps the
most painful aspect of a subjectivity stripped of mentalizing. Following trauma, verbal
reassurance means little. Interacting with others at a mental level has been replaced by
attempts at altering thoughts and feelings through action. Most trauma, certainly phys-
ical and sexual abuse, is by definition teleological. It is hardly surprising that the victim
may come to feel that the mind of another can be altered only in this same mode:
through action, such as threat or seduction.
The Aim of Mentalizing-Focused

Treatment of Trauma
The traumatized individual comes to treatment not simply to deal with the adversity
that he or she has experienced. The impairment of psychic function that attachment
trauma leaves in its wake devastates the capacity to cope with all the ordinary vicissi-
tudes of mental life such as unconscious conflicts over aggression, oedipal desires and
defenses mounted against them, narcissistic vulnerabilities, and conflicts in relation to
ambivalently cathected objects. All the inescapable pains of the human condition are
experienced with the immediacy of the open wound unprotected by the “skin” that
mentalizing provides. Some of these derivatives will interact with trauma suffered, but
the intensity of the associated feelings should not mislead the psychotherapist into
thinking that these later conflicts are the underlying cause of the patient’s mental an-
guish. They have been amplified and prolonged by the patient’s difficulty in mentally
processing any painful experience.
To reiterate, the overall aim of treating traumatized patients is to help them to es-
tablish a more consistent mentalizing self so that they become able to mentalize trauma
and conflict and thus to develop more secure attachments. Mentalizing provides a
buffer between feeling and action—in effect, a “pause button” (Allen 2001). Thus,
mentalizing puts the brakes on overwhelming emotions and impulsive actions, provid-
ing an opportunity for motivations of self and other to be monitored and understood.
Enhancing mentalizing bridges the gap between affects and their representation, espe-
cially with regard to current mental states. Promoting mentalizing in this sense does
not necessarily require direct processing of traumatic memories, but it does require
mentalizing painful emotions and conflicts in the context of an attachment relation-
Trauma 431
ship. In this vein, treatment fosters mentalizing in relation to the patient’s self, not just
in relation to the trauma. It entails finding or recovering mentalizing through a devel-
opmentally appropriate process—finding one’s authentic psychological self through
the mind of a benign attachment figure who is engaged in a reciprocal mentalizing re-
lationship.
How should therapists help a patient with memories of attachment trauma become
more able to mentalize about these experiences? Mentalizing-focused treatment of
trauma, as well as psychotherapeutic treatment more generally, is directed toward pro-
moting top-down regulation. Plainly, trauma-related hypofunctioning of the PFC is a
major treatment target for mentalizing interventions. Yet the overcontrol of emotion
typical of the dissociative subtype of PTSD also presents a target for mentalizing in-
terventions, which entail mentalizing emotion or “mentalized affectivity” (Fonagy et
al. 2002a; Jurist 2005)—namely, simultaneously feeling and thinking about feeling. Of
course, both extremes of underregulation and overregulation of emotion compromise
the capacity for mentalizing emotion (i.e., implicitly and explicitly, simultaneously).
The catch-22 for treatment is that mentalizing is most needed when it is least available.
Achieving effortful control of emotion is the goal of promoting explicit mentalizing in
psychotherapy as a top-down regulatory strategy (Luyten et al., submitted 2011c). Yet
this necessary treatment strategy runs counter to patients’ natural inclination toward
defensive avoidance of thinking about what has happened to them, an inclination
which, in the context of attachment trauma, is not easily mutable.
Working with traumatized patients presents the therapist with special challenges.
In normal development, acquisition of the capacity to think about mental states is likely
to be facilitated by attachment because attachment affords a safe context for making
mistakes. Missing out on early attachment experience (as was the case for Romanian
orphans, for instance) creates a long-term vulnerability from which a child may never
recover: the capacity for mentalizing is never fully established, leaving the child vul-
nerable to later trauma and unable to cope fully with attachment relationships (O’Con-
nor et al. 2003; Rutter and O’Connor 2004). More importantly, by activating the
attachment system, trauma, especially attachment trauma, will suppress the capacity
for mentalizing. Consequently, therapists will be challenged by three clinical phenom-
ena, which we discuss in turn: 1) hyperactivation of the attachment system, 2) adverse
effect of emotional arousal on mentalizing, and 3) externalization of the alien self.
Hyperactivation of the Attachment System

Attachment is normally the ideal training ground for the development of mentalizing
because it is safe and noncompetitive. This configuration, which is biologically adap-
tive in the context of normal development, becomes immensely destructive in the pres-
ence of attachment trauma. Attachment trauma hyperactivates the attachment system
because the person to whom the child looks for reassurance and protection is the one
causing fear. The devastating psychic effect of attachment trauma then results from the
hyperactivation of the attachment system by trauma, concomitant with the inhibition

of mentalizing. This trauma context demands extraordinary mentalizing capacities
from the child, yet the hyperactivation of the attachment system will have suppressed
the child’s limited capacity.
The coincidence of trauma and attachment creates a biological vicious cycle.
Trauma normally leads a child to seek safety in closeness to the attachment figure. This
heightened attachment generates a characteristic dependency on the maltreating fig-
ure, with the real risk of an escalating sequence of further maltreatment, increased dis-
tress, and an ever greater inner need for the attachment figure. The inhibition of
mentalizing in a traumatizing, hyperactivated attachment relationship leads to a pre-
mentalistic psychic reality, largely split into psychic equivalence and pretend modes.
The memory of the trauma feels currently real, so a continual danger of retraumatiza-
tion from inside is possible. The traumatized child often begins to fear his or her own
mind, needing the attachment figure even more. The inhibition of mentalizing is often
an intrapsychic adaptation to a traumatic violent attachment. The frankly malevolent
mental state of the abuser terrifies the helpless child. The parent’s abuse undermines
the child’s capacity to mentalize because it is no longer safe for the child to think about
wishing, for example, if this implies recognizing his or her parent’s wish to harm the
child.
A further complication follows because the child with attachment trauma who pho-
bically avoids awareness of the mind of the parent cannot use the other as a mirror to un-
derstand the self. This avoidance can result in diffusion of identity and dissociation. An
even more pernicious process ensues when the child is desperate for some kind of self-
awareness and psychic reality comes to be experienced through incorporating the malev-
olent other as part of the self. Taking the perspective of the other intent on destroying the
child is similar to what Anna Freud characterized as identification with the aggressor.
Adverse Effect of Emotional Arousal on Mentalizing

Arnsten (1998) aptly characterized hyperarousal as “the biology of being frazzled.” As
described in Chapter 1, Arnsten’s dual-arousal systems model delineates two comple-
mentary, independent arousal systems: 1) the prefrontal and 2) the posterior cortical
and subcortical systems (Arnsten 1998; Arnsten et al. 1999; Mayes 2000). The system
that activates frontal and prefrontal regions inhibits the second arousal system that nor-
mally engages only at quite high levels of arousal when prefrontal activity gives way to
posterior cortical and subcortical functions (i.e., more automatic or motor functions—
not thinking so much as running). The switch point between the two arousal systems
may be shifted by childhood trauma (see Figure 2–1 in Chapter 2 of this volume). Un-
doubtedly, because mentalizing involves the PFC, this switch accounts for some of the
inhibition of mentalizing in individuals with a history of attachment trauma; these in-
dividuals respond to increases in arousal that would not be high enough to inhibit men-
talizing in most of us.
Trauma 433
In light of the precariousness of mentalizing, it is important for therapists to mon-

itor the traumatized patient’s readiness to hear comments about thoughts and feelings.
As arousal increases, in part in response to interpretative work, traumatized patients
cannot process talk about their mind. Interpretations of the transference at these times,
however accurate they might be, are likely to be far beyond the patient’s capacity to ab-
sorb. The clinical priority must be reducing arousal so that the patient can again think
of other perspectives (mentalize).
Externalization of the Alien Self

Externalizing the alien self, with recipients being attachment figures—including ther-
apists—can become a matter of life and death for the traumatized patient. This need
has its roots in infant development. In the context of secure attachment, the infant
gradually constructs a representation of his or her internal states through mirroring
and “normal” projective identification. However, if the caregiver fails to contain the in-
fant’s anxieties, metabolize them, and mirror the self-state, the infant is forced to ac-
commodate the object, an alien being, within his or her self-representation. Edith
Jacobson (1954) and Donald Winnicott (1956) independently noted that the internal-
ization of the representation of another before the boundaries of the self are fully
formed undermines the creation of a coherent sense of self.
Of course, these introjections in traumatized individuals are colored by the trau-
matic context in which they occur. The caregiver with terrifying intentions is internal-
ized. This internalization can generate momentary experiences of unbearable psychic
pain when the self feels attacked—literally from within—and potentially overwhelmed
by an experience of badness that is impossible to mitigate by reassurance. Experienced
in the mode of psychic equivalence, the feeling of badness translates directly into actual
badness from which, in a teleological mode of functioning, self-destruction might ap-
pear the only escape. In our view, this intrapsychic state is commonly the trigger for the
acts of nonsuicidal self-injury and suicide attempts that are often associated with at-
tachment trauma.
The only way the traumatized person can deal with such introjects is by continually
externalizing these alien parts of the self-structure into a container. Through projective
identification, the persecutory parts are experienced as outside. It is then essential that
the alien experiences are owned by another mind, so that another mind is in control of
the parts of the self set upon its own destruction. To reiterate, the need for projective
identification is a matter of life and death for those with a traumatizing part of the self-
structure, but the constellation creates a dependence on the object that has many fea-
tures of addiction. Yet we know that the triggering of the attachment system (by the
need for a proximal container for traumatized, alien parts of the self) could further sup-
press mentalizing. This suppression reduces the chance of alternative solutions being
accepted or finding non-teleological (non-physical) solutions.
Therapeutic Work With

Traumatized Patients
The following patient’s traumatic experience illustrates some of the general principles
we have presented:
In some respects Mr. P was a privileged young boy: he had many friends whom he
trusted, he attended a good school, and he lived in a nice neighborhood. He had a close
extended family with whom he maintained regular contact. He had been very close to his
father, whose untimely death from cancer when Mr. P was 14 had represented a very
painful loss, but Mr. P felt that he had reconciled himself with his father’s death. He knew
that his mother had been unhappy; he was not sure why she was so unhappy. It might
have been the death of his father, he said, but he had never dwelled very much on this,
choosing instead to focus on his life outside the home and maintain a vitally important
and lively connection with his paternal grandparents.
One weekend when he was 17, Mr. P had gone on a field trip with his school. This
had long been planned for, but his mother had expressed some reservations about him
being away for “so long.” Still, he had gone, and his mother had not objected. He later re-
called having being very excited about this trip, in part because he was looking forward to
getting to know better the girl he had then been infatuated with. He was away for 2 days.
When he returned home, he found that his mother had hanged herself. Mr. P was the
first one to see her. He tried to revive her, but it was too late. He later learned that she had
probably killed herself the day he left.
Psychotherapy provides an opportunity for the patient to reconstruct his or her narra-
tive: to find the words to tell his or her story, not only in terms of the actual trauma that
the patient has endured but also in terms of the meaning the patient has given to that
experience. Crucially, it is an opportunity to help the patient (re)discover that he or she
has a mind. At its core must be the trust and hope that an “other” will hear the patient
and bear this narrative so that the effect of the experience, however bleak, can slowly
become more known to the self. In this way, a sustaining object may find its place in the
patient’s internal world. With Mr. P in mind, we now turn to discussing therapeutic in-
terventions with traumatized patients. It is clear from research that several therapeutic
techniques can be of help (Courtois and Ford 2009; Foa et al. 2009). Our emphasis is
less on techniques per se and more on a way of thinking about the therapeutic process
and about the therapist’s stance.
Interpersonal Security and Containment

In the aftermath of a traumatic event, the person’s sense of safety and trust in the good-
ness of life and of others is breached (Janoff-Bulman 1992). The unthinkable or unex-
Trauma 435
pected has happened, and a fearful state of mind dominates as a result. Nothing can be
taken for granted because terrible things do happen and, moreover, they have hap-
pened to the person. Consequently, the mind is in a hypervigilant state, which under-
mines mentalizing. Providing a safe and containing environment is therefore essential
and the first priority. The therapist can offer containment in several ways. At the most
basic level, containment is expressed through establishing safe parameters within which
the therapeutic process can unfold and on which the patient can come to rely. The im-
portance of a safe, reliable frame cannot be emphasized enough, especially in the case of
patients who have experienced trauma from attachment figures.
Psychoeducation also can help the patient to feel safer (Allen 2005). The symptoms
of PTSD and dissociation can be terrifying. Many patients fear they are going mad and
are hugely relieved when the therapist explicitly recognizes their symptoms as part of a
known clinical picture. This is not simply an exercise in educating the patient about
traumatic reactions, helpful as that may be. It is also about offering the patient an ex-
perience of being with a therapist who can understand states of mind that the patient
may fear will overwhelm not only him or her but also the therapist.
A trauma breaches the felt security of attachments, and the individual also may feel
in some way “marked” as different by virtue of what he or she has endured. To engage
the patient, it may be vital for the therapist to validate the sheer awfulness of what the
patient has experienced (e.g., “Most people who have endured what you have lived
through would feel as you do”). This validation is especially important when the
trauma implicates the individual in acts that he or she then may feel ashamed of, such as
rape or childhood sexual abuse.
In the therapeutic situation, the priority is to establish, as far as possible, a sense of
“interpersonal security” (Sullivan 1953) between therapist and patient that will contain
the patient’s anxiety. This process involves attending to the patient’s experience of the
therapy, and of the therapist, and responding to any anxieties or questions with genuine
interest and transparency.
It is unhelpful to approach the therapeutic encounter with long silences or to re-
spond to the patient’s questions or anxieties with a more classic interpretative stance,
particularly with those patients who have endured severe interpersonal trauma that has
undermined their trust in other people’s intentions toward them. Such an approach will
serve only to escalate their anxiety and will militate against the possibility of exploring
what they may be feeling or thinking. Naturally, because of their experiences, these pa-
tients will present with considerable paranoid anxiety: the therapeutic goal is not to es-
calate this quality of anxiety iatrogenically by being opaque but rather to create the best
possible conditions for the patient to be able to approach in his or her own mind what
will most likely feel both disturbing and terrifying.
In some cases, the patient’s paranoia is so pronounced that the therapist is very
quickly incorporated into the traumatized individual’s view of other people (e.g., as
“only torturers”). The therapist might be tempted to interpret this paranoia at the level
of transference; yet we believe that, particularly during the early phase of treatment, a
paranoid transference is best tackled directly by helping to ground the patient in reality,
as in the following case example:
Ms. Y, who had been sadistically tortured, arrived for her first assessment session looking
terrified. As the male therapist explained the boundaries of the session, it became appar-
ent that Ms. Y could barely look at him or take anything in. She was very agitated, ap-
peared confused, and could hardly speak. The therapist sensitively reflected on her
emotional state and invited Ms. Y to tell him whether something he had said or done had
contributed to how fearful she was feeling. Ms. Y struggled to reply; gradually, with the
help of the therapist, she was able to say that one of her torturers had a beard, like the
therapist, and that this likeness had acted as a powerful trigger for intrusive imagery. The
therapist then acknowledged how terrifying it must have felt to come to meet not only a
stranger but also a man and that to perceive such a disturbing similarity must have been
horrifying. He then reminded Ms. Y about who he was and the purpose of their meeting,
and Ms. Y noticeably relaxed.
The therapist’s mentalizing stance provided containment because of its emphasis on em-
pathically understanding the patient’s mental state and through his being transparent.
The way this therapist skillfully handled the opening sequence in this session set
the tone for the rest of the therapy. Ms. Y’s very disturbing experiences nevertheless
meant that she found it extremely hard to trust others, so she repeatedly cast the ther-
apist and others in her life in different versions of a torturing other. Part of the work
consisted of engaging the patient in thinking about these experiences as they arose in
relation to the therapist; that is, mentalizing the transference, a point to which we re-
turn later.
Mentalizing Trauma
The central therapeutic task is not specific to working with the content of the traumatic
events, but rather involves supporting a mentalizing stance in relation to the meaning
and effect of the trauma. That is, in this stance, the focus is primarily on the patient’s
mind, not on the event. In short, a mentalizing stance emphasizes process over content.
However, when working with traumatized individuals, content is clearly important, not
simply because the reality of what the patient has endured may need to be validated by
the therapist but also because the way the event itself has been processed by the mind is
often part of the problem; hence, the content of the actual event, in its affective detail,
is likely to require elaboration.
Ordinarily, memories of past events are recalled as stories that change over time
and that evoke manageable feelings. In the immediate aftermath of a traumatic event,
most people will experience a degree of stress, and memories of the event are likely to
intrude temporarily. As we have seen, a distinguishing feature of those patients who de-
velop PTSD is the reemergence of psychic equivalence (van der Kolk et al. 1996). Then
Trauma 437
the mind becomes a kind of danger zone that is best avoided. Recurring intrusive symp-
toms and reenactments are commonly observed in some patients (van der Kolk 1989).
The reenactments perpetuate the intrusive symptoms and vice versa (Allen 2001); this
vicious circle creates a feeling of “stuckness” in the traumatic past. This ongoing im-
mersion in the past has two important consequences. First, it severs connection be-
tween the pretrauma self and the posttrauma self: the person now becomes defined by
the trauma as it replays itself over and over again. Any prior resilience, for example, is
no longer within reach. Second, and connected to the first point, the stuckness para-
doxically represents an avoidance of thinking about the trauma in all its complexity and
hence having to confront painful affect. The patient has only one perspective and is
haunted by it. Although the patient feels that his or her mind is filled with only the
trauma—as a patient once put it, “I suffer from too much thinking about it”—in fact,
the patient is not engaged in the kind of thinking that involves developing a more subtly
nuanced understanding of what he or she feels and thinks. In many traumatized pa-
tients, the resistance to bringing to mind, and thinking about, highly distressing expe-
riences is understandable.
The meaning that the person ascribes to the trauma and its consequences requires
attention. Foa et al. (1999), for example, identified that negative cognitions about the
self, the dangerousness of the world, and the self’s perceived responsibility for the
trauma perpetuate PTSD. For Mr. P, his perceived responsibility for his mother’s sui-
cide became a central focus in the therapy. His preoccupation with questions of blame
and responsibility was apparent in several domains in his current life and in the thera-
peutic relationship, as we illustrate later with an excerpt from a session. An important
feature of any therapeutic intervention therefore involves elaborating the conscious
and unconscious meaning of the trauma for the individual—that is, developing an af-
fectively grounded narrative about the effect and meaning of the traumatic event so
that different perspectives on this experience can then be thought about.
Developing a Narrative About the Trauma

The conscious and unconscious meanings and affects that are attached to the traumatic
incident are a central part of the problem and of the recovery. The elaboration of mean-
ing and affect through focused questions and observations by the therapist aids the pro-
cess of gradually bringing these together into a coherent narrative about the self. Foa et
al. (2006) also identified narrative coherence as a mechanism of change in exposure
treatment for PTSD. Essentially, this mutative process involves developing a narrative
about the trauma that bridges the pre- and posttrauma self and that is forward looking.
Psychotherapy’s storytelling function has indeed been noted by several authors (e.g.,
Holmes 1998; Spence 1984).
Reconstruction is an important component of any therapeutic process. Nowhere is
this more relevant than when working with traumatized patients. One reason for this
lies in the particular problems with the encoding of memories for traumatic events.
The functioning of memory posttrauma presents a particular paradox: on the one hand,
patients complain of the intrusion of too much memory, as it were; on the other hand,
they may also present with very fragmented memories of the traumatic incident. In-
deed, intrusive symptoms frequently comprise fragmented sensory impressions, mostly
visual ones (Brewin et al. 1996; van der Kolk 1994). Patients also may reexperience par-
ticular physiological sensations or affects, such as intense fear, without any recollection
of the event itself. This kind of presentation has been cogently explained by Ehlers and
Clark (2000) as a manifestation of a problem with the way in which traumatic memories
are encoded and laid down. More specifically, they suggested that in PTSD the trauma
memory is “poorly elaborated and inadequately integrated into its context in time,
place, subsequent and previous information and other autobiographical memories”
(p. 325). Additionally, they proposed that “in those people with persistent PTSD for
whom the traumatic event has seriously threatened their view of themselves,...the gen-
eral organisation of their autobiographical memory knowledge base may be disturbed”
(p. 327).
Patients who present with the more fragmented, confused memories of the trau-
matic event appear to be more likely to develop chronic PTSD. This is probably partly
because they cannot intentionally retrieve the trauma memory and process it in such a
way that it can be integrated into a continuous narrative of their life pre- and post-
trauma (i.e., so that it can become part of autobiographical memory). Consequently,
they also remain hostage to strong perceptual priming (a form of implicit memory) for
stimuli that are temporally associated with the traumatic event. They therefore have
greater difficulty in discriminating between the stimuli present during the trauma and
those that bear some similarity to it (recall the earlier example of Ms. Y’s reaction to the
therapist’s beard). The more they feel hounded by the past through the intrusive symp-
toms, the more inclined they feel to revert to various avoidance strategies to protect
themselves from the painful affect. One of the most common strategies is to try to sup-
press thoughts about the trauma. This strategy is also a reliably unsuccessful one, be-
cause the more one tries to suppress such thoughts, the more their frequency increases
(Wegner 1994).
A core feature of the therapeutic intervention is the provision of a safe context
within which the patient can be helped to bring to mind the traumatic experience along
with the associated affects and the meanings ascribed to the trauma so that these cog-
nitive and affective components can be gradually unpacked. Cognitive-behavioral ap-
proaches have developed effective techniques for helping the patient who presents with
intrusive symptoms, such as reliving the traumatic incident and updating memories
(Ehlers et al. 2005; Foa et al. 2007; Resick et al. 2008). The use of these techniques may
be effectively integrated into an analytically informed therapeutic approach in the early
stages to help with the management of more acute symptoms that can have debilitating
consequences for day-to-day functioning.
As with any techniques that form part of an overall therapeutic approach, it is dif-
ficult to ascertain which components of the cognitive therapy are critical to eventual
Trauma 439
outcome. The important factor here, for example, may not be the specific memory
work; rather, the techniques are effective insofar as they enable patients to bring to
mind the traumatic event while foregrounding their affect and the meaning they as-
cribe to the experience. This is important because affect can be mentalized only if it is
“evoked, sustained and modulated” (Allen et al. 2008, p. 233) in the process of devel-
oping narrative coherence.
Working With the Past in the Present

Working with patients who have been traumatized necessarily involves working with
an event that occurred in the past. Especially when working with people who have en-
dured attachment trauma, the time lag may be considerable (e.g., between experiencing
sexual abuse in childhood and seeking help). Although we have been emphasizing that
it is helpful for the patient to develop a narrative about the trauma, we are not suggest-
ing that the primary aim of therapy is to excavate the past and to retrieve repressed
memories to develop insight. Rather, the goal is helping the patient to become curious
about his or her mind and hence to focus on current mental states. The therapist aims
to support the patient in attempts to make sense of the effect the trauma has on the pa-
tient’s current functioning and on current relationships, including the relationship with
the therapist.
Inevitably, this work at times will involve revisiting early experiences, particularly
when the trauma concerns abuse in childhood. Contextualizing traumatic events in a
narrative about one’s experiences over time is important, but it is unlikely that this will
be sufficient to support change. Reconstruction of the distant past is probably best
viewed as a component of the work, in the context of a more overarching focus on ex-
ploring the current implications of painful and confusing early experiences. The aim is
to help the patient develop perspective on the past by reworking current experience
(Bateman and Fonagy 2004).
The Therapeutic Relationship and Enactments

The interpersonal context in which the trauma narrative unfolds is vitally important, in
particular because traumatic experiences can severely undermine trust in the goodness
of others. No matter how benign the therapist, the patient may experience him or her
as a potential abuser. Often the patient will unconsciously seek to evoke particular re-
sponses from the therapist, and inevitably these will sometimes be enacted. The reex-
posure to situations reminiscent of the trauma may be compelling for some patients and
may exert tremendous pressure on the therapist. This tendency to reenact is also likely
to be apparent in other current relationships.
We consider reenactments to be ubiquitous and inevitable, and if we view them as
such, we are more likely to allow ourselves to spot them and to use them to further the
therapeutic work. Let us return now to Mr. P.
During the early phase of the work, it became very clear that Mr. P struggled to reconcile
himself with his guilt for having left his mother during the weekend when she hanged
herself. He blamed himself for having been selfish and wished that he had heeded her
sense that he was going away for “so long.” He was plagued by recurring nightmares in
which he opened the door to his mother’s bedroom and saw her dead body. He never
spoke about feelings other than sadness, loss, and guilt. Mr. P’s focus on the damage he
felt he had done to his mother could not yet give way to any reflection on the hurt she had
caused him. As the therapist listened to his self-recriminations, she imagined the rage
that Mr. P probably also felt toward his mother but that he could not yet acknowledge to
himself.
One week, there was a mix-up about a session: a few weeks earlier, Mr. P had in-
formed the therapist that he would need to miss one session, but the therapist apparently
had written down the wrong date, causing her to miss an appointment with Mr. P (the
canceled session was in fact 2 weeks later than the therapist had thought). When she ar-
rived at her office, she listened to a message from Mr. P saying that he had come but the
therapist had not been there. On the telephone message, Mr. P said that he had probably
“got it wrong” and would see her the following week. The therapist was puzzled and
deeply concerned about the sequence of events, unsure whether she had written down
the wrong date or whether Mr. P had been confused when he gave her the date. Later, she
called him and left a message.
The following week, Mr. P was very late—unusually so. The therapist noted that he
was markedly different as he walked into the room. He did not look at her and said that
he had little to say, claiming that things in his life were pretty much the same. Yet he
seemed irritable and distant. The therapist thought it was important to acknowledge
frankly that there had been confusion about dates and that she was sorry she had not been
there when he had come. Mr. P said that it had not been a problem; it had given him time
to go over to a friend’s house, and he understood that people could be so busy that they
forgot things. It happened to him, too, he added; he was forever losing or forgetting
things. In any case, he threw in, it was probably his fault. By this point, the therapist felt
that Mr. P was actually speaking as if he believed at some level that she had in fact been
at fault, and at the same time, he was keen to rescue her from her culpability and blame
himself instead.
The therapist shared that she felt concerned that she had not been there for his ses-
sion, that she was not clear in her own mind how they both ended up in this situation, that
it might actually have been her mistake, but that—whatever the facts of the matter—he
seemed to feel the need to reassure her that it did not matter anyway and that it was prob-
ably his fault. Mr. P replied that it really was “not a big deal,” and the therapist sensed that
he did not want to discuss this further. She said that as she listened to him, she wondered
whether it was not so much that he had nothing to say but that perhaps what he might
have to say was difficult to put into words.
At first, Mr. P shrugged his shoulders, but he said eventually that he had almost not
come to the session today. He had gotten distracted by a book he had picked up, time flew
past, and then he thought it would be too late to make it to the session. The therapist
asked him what he made of all this. Mr. P said that he was very distracted of late. The
therapist said that perhaps he was concerned that she also had been distracted when he
gave her the date for the canceled session. Mr. P replied again that “these things happen.”
Trauma 441
The therapist gently persevered, mindful that she did not want to be too intrusive but
also picking up that this was an important juncture in their relationship. She asked Mr. P
how he had felt when he had rung the doorbell the week before and she had not an-
swered. At first, Mr. P was silent, but he then told her that he had felt very panicky and
“sick,” and then, after a few minutes of waiting, he had started to say to himself that he
must have gotten it wrong. The therapist drew attention to the way that Mr. P had im-
mediately blamed himself when she had not answered the door, whereas in fact, it was not
clear how they had both ended up with different dates in their minds; maybe it had in-
deed been her error...? Mr. P interrupted and said that he thought it was more likely to
be his error. The therapist said that he seemed very preoccupied with the issue of who
was to blame. She wondered whether, in a way, it was easier for him to shoulder the blame
than to feel angry with her.
Mr. P looked up, and it was clear by now that he was tearful. He said that when she
had not answered the bell, he had been gripped by panic that something might have hap-
pened to her. After receiving her call later in the day, he had felt better, but later that
evening, he had felt inexplicably angry and was not sure why. He hated the feeling, and
that night he had gone out with a friend and got drunk. The therapist observed that her
unexpected absence had exposed him to a truly horrible experience: not only the panic
that something awful might have happened to her but also the anger that later overcame
him and that he had tried to dampen with alcohol. The therapist suggested that this an-
gry feeling was one he found really disturbing. Then Mr. P was able to talk about his in-
tense rage at times and how only the previous week he had hit the wall in his room so hard
that he had hurt himself. The therapist said that it seemed hard for him to feel free to
mentally acknowledge that he felt not only terrible loss and guilt but also, at times, rage.
Mr. P was silent for a while, and then he said, poignantly, that it was hard to hate someone
you also love. He then moved on to talk about his mother.
In this scenario, it was not possible for the therapist to know with any certainty
whether she had in fact made a mistake about the date, perhaps enacting a projective
identification with a mother whose mind is filled with her own preoccupations and
abandons her son/patient, exposing him to terrible dread. Ultimately, from Mr. P’s
point of view, knowing whether it was his therapist’s fault was less important than the
experience of the therapist being open to the possibility that this might have been so
and the therapist’s willingness to think about this with him. What appeared to have
helped Mr. P was the opportunity to explore a difficult event in the therapy with his
therapist and to be able to express his true feelings about it, which resonated poignantly
with his experience of and feelings about the traumatic scenario that had brought him
to therapy in the first place.
One of the challenges for the therapist when working with the immediacy of the
therapeutic relationship is to pitch the intervention according to the patient’s level of
emotional arousal. Mentalizing modulates strong needs and emotions and makes them
bearable, but we cannot mentalize if the emotional level of arousal is too high. This is
an especially important consideration when working with traumatized patients who
may be either hyperaroused or so dissociated from the trauma and everything around
them that it proves difficult to engage them in any reflective process. Mr. P was able to
make use of his therapist’s perseverance to explore what had happened, but other pa-
tients might have experienced a similarly benign intent as intrusive.
Objects of Hope
In the face of someone who has endured unthinkable experiences, therapists may be
tempted to reassure and to give hope. At one level, instilling hope as it is advocated by
some therapeutic modalities appears to be a humane factor that may be supportive for
some patients who have been traumatized. The patient who believes that he or she will
never be able to love or to trust another human being again might feel, at some level,
immensely relieved if the therapist reassures the patient that he or she can get better
and will feel love again. The key question here is how to help the patient to mobilize
this kind of hope. Is it by giving verbal reassurance? Is it by actively doing something to
help the patient? Is it by maintaining a thoughtful attitude in the face of unthinkable ex-
periences without being drawn into a “doing” mode? Or is it a mixture of all of these?
These questions have no easy answers. It is clear, however, that within the limits of
the therapeutic role, the therapist potentially provides a point of reentry into a non-
traumatized world. The therapist often becomes an “object of hope” (Cooper 2000)
and, in so doing, arouses both a wish and a need that can never be fully met. The pull to-
ward meeting these needs is often powerful, thereby making the therapeutic relation-
ship ripe for enactments.
In their work with traumatized patients, therapists must recognize their own sus-
ceptibility to the lure of omnipotence. Klein (1957) warned against identifying with the
patient’s need for reassurance, as this may lead the therapist to take the mother’s place
in the countertransference and so alleviate anxiety. This palliative effect is seldom re-
lated to enduring psychic change, even if it is eagerly sought by the patient and willingly
provided by the therapist. Well-intended attempts to give hope may conceal an anxiety
about one’s own helplessness in the face of a horrific reality. We suggest that therapists
can become objects of hope that the patient can internalize and “use” only if therapists
can bear to live within the limits of their therapeutic endeavors; that is, if they can bear
the pain of being unable to rescue the patient. Equally, therapists can sustain hope if
they can bear to be the hated object, the one who at times becomes indistinguishable in
the patient’s mind from the torturer or abuser, while remaining committed to working
collaboratively to help the patient understand what is happening in his or her mind
when experiencing the therapist in this manner. For the patient, the therapist’s capacity
to contain painful emotions and remain collaboratively engaged in a mentalizing stance
models a way of approaching the contents of one’s own mind openly, thereby broaden-
ing one’s perspective on particular events. Ultimately, this stance conveys the possibil-
ity of reconciling loving and hateful feelings within the self (Lemma 2004).
Because it casts patient and therapist in highly specified roles in relation to each
other, the transference relationship is one vehicle for hope. This relationship offers the
Trauma 443
patient the possibility of understanding and experiencing a different way of relating

(Cooper 2000). Possibility, and hence hope, is inherent in the immediacy of the ther-
apeutic dyad. Speaking of the effect of the trauma of genocide, for example, Auerhahn
and Laub (1984) proposed that the “role of the other is central in the effort at restitu-
tion of the good object and integration of evil and good, because it is specifically the in-
ternal representation of the link between the self and the other that has been devastated
during genocide” (p. 338).
The kind of “other” that the therapist strives to become for the patient is one who
is interested in knowing the patient, even when the patient hates what he or she dis-
covers about himself or herself. This is the best that therapists can offer patients. This
does not suggest at all that traumatized patients need only therapy or that the practical
support and the hopeful reassurance of others have no value. However, therapists must
be mindful of the very specific ways in which patients need to make use of them. These
specific functions may preclude therapists from meeting a range of other needs that are
equally important but not necessarily ones with which they can assist without overly
compromising their distinctive therapeutic contribution.
Hope is rooted in reality. This does not mean that therapists should squash expres-
sions of sometimes so-called fantastical hopes in patients by only interpreting their de-
fensive function. For those patients who have been severely traumatized, “hoping
against hope” may in the early stages be defensive, yet psychically adaptive, as the ego
slowly reintegrates itself in trying to overcome the trauma (Alvarez 1992). Hoping that
things could be different, perhaps by identifying with therapists as objects of hope,
might well be based on fantasies of potency, as well as on a version of the therapist as an
idealized object. These fantasies are defensive in one sense, but they may yet contain
the seeds of hope and therefore of change.
Conclusion
The psychological consequences of trauma, in an attachment context and perhaps be-
yond, entail a decoupling of mentalizing and a reemergence of nonmentalizing modes
of representing internal reality. This shift is pernicious because the immediacy of a
memory experienced in the nonmentalizing mode of psychic equivalence has the ca-
pacity to retraumatize repeatedly. This ongoing exacerbation of trauma further decou-
ples mentalizing and makes the experience ever more real. Trauma in the attachment
context is most pernicious because at a fundamental biological level, attachment entails
trust in the context of trustworthiness. Ironically, although secure attachment is the
training ground for mentalizing, security also affords the safety of not having to men-
talize and of knowing that others are thinking for us and we need not monitor our own
or others’ thinking.
Trauma inevitably activates the attachment system. Probably for evolutionary
reasons, this activation temporarily inhibits areas of the brain concerned with both
remembering and mentalizing. This is why mentalizing comes to be so readily aban-

doned in the face of trauma, particularly attachment trauma. Unmentalized trauma en-
dures and compromises mental function and interferes with new relationships. The self
being destroyed from within, by identification with the aggressor, compels projective
identification, drawing the other closer and selecting relationships that will retrauma-
tize. Thus, the individual loses a possible route to be freed from the shackles of a trau-
matic past that is continually relived.
As we have summarized elsewhere (Allen et al. 2008), the therapeutic benefit of
treatment is grounded in extensive research supporting a fundamental principle:
mentalizing begets mentalizing, in development and in psychotherapy. To escape from
the grip of trauma, the traumatized individual needs help to recover mentalizing by
means of a relationship with a therapist whose challenge is to sustain a mentalizing
stance while thinking the unthinkable.
Suggested Readings
Allen JG: Coping with Trauma: A Guide to Self-Understanding, 2nd Edition. Washington, DC,
American Psychiatric Publishing, 2004
Allen JG, Fonagy P, Bateman AW: Mentalizing in Clinical Practice. Washington, DC, American
Allen J, Fonagy P, Bateman A: The role of mentalizing in treating attachment trauma, in The
Impact of Early Life Trauma on Health and Disease: The Hidden Epidemic. Edited by
Lanius RA, Vermetten E, Pain C. Cambridge, UK, Cambridge University Press, 2008,
pp 247–256
CHAPTER 17
Drug Addiction
Ulla Kahn
I n this chapter, we discuss the relationship between personality disorder and drug ad-
diction and consider the rationale for mentalization-based treatment (MBT) as an in-
tervention for patients with both conditions. Mentalization-enhancing techniques
might be useful for several reasons (Table 17–1). First, a well-known overlap exists be-
tween personality disorders and drug addiction. Second, it is obvious that patients with
substance use disorders (SUDs) lack capacities in mentalizing as a consequence of their
addiction or turn to drugs because their mentalizing capacities fail them at times of
stress. Third, there may be a neurobiological link between brain processes related to
mentalizing and those involved in addiction mediated via the attachment system. We
now consider these areas in more detail.
445
Personality Disorders and Drug Addiction

The most common psychiatric comorbidity among drug abusers is personality disorder
(Uchtenhagen and Zeiglgänsberger 2000). Numerous studies of personality disorders
among substance abusers were summarized by Verheul (2001). This review showed
that among treated addicted persons, a median of 56.5% had at least one personality
disorder (range=34.8%–73.0% among different studies). The most prevalent person-
ality disorders in this group were antisocial (median = 22.9%; range =3.0%–27.0%),
borderline (median = 17.7%; range = 5.0%–22.4%), and paranoid (median = 10.1%;
range=3.2%–20.7%). Thus, personality disorders are about four times more prevalent
among psychiatric and addicted patients than among the general population. This con-
clusion also has been found to be true among nonpatient substance abusers (Zimmer-
man and Coryell 1989).
Trull et al. (2000) reviewed the empirical literature between 1987 and 1997 on the
comorbidity between borderline personality disorder (BPD) and SUDs. They found
17 studies that provided comorbidity rates of SUDs in individuals with BPD and 26 stud-
ies that provided comorbidity rates of BPD in individuals with SUDs. Among partici-
pants with BPD, 57.4% received an SUD diagnosis. More specifically, 48.8% in this
group met criteria for an alcohol use disorder, and 38.0% had a drug use disorder. The
prevalence of BPD among individuals with SUDs was as follows: 27.4% had BPD
among those with unspecified SUD; 14.3% had BPD among those with alcohol abuse
or dependence; 16.8% had BPD among those with cocaine abuse or dependence; and
18.8% had BPD among those with opioid abuse or dependence.
Cause or Effect?
An intriguing question is whether personality disorder leads to substance abuse or
whether drug problems cause subsequent personality disorders. This question was ad-
dressed in a longitudinal study of a random sample of children from Upstate New York,
who were assessed for Axis I and Axis II disorders, first in 1983 at a mean age of 13.7
(SD=2.6) years and most recently in follow-up at a mean age of 33.2 years (SD=2.9).
The study revealed that several personality disorders (schizotypal, borderline, narcis-
sistic, and passive aggressive) and conduct disorder (the predecessor of adult antisocial
personality disorder) in early adolescence were significantly related to later SUDs
(Cohen et al. 2007).
The co-occurrence of personality disorders and SUDs might be partially a result of
shared underlying personality traits. The role of negative emotionality and impulsivity
in this regard was studied among university students with self-reported substance abuse
and Cluster B personality disorder problems. Results showed that negative emotional-
ity was significantly related to drug and alcohol use problems, antisocial personality
Drug Addiction 447
TABLE 17–1. Mentalizing, drug addiction, and personality disorder
• Research shows co-occurrence of substance use disorders and personality disorder.

• Negative emotionality and impulsivity may mediate the co-occurrence.
• Vulnerability to loss of mentalizing in high arousal states may lead to drug use.
• Drug use impairs mentalizing.
• Drug addiction and attachment share a common neurobiology.
disorder, BPD, and narcissistic personality disorder. Impulsivity was significantly asso-
ciated with drug use problems, antisocial personality disorder, and histrionic personal-
ity disorder. Negative emotionality mediated the relationship between alcohol use
problems and symptoms of each of the Cluster B personality disorders. Impulsivity
only mediated the relationship between drug use problems and histrionic personality
disorder. These findings suggest that negative emotionality is more relevant than im-
pulsivity for understanding the co-occurrence of substance abuse and Cluster B per-
sonality disorder features (James and Taylor 2007).
The relationship between emotion dysregulation and BPD was examined among
inner-city substance abusers in residential treatment (N=76; 33% with BPD). The re-
sults showed that the presence of BPD was associated with higher levels of emotion
dysregulation, as measured with both a self-report measure and a behavioral test
(Bornovalova et al. 2008).
Other studies have suggested links between SUD and BPD. Victimization and per-
petration were studied among 77 women admitted to a residential treatment program
for pregnant and postpartum substance abusers. Two-thirds were pregnant, and the
rest were mothers of infants. Cocaine was the drug of choice for 88% of the partici-
pants. The victimization rate was 71%, and the perpetration rate was 73%. Victimiza-
tion was predicted by psychiatric and drug use severity, childhood physical abuse, BPD,
and posttraumatic stress disorder (PTSD). Perpetration was predicted by psychiatric
and drug use severity, BPD, PTSD, and aggressive-sadistic and antisocial personality
disorders (Haller and Miles 2003).
Finally, factors associated with suicidal behavior may be important in linking drug
misuse and personality disorders. Five independent major risk factors for suicide were
found in a study that used case-control psychological autopsy: major depressive episode
increased the suicide risk 41.2 times; SUD 3.2 times; emotionally unstable personality
disorder (the ICD-10 equivalent to BPD) 4.3 times; loss events 6.1 times; and suicidal
behavior in first-degree relatives 5.2 times (Cheng et al. 2000). The prevalence and rel-
evance of a suicide attempt history were studied among 103 participants in a substance
abuse program. A positive suicide history was found among 19% of the subjects, with a
significant overrepresentation among the women. Suicide attempters had a history
of abusing significantly more substances than did nonattempters. Abuse of alcohol and
sedative-hypnotics was significantly more frequent among attempters than among non-
attempters. No significant differences were found between the two groups with regard to
abuse of cocaine, marijuana, opiates, or stimulants. Attempters were more likely to have
psychiatric comorbidity because 60% had an additional current psychiatric diagnosis,
and 80% had an additional past psychiatric diagnosis. Most common were mood disor-
ders, such as major depression. With regard to personality disorders, male attempters had
significantly higher levels of borderline pathology, whereas female attempters had signif-
icantly higher levels of dependent, histrionic, and borderline pathology (O’Boyle and
Brandon 1998).
Diagnostic predictors of suicide attempts in a personality disorder sample were ex-
amined with a prospective design. During 2 years of follow-up, 9% reported at least
one suicide attempt. Multivariate logistic regression analysis indicated that baseline
BPD and drug use disorders significantly predicted later suicide attempts. Suicide at-
tempts were seen in 20.5% of those with BPD and 22.4% of those with drug use dis-
orders. Worsening in the course of major depressive disorder and of SUDs in the
month preceding the attempt also were significant predictors (Yen et al. 2003).
In a longitudinal study, a consecutive sample of drug users admitted for detoxifi-
cation in Lund, Sweden, was followed for 15 years. At 15-year follow-up, 24% were
dead. Predictive of 15-year mortality was the psychiatric status at 5-year follow-up,
whereas neither abstinence at 5 years nor any characteristics at baseline were predictive
of 15-year mortality. The authors concluded that psychiatric treatment, including psy-
chotherapy, may save more lives among substance abusers than do drug abuse services
(Fridell and Hesse 2006).
Psychotherapy for Dual Diagnosis

Only a few randomized controlled trials (RCTs) of psychotherapy for personality dis-
order and concomitant SUD have been done. Two of these studies involved dialectical
behavior therapy (DBT), specially modified for substance abusers with BPD. The es-
sential functions of this treatment are improving patients’ motivation to change, en-
hancing patients’ abilities, generalizing new behaviors, structuring the environment,
and enhancing the therapist’s ability and motivation (Dimeff and Linehan 2008). In the
first RCT, DBT for substance abuse (DBT-S) combined with drug replacement ther-
apy (methadone and methylphenidate) was compared with treatment as usual (TAU)
for 28 women with BPD and drug dependence. Patients receiving DBT-S had signifi-
cantly lower dropout rates and showed significantly greater reduction in drug abuse
throughout the treatment year and at 16-month follow-up than did the control group.
However, no between-group differences in parasuicide or inpatient use were seen
(Linehan et al. 1999). A second RCT compared BPD with substance abuse (BPD-S)
with comprehensive validation therapy with a 12-step program (CVT+12S) for 23 heroin-
Drug Addiction 449
dependent women with BPD, with both groups receiving drug replacement therapy
and an equivalent amount of contact hours. Both treatments were effective in reducing
opiate use and improving global adjustment but not in improving social adjustment or
reducing parasuicide (Linehan et al. 2002).
Another psychotherapy method especially designed for dual-diagnosis patients is
dual focus schema therapy (DFST), which is a 24-week manual-guided individual ther-
apy for a broad range of Axis II comorbidities that integrates symptom-focused relapse
prevention, coping skills techniques, and schema-focused techniques for maladaptive
schemas and coping styles (Ball 1998). In a randomized pilot study of 30 methadone
maintenance patients, DFST was compared with 12-step facilitation therapy (12FT).
Substance use frequency was reduced more rapidly in patients assigned to DFST. Fur-
thermore, patients receiving DFST reported strong and increasing therapeutic alli-
ance, in contrast to patients receiving 12FT (Ball 1998).
Dynamic deconstructive psychotherapy (DDP) is a manual-based psychodynamic
treatment developed for BPD patients with complications such as co-occurring SUDs.
It has been tested in one RCT. The treatment model is based on the hypothesis that
BPD patients have deficits in three areas of neurocognitive functioning essential for
building coherent and differentiated self-structures: 1) the ability to form associations
between different aspects of affective experience, 2) the ability to provide integrated at-
tributions to these experiences, and 3) the ability to assess the accuracy of these attri-
butions in an objective way. DDP aims to activate these neurocognitive functions
repeatedly to facilitate the development of an integrated and differentiated self. The
therapeutic stance is nonjudgmental and nondirective. It proposes an “openness to the
other,” which implies deferral of assured meaning and anticipation that new possibili-
ties will emerge during the course of treatment. DDP involves individual weekly ses-
sions, and the treatment duration is limited to 12–18 months. Additional treatments—
such as group therapy, 12-step groups, art therapy, and medication—are encouraged
but not required (Gregory and Remen 2008). In an RCT, DDP during 1 year was com-
pared with TAU for 30 patients with BPD and alcohol use disorder. Patients receiving
DDP showed significant improvement in parasuicidal behavior, alcohol misuse, insti-
tutional care, depression, dissociation, and core symptoms of BPD. TAU participants
showed only limited change during the same period (Gregory and Remen 2008).
Knowledge about the effectiveness of psychotherapy for dual-diagnosis patients
also could be derived from some of the clinical trials that had drug addiction as an in-
clusion criterion but that included a mixture of patients with and without concurrent
psychiatric disorders. Two examples are the clinical trials carried out in Philadelphia,
Pennsylvania, for opiate-dependent patients receiving supportive-expressive psycho-
therapy (SEP, a manual-based psychodynamic treatment) and concurrent methadone
treatment. In the first study, 110 patients were randomly assigned to drug counseling
alone, drug counseling plus SEP, or drug counseling plus cognitive-behavioral therapy
(CBT). The results showed general improvement across all therapies. Important inter-
action effects were found. Patients with low levels of psychiatric symptoms did equally
well with drug counseling alone as with drug counseling plus SEP or CBT. Patients
with mid-level symptoms did somewhat better if they had the extra psychotherapies.
Finally, patients with high levels of psychiatric symptoms did substantially better with
the additional psychotherapy than with drug counseling alone. The improvements
concerned employment, legal, psychiatric, and drug use indices. Another finding was
that patients with addiction and antisocial personality disorder did not show much im-
provement beyond reduction of drug use. However, patients with addiction, antisocial
personality disorder, and depression showed improvement in several areas, comparable
with the change among patients without antisocial personality disorder (Woody et al.
1984). A second study included only opiate-dependent patients with high levels of psy-
chiatric symptoms. After stabilization in methadone treatment, patients were randomly
assigned to two drug counselors or a drug counselor plus an SEP therapist. All patients
improved, with no between-group differences at 6 months. However, at 12 months, the
patients assigned to two drug counselors had lost some of their gains, whereas the pa-
tients assigned to a drug counselor plus an SEP therapist had maintained gains or con-
tinued to improve (Woody et al. 1995).
The National Institute on Drug Abuse Cocaine Psychotherapy Study included 487
patients who were randomly assigned to one of four conditions: 1) group drug coun-
seling alone, 2) individual drug counseling plus group drug counseling, 3) CBT plus
group drug counseling, and 4) SEP plus group drug counseling. At 6 months across all
treatments, the median level of cocaine use had declined, and psychiatric symptoms
and various areas of adjustment had improved. Patients with high levels of psychiatric
symptoms did worse than those with low symptom distress, but no interaction effect
was found between psychiatric severity and type of psychotherapy. An unexpected find-
ing was that individual drug counseling plus group drug counseling proved to be more
effective than both psychotherapy conditions (Woody et al. 1995).
Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity)
studied the efficacy of three therapies for alcohol dependence: CBT, motivational en-
hancement therapy, and 12FT. The study included 1,700 patients who were randomly
assigned to these three conditions. All three treatments showed good improvement in
terms of reduced drinking. However, the psychotherapies had no advantage, no inter-
action between outcome and psychiatric severity was seen, and 12-step facilitation
therapy had a slight advantage at the 15-month follow-up (Project MATCH Research
Group 1998).
Woody (2003) reviewed these findings and concluded that a consistent finding was
that psychosocial treatments (either psychotherapy or drug counseling) help patients
with addictive disorder. The best evidence for a specific role for psychotherapy appears
in the two Pennsylvania studies with methadone patients (Woody et al. 1984, 1995).
The methadone treatment engages the patients in treatment for extended periods of
time and substantially reduces opiate use and substance-related symptoms. This makes
it easier for the psychotherapist to focus on psychiatric symptoms and their relation to
drug use.
Drug Addiction 451
Attachment, Mentalizing, and

Drug Addiction
Findings from neurobiological research, reviewed by Insel (2003), suggested that
attachment and drug addiction to a large extent involve overlapping regions and pro-
cesses in the brain: the reward system. Several lines of evidence implicate mesocorti-
colimbic dopamine in the addiction process, and the pathway of interest includes the
ventral tegmental area (VTA), amygdala/bed nucleus of the stria terminalis, nucleus
accumbens, ventral pallidum, and thalamus. Thalamic projections to the prefrontal
cortex and cingulate cortex seem to activate feedback to the VTA. Addictive drugs lead
to dopamine release in this system. Research on rats and voles suggests that this neural
pathway is also involved in maternal care and pair bonding. Studies on maternal rats
showed that dopamine is released and c-fos is activated in the nucleus accumbens fol-
lowing pup exposure. Furthermore, injection of cocaine or a nonspecific dopamine ag-
onist directly into the nucleus accumbens decreases pup retrieval. In one experiment
(Mattson et al. 2001), maternal rats were trained to go to one cage for access to pups
and another cage for access to cocaine. At day 8, postpartum female rats preferred pups
to cocaine, whereas at day 16, they preferred cocaine.
Pair bonding is the development of a selective, enduring relationship with another
individual and is found among monogamous mammals, such as the prairie and pine
voles. Studies on such voles have shown that partner preference could be facilitated
with a dopamine D2 receptor agonist infused directly into the nucleus accumbens.
Conversely, a D2 antagonist infused directly into the nucleus accumbens blocked de-
velopment of a partner preference in the presence of mating. Insel (2003) suggested
that addictive drugs such as cocaine or heroin hijack the neural system that was selected
by evolution for behaviors associated with attachment and reproduction.
Studies that used functional magnetic resonance imaging suggested that the neural
processes described earlier are also present in humans with regard to maternal and ro-
mantic love. Bartels and Zeki (2004) studied the brain activity of mothers while viewing
pictures of their own children, contrasted with pictures of other children. Previously,
they had studied the brain activity of individuals in love when viewing pictures of their
loved one and other people (Bartels and Zeki 2000). Both types of attachment activated
regions in the brain’s reward system that coincide with areas rich in oxytocin and vaso-
pressin receptors. In addition, both types of attachment deactivated a common set of
brain regions associated with negative emotions, social judgment, and mentalizing.
Thus, the power of love includes both a strong neurochemical reward and a decrease in
social judgment and mentalization. Gabbard et al. (2006) suggested that these mecha-
nisms are involved in the hyperactivation of attachment found among patients with
BPD and may contribute to their frequently seen repeated strong attachments to abu-
sive others. Insel (2003) asked the following question: Is social attachment an addictive
disorder?
Flores (2004) flipped the coin and proposed that addiction is an attachment disor-
der. He views addiction as an attempt at self-regulation and self-soothing. The addicted
patient must learn the skills necessary to regulate affect and develop the capacity for in-
terpersonal mutuality and healthy intimacy. Addiction is viewed as a way of avoiding at-
tachment needs by retreating into a grandiose self or a false self; thus, addiction is
considered to be a manifestation of unmet developmental needs. The addicted person
is vulnerable to addictive behavior until the self-structure is repaired. Psychotherapy
could be seen as a regulatory attachment relationship, aimed at stabilizing emotions
and revising the emotional memory of attachment patterns. The therapeutic stance
should be fully emotionally engaged, in contrast to classical neutrality, to alter the pa-
tient’s inherently coded rules for being in relationships. The first phase of treatment
must consist of achieving sobriety. Before the patient can become attached to the ther-
apist and the treatment, he or she must detach himself or herself from the object of ad-
diction. The phase of achieving sobriety occurs when the addicted individual has a
moment of crisis and the attachment system opens. Receiving satisfaction from inter-
personal attachments at this moment is necessary to enable the individual to detach
himself or herself from drugs.
A cognitive, information-processing analysis of relapse in addictive behavior was put
forward by Breslin et al. (2002). They claimed that most drug and alcohol use is governed
by memory-based, drug use action plans established by repetitive, stereotyped drug use.
Both ongoing drug use and relapse are often automatic and scripted (i.e., with little con-
scious awareness or effort). According to the authors, these overlearned patterns of
thoughts and emotions could be prevented from leading to relapse by using mindfulness
practices through increasing awareness about those patterns and through exposure and
desensitization to triggers, especially negative affect. These treatment principles corre-
spond somewhat to the focus on mentalization and affect in MBT.
A relatively straightforward observation is that substance abuse impairs mentaliz-
ing because intoxication clouds all types of thinking and feeling (Tobias et al. 2006). In-
toxication induces relative mindblindness with regard to the experiences of others (e.g.,
how spouses and family members are affected by the substance abuse) and also distorts
mentalizing about oneself (e.g., by inducing feelings of omnipotence). A more subtle
question is whether mentalizing problems lead to substance abuse. Evidence for this
can be found in frequently reported triggers for substance abuse: dysphoric feelings
that the individual could not contain and regulate often precede substance abuse epi-
sodes, for example. Interpersonal difficulties, such as arguments with the partner that
the individual cannot tolerate and solve, are also a common trigger of substance abuse.
Rössel (2008) pointed out that substance abuse behavior is characterized either by psy-
chic equivalence mode or by pretend mode.
In summary, research findings and clinical observations suggest that substance
abuse behavior is related to issues of attachment and mentalizing. Drugs and alcohol
are used by the individual for affect regulation in the form of soothing, reducing fear
and anxiety, and generating euphoria. These functions are all performed by attachment
Drug Addiction 453
figures during childhood and sometimes also in adulthood. Episodes of substance abuse
among persons with borderline features are often characterized by failures in mental-
izing. The person is overwhelmed by strong affects, interpersonal difficulties, or
threats of separation (real or imagined), which trigger the substance abuse. In this way,
misuse of drugs or alcohol resembles the use of self-mutilation or other impulsive acts
also found among borderline patients. In the search for effective strategies for patients
with drug addiction, it seems promising to direct the therapeutic work toward improv-
ing the mentalizing ability in those situations that generally trigger substance abuse.
Mentalization-Based Treatment and

Drug Addiction
In this chapter, we are mostly concerned with those borderline patients who have SUDs
and require specialist treatment because of the extent of their addiction. However, many
patients with BPD frequently misuse drugs but not to the level at which they need a spe-
cialist program of treatment. This is well evidenced in most studies of patients with BPD.
In the original trial of MBT in the context of a partial hospital program (Bateman and
Fonagy 1999), nearly 50% of the patients were using illegal substances on a regular basis,
and in the most recent trial of outpatients, more than half were using cannabis on a daily
basis (Bateman and Fonagy 2009). Bearing in mind that substance misuse negatively af-
fects outcome of treatment, the treatment needs to take drug use into account for this
group of patients and integrate help for this problem into treatment.
In the MBT for dual diagnosis (MBT-DD) treatment programs, we suggest that
the interaction between mentalizing and drug use be discussed with patients at the start
of treatment as part of the psychoeducational component of the assessment and intake
process. Strong emotions lead to a reduction in mentalizing. As mentioned earlier,
drugs clearly reduce mentalizing, and loss of mentalizing, in the context of anxiety,
stimulates drug use. An outline of the interaction is proposed in Figure 17–1. Loss of
mentalizing leads to difficulties in paying attention to others’ mental states and increas-
ing anxiety about managing one’s own inner state. Recourse to drugs reduces anxiety
and induces a sense of control and pleasure but at the same time leaves the individual
unable to differentiate between inner and outer reality. Psychic equivalence predomi-
nates, meaning that further emotional states and thoughts are experienced with the
force of reality. This provokes further emotional experience, and the vicious cycle of
destructive interaction is completed. MBT for comorbid BPD and drug misuse is or-
ganized and delivered in line with this formulation.
The principles followed by the therapist when discussing drug use are the same as
those followed when exploring self-harm, as outlined in Table 17–2. A mentalizing
functional analysis needs to be done (see Mentalizing Functional Analysis section in
Chapter 9 for additional details). The therapist clarifies the narrative first, then asks the
Powerful emotion
Frightening, undermining,
frustrating, distressing, or Poor mentalizing
coercive interactions
Pleasure, but Inability to understand

loss of certainty or even pay attention
that thoughts are to feelings of others
not real
Drug use in Inner/outer world

attempt to control or seems
change self incomprehensible
FIGURE 17–1. Vicious cycles of inhibition of mentalizing within drug addiction.
patient to rewind to explore the mental states involved in drug taking in more detail.
The therapist requires the patient to rewind to a time before the actual drug use oc-
curred. The patient’s feelings and relationship experiences are discussed because many
people with BPD socialize with other drug users, which increases the likelihood of drug
taking and of being placed at risk for exploitation. For example:
Ms. A met regularly with a man who “spoiled” her by taking her to dinner and then giv-
ing her cocaine before they engaged in sadomasochistic sexual activities that she did not
enjoy but in which she felt she had to participate. She described him as her boyfriend,
even though he had other girlfriends. Over time, Ms. A had become dependent on him.
He gave her enough cocaine to last between their meetings.
When Ms. A was describing her meeting with her “boyfriend” the night before the
therapy session, the therapist asked her to consider her feelings before she had met him.
She said she was excited about the attention she would receive and his physical affection
toward her. Ms. A later described how this excitement was heightened through the use of
drugs, but she also glimpsed a feeling she described as desperation. The therapist focused
on her excitement about the attention and asked her to describe her feelings of wanting
attention in more detail. She said that she craved attention most of the time and was will-
ing to submit herself to physical pain and degradation to get it. This led to an exploration
of her shame, which initially seemed related to the sadomasochistic activity but turned
out to be linked more to her desire for attention, which Ms. A felt was humiliating be-
cause she believed that she should not need it. The therapist normalized her desire for at-
tention so that he could explore the aspects of the attention that she experienced as
inappropriate.
Drug Addiction 455
TABLE 17–2. Mentalizing and nonaddicted substance misuse
• Discuss the interaction between mentalizing and drug use during assessment
• Terminate the session if the patient is under the influence of drugs or alcohol
• Clarify narrative of drug taking
• Focus on mental states leading up to drug use
• Explore relationship context of drug activity
Only after careful investigation of the prior affects and mental states leading up to
the drug use, as exemplified in this vignette, does the MBT therapist consider possible
links to the therapy itself. In general, the MBT therapist focuses only on the process of
therapy or the patient-therapist relationship when considering impulsive and self-
destructive behaviors once the work of clarifying the allied mental states is complete.
Mentalization-Based Treatment for

Opiate-Dependent Borderline Personality
Disorder Patients: The Stockholm Model
Further development of MBT-DD for opiate-dependent patients with BPD occurred
in Stockholm because several therapists, who had been conducting psychodynamic
psychotherapy for many years with substance-dependent patients, gradually integrated
elements of MBT into their treatment. (Features of the use of MBT in the context of
SUDs are outlined in Table 17–3.) Most notably, this mentalizing-informed psychody-
namic approach was developed in a project conducted by the second author (U.K.), in-
volving psychodynamic psychotherapy in combination with buprenorphine treatment
for opiate-dependent patients with various concurrent psychiatric diagnoses.
Our current MBT model is especially designed for patients with opiate depen-
dence and BPD. In our model, the patients should already be receiving medication-
assisted treatment (MAT) for opiate dependence before starting psychotherapy. MAT
includes regular visits (initially daily) to an outpatient clinic for methadone or bu-
prenorphine medication and urine testing. The patients have regular contact with a
physician, a nurse, and a contact person. They have brief conversations with the contact
person at every visit at the outpatient clinic and the option of one longer talking session
weekly. Meetings are arranged with social services staff for planning future treatment.
Family sessions and crisis interventions occur when necessary. Patients should be given
MAT for at least 3 months before entering MBT to ensure that their medical and social
condition is relatively stable. Subsequently, the patients undergo parallel MAT and
MBT. A future goal is to develop a more definitive integration of MBT and MAT
rather than two parallel treatments. Such an integration was carried out with positive
results in the psychotherapy project involving psychodynamic therapy and buprenor-
phine.
Pharmacological treatment with buprenorphine or methadone decreases the crav-
ing for heroin, and, to quote one patient, “you can think about other things.” During
the first phase of MAT, most patients feel relieved that they have left their heroin abuse
behind. Soon, however, reality is thrust on them, but they are inadequately prepared
psychologically to meet this reality. Patients with an opiate dependence diagnosis gen-
erally have many years of heroin abuse behind them, so it will have been a long time
since they functioned in a regular adult life, and this inevitably will have had a profound
effect on their relationships with others, personal responsibilities, and intimate in-
volvements. That is, if they have ever had such an adult life; continuous drug abuse
since early adolescence is not uncommon in this patient group. The situation is more
complicated for patients with psychiatric comorbidity. Thus, patients receiving MAT
are in a psychologically vulnerable position, with fragile tolerance of anxiety and frus-
tration. The reality that the patient previously has avoided is now causing pain and anx-
iety: broken relationships, a wrecked social situation, perhaps ruined health, and the
consequences of crimes. At this stage, treatment options that can help the patients to
become psychologically better equipped could play a major role in enabling the pa-
tients to carry on with their lives and continuously abstain from using drugs.
Therapeutic Alliance
Our experiences of psychotherapy with opiate-dependent patients have indicated that
establishing a therapeutic relationship and alliance is the crucial part of initiating a
treatment. The therapist initially should focus on asking the patient about feelings and
experiences in order to stimulate mentalization, however rudimentary it may be. Ask-
ing about drug habits and drug anamnesis can wait because the patient is already in a
drug rehabilitation program and has undergone that sort of inquiry many times before.
At the outset of therapy, the therapist should emphasize that the treatment team will
help the patient to break an ongoing cycle of relapse into drug abuse, in every way pos-
sible (e.g., through temporary hospitalization). This promotes a sense of security and
counteracts feelings of shame.
Psychotherapy with patients with a long history of opiate dependence is about
starting from the beginning. The patient must psychologically gain more autonomy as
a person and develop stronger agency in determining his or her own life so as to in-
crease the chances of living drug free. The period of treatment also can be the time for
the patient to organize practical aspects of his or her life by finding permanent accom-
modations, developing stable finances, and perhaps entering working life. Emotional
states such as hopelessness that interfere with the development of a sense of agency are
carefully targeted early in therapy as the therapist actively promotes exploration of so-
lutions and supports constructive activity.
Drug Addiction 457
Promotion of Mentalizing
Psychotherapy aims to mobilize the patient’s ability to reflect on current behaviors,
feelings, and reactions in himself or herself and others so as to understand better that
there are inner mental states behind the behaviors, that therapists have reasons for do-
ing what they do, and that some things therapists do are predictable (i.e., that they all
have behavior patterns). The inner world is, to a large extent, blocked by the use of her-
oin; this is the major purpose for using heroin. One patient said: “I’m used to not hav-
ing to get a grip on things at all, but now I’m drug free, and I’m supposed to manage
everything without having an easy way out. It’s so complicated.” The patients who start
in psychotherapy are not accustomed to continuous reflection (i.e., the mental process
in which the subjective meets the objective and new impressions, feelings, and experi-
ences confront memories and existing knowledge). The continuity in time and the con-
stant frames of the therapy sessions, together with the therapist’s reliability and
attention, provide the patient with a sense of security, described by Winnicott (1972a)
as a holding environment. This secure base offers the patient a relationship in which to
develop his or her mentalizing ability as soon as a therapeutic alliance is established. In
therapy, the patient may be unsure about what he or she feels and thinks; feeling and
thinking are so unfamiliar that they are experienced as unreal, and the feelings and
thoughts must reappear many times in therapy before they gain a sense of reality.
A frequent difficulty among opiate-dependent patients in psychotherapy concerns
regulating negative emotion and strong affects. Van der Kolk (2005) pointed out that
traumatized children later, as adults, show affective reactions that are not modified by
thinking: instead, their impulses immediately lead to a response. Secure attachment
plays a critical role in the development of the child’s ability to regulate strong affects.
Traumatized children show insecure attachment patterns. In therapy, patients with a
history of traumatic childhood experiences can shut down, stop thinking, and stop feel-
ing in situations of increased emotional pressure. The therapist should pay attention to
this and show the patient that he or she might not understand what is happening, but
that the therapist is there and wants to explore together with the patient what became
overwhelming. The anxiety must be managed first before the patient can begin to think
about and express what he or she needs.
Educative ingredients are included in the therapeutic work. The therapist explains
to the patients how they are influenced by their psychological vulnerability in times of
increased stress. This helps the patients to recognize an emergent situation of risk for
relapse in substance abuse, and they can use their own inner warning signs before the
feelings become overwhelming instead of their regular approach to stress: “I ought to
be able to handle this.” If the therapist’s concern for the patient’s mental states is inter-
nalized by the patient, then the therapy becomes a step on the way to being able to take
care of oneself in a satisfactory way as an adult.
Episodes of relapse in drug or alcohol abuse during therapy are treated as tempo-
rary failures of mentalization (see Table 17–3). As we have previously discussed, the
therapeutic strategy for working with relapses resembles the strategies for working
with self-harm and other self-destructive behaviors. In the session following a relapse,
the therapist starts by using supportive and empathic interventions to relieve the pa-
tient from shame and pave the way for a full exploration of the episode. The therapist
then aims to explore the interpersonal context of the relapse. The patient is asked to
give a detailed account of the days and hours preceding the relapse with an emphasis on
affective states. The therapist does a meticulous exploration of the actual relapse epi-
sode. Communication problems, misunderstandings, and oversensitivity are identified
and explored. Moreover, attempts are made to link the patient’s feeling states to the
therapy process. Affective changes since the previous therapy session are explored and
considered in relation to events within treatment. The relapse episode is thoroughly
reviewed in several contexts in both individual and group therapy. Gradually, the pa-
tient’s ability to mentalize around those situations that constitute risk for relapse in-
creases. As a result, the patient gains the capacity to tolerate and regulate the affects
invoked in these situations, without having to take refuge in drugs or alcohol. Accord-
ingly, it becomes possible for the patient to learn from experiences and to continue to
find increasingly better ways to manage difficult interpersonal situations. For example:
Mr. B reported that he had taken heroin during the week between sessions. The thera-
pist reacted by expressing surprise:
THERAPIST: Oh, I’m somewhat surprised. You’ve managed to remain clean for more
than a month now, so things must have been difficult. Tell me what happened.
PATIENT: I just shot up because a friend of mine had some good smack. She
thought I might like it just for old times’ sake. I don’t think I will do it
again, so it’s fine.
THERAPIST: What makes you think you won’t do it again?
PATIENT: Well, I just won’t.
THERAPIST: I hope not, too, but I wondered how you were so certain. Can you
say something about that?
Here the therapist is taking up the quality of Mr. B’s feeling and asking him to talk
about that rather than the facts about the heroin use. This is primarily because Mr. B’s use
of the word just and the lack of development about the certainty had alerted the therapist
to the lack of mentalizing. The best way to rekindle mentalizing is often to stimulate con-
sideration of an allied affective aspect of the conversation as opposed to tackling the con-
tent of the problem head on:
PATIENT: At the moment, I feel quite sure about it. It was a temptation at the
time, and I feel okay about it now. So I suppose that my certainty is more
a statement that I really want to avoid it now, and I want to feel that I can
do so without feeling bad about it.
THERAPIST: That’s great. Would it help to think about what sort of state you
were in when your friend visited?
Drug Addiction 459
TABLE 17–3. Mentalization-based treatment and substance use disorders
• Stabilize medical and social problems

• Integrate pharmacological treatment
• Promote use of treatment team to avoid situations likely to stimulate relapse
• Incorporate educational elements about mentalizing in situations causing relapse
• Establish a therapeutic relationship
• Focus on current feelings and experiences in relation to substance use disorder
• Treat relapse as a failure of mentalizing; rewind and explore interpersonal context
• Mobilize ability to reflect in current mental states
• Target regulation of negative emotions and strong affects
This supportive work is an important prelude to the exploration of other aspects of

the drug taking, especially the more complex psychological areas of the relapse. Fol-
lowing the supportive work that stimulated an increase in mentalizing, Mr. B was able
to talk about his relationship with his friend and how he was excited about his visiting
him again. From there, it was possible to explore the feelings leading up to the use of
heroin. In effect, the use of heroin meant that Mr. B felt an intimacy with his friend that
he had missed. It gave him a feeling of belonging and completeness that he felt he
lacked otherwise. At this point, the therapist was able to work in the session, mental-
izing the transference.
MBT-DD: A Randomized
Controlled Trial in Progress
As a part of introducing MBT-DD for patients at an addiction clinic, we are conducting
a clinical trial to examine the efficacy of such treatment. This is an important replica-
tion of the previous studies of Bateman and Fonagy (1999, 2001, 2008b, 2009) on MBT
for BPD patients, as well as a further application of the treatment model to dual-
diagnosis patients—a group that has severe problems and restricted access to psycho-
therapy.
Study Design
The study started in spring 2009. The aim of the study is to examine whether MBT, in
combination with MAT for opiate dependence, is more efficacious than MAT alone for
comorbid BPD and opiate dependence with regard to severity of borderline personality
pathology as a primary outcome measure, and to opiate use, alcohol and drug use, suicidal
acts, self-mutilation, retention in treatment, psychiatric symptoms, interpersonal prob-

lems, and social functioning as secondary outcomes. Long-term follow-up of health eco-
nomics, criminality, and survival is planned.
This RCT will include 80 patients in total. Assessors are blind to the patient’s treat-
ment assignment. The patients who are considered for the study will begin receiving
pharmacological treatment with buprenorphine or methadone supported by regular
urine tests and appointments with physicians and nurses at dependence care units.
Thereafter, each patient who is considered for inclusion will attend at least two meet-
ings for diagnostic interviews, which will provide data to decide whether the patient
fulfills the inclusion criteria. By the end of the second meeting, the patient will be in-
formed about the result of the assessment and whether he or she can be included in the
study. Exclusion criteria are kept to a minimum. Subsequently, the patient is called to a
third meeting—an inclusion meeting. The aim of having three meetings prior to in-
clusion is to reduce the number of patients who drop out immediately after inclusion.
Intervention Group
Patients in the experimental group receive MAT for their opiate dependence, as de-
scribed earlier, but are offered MBT-DD as well, with the core of treatment being de-
livered in accordance with a manual (Bateman and Fonagy 2006a) over 18 months. The
treatment consists of the following:
1. Individual psychotherapy: one 50-minute session weekly

2. Group psychotherapy: one 90-minute session weekly
Inclusion criteria are:
• Man or woman age 18–65
• Signed informed consent to participate in the study
• Address and telephone number where the patient can be reached
• BPD in accordance with DSM-IV-TR (American Psychiatric Association 2000)
• Opiate dependence (present or in remission) in accordance with DSM-IV-TR
• Ongoing pharmacological treatment with buprenorphine or methadone for at
least 3 months
Opiate-dependent patients with BPD have severe, difficult-to-treat problems, and
currently an evidence-based psychosocial treatment is lacking. These patients share a
high risk for destructive and self-destructive behavior. At present, the treatments of-
fered to them often fail. They are regularly rejected from general psychiatric clinics be-
cause of their substance abuse. Within dependence care, they are most often offered a
treatment that focuses almost exclusively on their substance dependence and therefore
might not help them with their complex set of problems. Severe personality disorder in-
creases the risk that the patient will not be able to stay in and benefit from a treatment
for his or her addiction problems. The establishment of a well-functioning combination
Drug Addiction 461
of psychotherapy and pharmacological treatment for this group of patients, which

would be effective for both the psychiatric problems and the substance dependence,
would be an important piece of clinical progress.
Suggested Readings
Brehm N, Khantzian EJ, Dodes M: Psychodynamic Approaches in Recent Developments in Al-
coholism, Vol 11: Ten Years of Progress. New York, Plenum Press, 1993
Reading B, Weegman M: Group Psychotherapy and Addiction. London, Whurr, 2004
Sellman D: The 10 most important things known about addiction. Addiction 105:6–13, 2009
Weegman M, Cohen R: The Psychodynamics of Addiction. London, Whurr, 2002
Woody GE, McLellan AT, Luborsky L, et al: Psychotherapy in community methadone pro-
grams: a validation study. Am J Psychiatry 152:1302–1308, 1995
CHAPTER 18
Adolescent Breakdown
and Emerging
Borderline Personality
Disorder
Adolescence has been characterized in the popular and clinical literature as a devel-
opmental phase marked by psychological turmoil, impulsivity, dramatic and rapidly
fluctuating mood, and heightened vulnerability to adaptive breakdown. Identity seems
elusive, bouts of despair alternate with feelings of invincibility, and mentalizing appears
to be in short supply (Blos 1967).
Efforts to track the course of adolescence, starting with Offer and Offer’s (1975)
classic study of a sample of adolescent boys, indicate that about one-third of adolescents
experience a “tumultuous” adolescence, marked by pervasive misery and maladjust-
463
ment, impaired relationships, emotional storms, regression in coping and adaptive

competence, limited capacity to meet adaptive demands, struggles with identity, con-
flicts with parents and parental values, impulsive and self-harmful behavior, and painful
questions about self-esteem and self-worth.
Empirical studies show that risk taking, novelty seeking, and hunger for stimulation
increase during adolescence, together with a shift toward an increased focus on peer-
directed social interactions and greater conflict with parents (Irwin 1989). More than
50% of American adolescents engage, regularly or sporadically, in drunk driving, unpro-
tected sexual intercourse, use of illegal drugs, fighting, and other impulsive behaviors (Ir-
win et al. 2002). Increased impulsivity, risk taking, and peer-focused interactions may
have become highly conserved because they serve to facilitate adaptive fitness. This fa-
cilitation involves an impetus for exploration and a promotion of the transition from de-
pendents who are reliant on caregivers to individuated adults who can engage in the
fundamental reorganization of the self necessary to encompass physical and sexual mat-
uration; the acquisition of sex-specific, nonincestuous attachment roles of mating and
parenting; a remarkable increase in the capacity for representing events with abstract
concepts; and the transformation from dependent children to independent adults (Spear
2007; Tucker and Moller 2007). However, the developmental toll of these transforma-
tions appears to impose a heavy burden on many youngsters and their families.
The extent of the burden is borne out by studies that show that the three leading
causes of death among adolescents are accidents, suicides, and homicides—the latter
most often perpetrated by other teenagers (Irwin et al. 2002). A remarkable conver-
gence in the findings of epidemiological studies (Angold and Costello 2001; McDer-
mott 1996; Moffitt et al. 2002; Offord et al. 1987) indicates a marked elevation in the
rate of psychiatric disorders in adolescence, consistently showing that one in five ado-
lescents is affected by a serious mental health problem; that both internalizing and ex-
ternalizing problem behaviors increase during adolescence; and that the natural history
of many severe psychiatric disorders, including depression, drug abuse and depen-
dency, bipolar disorder, eating disorder, and psychotic disorder, confirms that the onset
of adolescence plays a significant role in the emergence, organization, and exacerbation
of these disorders. Longitudinal studies, such as the Dunedin Multidisciplinary Health
and Development Study (Kim-Cohen et al. 2003), show that the prevalence of major
psychiatric disorders increases during adolescence and that they persist into adulthood.
Over the last three decades, clinicians and researchers (e.g., Bleiberg 2001; Chanen
et al. 2004; Ludolph et al. 1990; Winograd et al. 2008) have increasingly noted that a
substantial percentage of maladjusted adolescents present symptom structures of affec-
tive dysregulation, impulsivity, and instability in relationships and in self-image that are
hardly distinguishable from the symptomatic picture that would qualify for a diagnosis
of borderline personality disorder (BPD) in those older than age 18. This raises the
question of whether it is plausible to suggest that BPD suddenly appears in an individ-
ual after he or she turns 18. However, applying the diagnosis of a personality disorder
to adolescents is fraught with controversy. DSM-IV-TR (American Psychiatric Asso-
Adolescent Breakdown and Emerging Borderline Personality Disorder 465
ciation 2000) defines personality disorders as relatively stable, enduring, and pervasively
maladaptive patterns of coping, thinking, feeling, regulating impulses, and relating to
others. By contrast, adolescents are engaged in dramatic and very fluid developmental
processes, in which very little appears stable or enduring.
The stability of diagnosis and the developmental continuity or discontinuity be-
tween BPD symptomatology in adolescence and adulthood are certainly not well estab-
lished (Miller et al. 2008). Questions remain about how to characterize the developmen-
tal trajectory of BPD and distinguish its enduring features from symptoms and adaptive
problems reflecting the acute expression of a psychiatric disorder such as bipolar disorder
or the manifestations of the neurodevelopmental and psychosocial pressures affecting ad-
olescents (Cohen 2008; Deschamps and Vreugdenhil 2008; Paris and Zweig-Frank
2001). The high comorbidity of BPD symptomatology with other Axis I diagnoses, such
as attention-deficit/hyperactivity disorder (ADHD), eating disorder, substance abuse,
depression, anxiety disorder, posttraumatic stress disorder, and bipolar disorder, also
raises questions about diagnostic specificity.
However, several retrospective and prospective studies are providing an increas-
ingly clearer delineation of 1) the developmental antecedents and risk markers of adult
BPD; 2) the specificity and consistency of the clinical presentations of BPD emerging
in adolescents as distinct from other psychiatric disorders; and 3) the differentiation of
those adolescents who experience significant emotional turmoil and adaptive break-
downs during adolescence yet come “out of the woods” (Hauser et al. 2006) to function
well, even exceptionally well, in adulthood from those for whom adolescent breakdown
is a harbinger of more enduring misery and maladjustment.
In an effort to outline developmental antecedents of adult BPD, Siever et al. (2002)
surveyed parents of patients with BPD who stated that their children’s development
was characterized by a pattern of unusual sensitivity, self-soothing, and moodiness,
present in infancy, that differentiated these individuals with BPD from their unaffected
siblings. This pattern appears to increase ninefold the likelihood of subsequently ac-
quiring BPD. The same survey showed the appearance in early adolescence of promis-
cuity, verbal outbursts, impulsivity, suicidality, and self-harm in girls who subsequently
received a diagnosis of BPD and of substance abuse, aggression, impulsivity, suicide at-
tempts, and self-cutting in boys later given the diagnosis of BPD. These parental
reports match the evidence of autobiographical accounts of adults with BPD, who re-
member that, on average, their difficulties started in early adolescence and became pro-
gressively worse in middle and late adolescence, when they were associated with a range
of problems, including eating-disordered behavior, drug abuse, depression, anxiety,
promiscuity, self-mutilation, and suicidality. Other retrospective studies, such as that
by Zanarini et al. (2006), also suggested that self-harm in childhood and adolescence is
an early risk marker for BPD. On the contrary, other studies, such as that by Siever et
al. (2002), pointed out that a significant percentage of people who engage in deliberate
self-harm during adolescence will not develop BPD in adulthood. This group may rep-
resent 25% of adolescent girls and 6% of adolescent boys.
A prospective study (Crick et al. 2005) that followed a sample of 400 children be-
tween fourth and sixth grade found moderate general predictive stability for features of
BPD after the investigators controlled for depression. Indicators of social-emotional
dysfunction—such as relational aggression, a hostile, untrusting view of the world, and
affect instability in relational contexts—were better predictors of BPD. The link be-
tween BPD symptoms in adolescence and a broad range of psychopathology in adult-
hood, including internalizing and externalizing disorders (Crawford et al. 2001),
substance abuse (Cohen 2008), and violent behavior (Johnson et al. 2000), is more
clearly established.
Zanarini (2007) used the child version of the Diagnostic Interview for Borderline
Patients to examine children in a community sample recruited at birth in Bristol, En-
gland. Of the 6,330 children interviewed after their eleventh birthday, 3.27% met five
or more DSM-IV-TR (American Psychiatric Association 2000) criteria for BPD, sug-
gesting a similar prevalence of BPD in early adolescence to the prevalence in adults.
Zanarini’s findings match the results of the Children in the Community Study (Cohen et
al. 2005), an ongoing longitudinal assessment of a sample of 733 children recruited be-
tween ages 9 and 19 years, which found a 3% prevalence of BPD. The Children in the
Community Study also showed stability of BPD symptoms between ages 14 and 16 years
(Johnson et al. 2000), as well as consistently greater stability and persistence of BPD
symptoms compared with other internalizing or externalizing symptoms (Crawford et al.
2001).
Several studies (e.g., Becker et al. 2006; Bondurant et al. 2004; Chanen et al. 2007;
Ludolph et al. 1990; Westen et al. 2005) found differences between adolescents who
met diagnostic criteria for BPD and clinical samples who met criteria for other Axis I or
Axis II disorders. These studies indicated significantly higher levels of abuse and ne-
glect and significantly worse adaptive functioning in the BPD group. Arguably, as de
Clercq and De Fruyt (2003) suggested, the enormous adaptive problems and symptoms
of adolescents with BPD set in motion a pernicious cascade or “snowballing” effect of
missed developmental opportunities; exclusion from adaptive, competence-building
avenues; rejection and alienation of mainstream peers, parents, and teachers; and in-
volvement in addictive and other maladaptive patterns of coping and affect regula-
tion—all of which reinforced the trajectory leading to BPD in adulthood.
Studies that have investigated rates of BPD in adolescents in inpatient treatment
point to higher prevalence rates in adolescents compared with adults. A much higher
prevalence of BPD in adolescence was reported by Chabrol et al. (2001), whose com-
munity-based study of 1,363 high school youths found that almost one-third met di-
agnostic criteria for BPD. Such studies suggest an increased rate of BPD in adolescence
followed by a significant decreased rate of BPD in young adulthood. As Cohen et al.
(2005) argued, although developmental factors likely mediate a substantial increase in
BPD prevalence in adolescence, and a subsequent decrease in adulthood, BPD cases
that persist into adulthood are likely to represent the extreme end of severity, a group
that become increasingly deviant relative to their peers.
Seeking to identify what factors protect adults from persistent “tumult,” Hauser et
al. (2006) followed a sample of 150 teenagers, half of whom had been psychiatrically
hospitalized in their early adolescence. First, the teenagers were seen in four yearly in-
terviews. Ten years later, they underwent in-depth interviews with interviewers blind to
their past. A “surprising” group of former patients were functioning in the top half of
all the young adults, both former patients and those never hospitalized, in measures of
social and emotional functioning, quality of relationships, antisocial behavior, and psy-
chiatric symptoms.
Those in the “surprising” group liked their lives and talked about them openly in a
lively and fluent manner. They had lasting and satisfying relationships and were in-
volved in work or education they found meaningful. They were interested in psycho-
logical experience and thought about themselves and about others’ experience, and
they felt hopeful and optimistic about the future. In short, the “surprisingly” resilient
young adults showed the markers of effective mentalizing. Hauser et al. (2006) iden-
tified three key protective factors: 1) reflection—that is, the capacity and willingness
to recognize, experience, and reflect on one’s own thoughts, feelings, and motivations;
2) agency—that is, a sense of oneself as effective and responsible for one’s actions; and
3) relatedness—that is, a valuing of relationships that takes the form of openness to the
other’s perspective and of efforts to engage with others. Studies such as this point to the
skills involved in influencing and shaping adolescents’ effective adaptation in the face of
adversity, emotional turmoil, and vulnerability.
Here, we make eight key proposals:
1. Increasing evidence supports the perspective that the symptom constellation of

BPD is rooted in childhood and adolescence and can be reliably assessed in ado-
lescents with BPD, differentiating them from adolescents with other disorders.
2. Prevalence studies point to BPD becoming significantly more common during ad-
olescence, in the context of widespread increases in vulnerability to adaptive break-
down and to psychiatric disorders.
3. Neuroscientific studies suggest an association of such increased vulnerability with
neurodevelopmental changes during adolescence, which compromise different
facets of mentalization, leading to poor integration of cognitive, explicit, con-
trolled, internally focused mentalizing and affective, implicit, automatic, externally
focused mentalizing.
4. Increasing evidence from multiple lines of research supports the mentalization-based
approach to the development of BPD. This approach suggests that a phase-specific
compromise in mentalizing during adolescence affects individuals who are vulnerable
to developing BPD because of preexisting impairments, including a low threshold for
the very intense and rapid activation of the attachment system and a corresponding de-
activation of controlled mentalizing. This set of core impairments leads to difficulties
in differentiating self and others and to affect dysregulation in attachment and emo-
tional contexts and appears to be associated with the emergence of BPD in adolescence.
5. Adolescence appears to be a critical point for preventive and therapeutic interven-

tion because of the increased prevalence of severe psychiatric problems and adap-
tive breakdown in general and BPD symptomatology in particular. Because
adolescent turmoil affects society, peers, school environments, family functioning,
and ultimately the adolescents’ own capacity to meet developmental tasks, it shapes
life-span trajectories, leading to the persistence of psychopathology.
6. Identifying natural protective, adaptation-promoting processes creates a frame-
work to organize preventive and therapeutic interventions that can more effec-
tively assist young people and families in turmoil. In this regard, the association we
have noted between good and even exceptional adaptation in adults who had been
buffeted as teenagers by severe emotional turmoil and maladjustment, on the one
hand, and the capacity to mobilize mentalizing skills in the context of attachment
and stress, on the other, is highly significant. These skills involve the capacities to
engage in agency, reflection, and relationships.
7. In seeking to explain the decline in BPD rates in adulthood, no empirical study has
established a link between mentalizing skills and protection from adult BPD in ad-
olescents meeting criteria for BPD. It is compelling, however, to hypothesize that
the recruitment of mentalizing skills opens a path for adolescents at risk to resil-
iently “come out of the woods” and avoid persistent misery and maladjustment.
8. The above-mentioned hypothesis, together with the conceptual soundness and
empirical support of the mentalization-based approach to BPD and its treatment in
adults, provides the impetus to test an adolescent model of mentalization-based
treatment (MBT-A). This model is designed to address the specific developmental
issues facing teenagers with BPD and adaptive breakdown in general.
In this chapter, we describe this treatment framework and two complementary pro-
grams, a 3- to 6-week inpatient program followed by a 6-week partial hospital program
and a 12-month intensive outpatient program. The latter is currently part of a research
clinical trial comparing this intensive outpatient MBT-A with treatment as usual.
Neurodevelopmental Changes,
Mentalizing, and Borderline Features
in Adolescence
The developmental pathways leading adolescents to experience increased rates of psy-
chiatric disorders in general, and BPD symptomatology in particular, are undoubtedly
complex. Masten (2006, 2007), presenting the perspective of developmental psychopa-
thology, postulated that the multiple difficulties that emerge across individuals during
adolescence arise from developmentally mediated dysfunctions in basic adaptive com-
petencies interacting with the adolescent’s preexisting and underlying risks and assets,
vulnerabilities, and protective factors.
A central hypothesis of our dynamic, adaptive system framework of developmental
psychopathology is that psychiatric disorders reflect dysfunctions in core processes and
mechanisms involved in social-emotional adaptation that are developmental in nature
and emerge in the context of interactive systems (Masten 2006).
Growing evidence suggests that disruptions in mentalizing are at the heart of the
vulnerabilities of adolescents. This is reflected in the emergence of BPD symptoma-
tology, particularly in predisposed youngsters. Fonagy and Luyten (2009) summarized
a large body of neuroscientific research and pointed out that adult BPD patients appear
to have a lower threshold for the activation of the fight-or-flight system (Jogems-
Kosterman et al. 2007) and an associated readiness to deactivate explicit or controlled
mentalizing—that is, the reflective, conscious, verbal mode of interpreting mental
states. These capacities are mediated by the lateral prefrontal cortex (PFC), the medial
PFC, the medial parietal cortex, the medial temporal lobe, and the rostral anterior cin-
gulated cortex, structures that normally undergo massive reorganization during ado-
lescence, as we discuss later.
Fonagy and Luyten (2009) cited research evidence in adults with BPD that esca-
lating stress and emotional arousal lead rapidly to a specific deactivation of the neural
circuits involved in the explicit, controlled, internally focused, cognitive aspects of
mentalizing, with a shift to automatic, externally focused, affective processing involv-
ing the amygdala, basal ganglia, and ventromedial PFC. Increased reactivity of the
amygdala in response to negative stimuli has been documented consistently in func-
tional neuroimaging studies of patients with BPD (Goodman et al. 2009). Further-
more, the normal reciprocal relation between the PFC and the amygdala, reflecting the
PFC activation that provides “top-down” reduction of amygdala activation, is abnor-
mal in BPD patients. Individuals with BPD have amygdala hyperresponsivity, espe-
cially to anger-provoking stimuli (New et al. 2007). As Siever and Weinstein (2009)
concluded, in BPD patients the areas in the PFC that are responsible for social judg-
ment and emotion evaluation are not efficiently used in suppressing the limbic activity
that generates aggression and affect instability.
The neurobiological and processing markers of BPD, outlined earlier, bear strik-
ing similarities to the normal neurodevelopmental features of the developing adoles-
cent brain. Brain imaging research indicates significant brain remodeling during
adolescence and into young adulthood (e.g., Giedd et al. 1999; Gogtay et al. 2004; Sow-
ell et al. 2007). Myelination and associated developmental shifts in gray and white mat-
ter volume continue in neocortical regions into adulthood (Sowell et al. 2007), and new
neurons are generated in certain brain locations, such as the hippocampus (Eriksson et
al. 1998), providing opportunities for remodeling and plasticity. Dramatic neurodevel-
opmental changes during adolescence entail the transformation of the seemingly less
efficient brain of childhood into the more rapidly communicative and more energy-
efficient adult brain (Spear 2007).
This transformation is evident in the rapid decrease or “pruning” in gray matter

volume, particularly that of the brain structures that underlie social cognition and men-
talizing. During adolescence, neurotransmitter receptor density and synapses increase
in the PFC, following steady growth in PFC gray matter, indicative of the formation of
new synaptic connections up to the onset of puberty. Thus, the trajectory of gray mat-
ter development in the PFC resembles an inverted U curve that reaches its apex at age
12. Gray matter in the superior temporal cortex or superior temporal sulcus (STS) also
decreases but less sharply than in the PFC, reaching maturity relatively late. At the
same time, enhanced connectivity between gray matter centers is indicated by the
steady increase in white matter density (myelin), improving the efficiency of the con-
nections between the axons linking specialized gray matter centers. This increase ex-
tends steadily from childhood throughout adolescence and into adulthood (Sowell et
al. 2003; Toga 2000). Postmortem studies (Huttenlocher 1984; Spear 2007) also show
a protracted process of myelination, particularly in frontal and parietal regions, that is
continuous into the third decade of life, as well as reductions in synaptic density
throughout adolescence.
Taken together, these studies suggest that the adolescent brain undergoes two dis-
tinct neurodevelopmental processes, particularly involving the PFC: 1) synaptic for-
mation, followed by synaptic pruning, and 2) axonal myelination, which increases the
efficiency of neural transmission in the PFC, the superior temporal cortex/STS, and
other cortical areas. These changes were proposed by Nelson et al. (2005) to be part of
a three-stage model of social information processing, involving a node for detecting so-
cially relevant cues, which matures in infancy and early childhood; a node to ascribe
emotional significance to the social cues, which matures in adolescence; and a cogni-
tive-regulatory node, which matures in late adolescence or early adulthood and serves
to inhibit responses and direct behavior.
Although the findings on the changes in brain structures and connectivity during
adolescence are complex, it appears likely that the capacities subserved by these regions
also undergo developmental changes associated with less efficient connections and
more diffuse activity. This is consistent with findings of increasing frontal and prefrontal
activity on social-cognitive and mentalizing tasks between childhood and adolescence,
when synaptic formation is occurring (Yurgelun-Todd and Killgore 2006), and decreas-
ing activity between adolescence and adulthood, when synaptic pruning takes place
(Wang et al. 2006).
Behavioral and magnetic resonance imaging studies provide evidence of the effect
of brain reorganization on the adolescent’s mentalizing and social-cognitive capabili-
ties. For example, social perspective taking is disturbed during puberty and adolescence
(Choudhury et al. 2006). The capacity to decide whether words match the expression of
emotion declines in speed and accuracy (Monk et al. 2003), whereas activation of the
amygdala in response to pictures expressing emotion is significantly greater in adoles-
cents (Killgore et al. 2001). Adolescents are markedly less able than adults to recruit the
frontal cortex and PFC when reading emotions. In responding to an explicit verbal in-
quiry, such as whether it is “a good idea” to swim with sharks, adolescents are far less ef-
fective than adults in identifying clearly and rapidly that it is “a bad idea” to engage in
such risky behavior. Such differences correlate with adults’ greater activation of the in-
sula and right fusiform face area, in response to the risky probe, suggesting a capacity to
process possible outcomes in ways that link controlled, reflective processing with the
automatic, procedural “feel” of the self in danger, in line with the somatic marker hy-
pothesis (Damasio 1999). Adolescents’ brain response, on the contrary, remains largely
at the dorsolateral PFC, without the “visceral” input that would allow for the risk to be
felt “for real” rather than as a “pretend” or purely explicit or symbolic mental image
that does not bridge to reality. Fonagy and Luyten (2009) cited evidence of hypermen-
talization in adults with BPD, suggesting attempts to mentalize that fail to integrate
cognition and affect.
Considerable overlap exists between these social brain regions and regions that are still
developing structurally in adolescence. Some recent developmental neuroimaging data
suggest that the overall structure of the network that subserves mentalizing may be in place
by age 5 years, but these regions continue to show functional changes throughout middle
childhood and adolescence (Blakemore 2008, 2010; Saxe et al. 2009). For example, the right
temporoparietal junction initially may be broadly involved in thinking about any socially
relevant information, only gradually acquiring the highly selective response to thinking
about thoughts observed in adults. The central question here is how functional changes link
to behavioral performance in both normally developing and at-risk groups.
One implication of these models is that neural development underlies commonly
observed adolescent phenomena such as susceptibility to peer influence and sensitivity
to peer rejection. Experimental behavioral evidence of rejection sensitivity in adoles-
cence is currently sparse. However, not many developmental neuroimaging studies
have examined the emergence of social cognition. On the whole, the studies point to a
developmental shift in the neural strategy: the decreased activity found in the medial
PFC suggests that adolescents and adults use different cognitive strategies to perform
social cognition tasks or that the shift is a by-product of structural brain development
that takes place during this period of life. To summarize the observations in relation to
adolescent neural development reviewed so far:
• Studies have consistently shown that dorsal medial PFC activity decreases between
adolescence and adulthood. For young adolescents, greater effort is required to ad-
dress problems requiring mentalizing (e.g., the need to resolve the discrepancy be-
tween the literal and intended meaning of an ironic remark; Wang et al. 2006).
• The same decrease in activation in the dorsal medial PFC in the right hemisphere
was reported, contrasting adolescents and adults when participants were required to
think about their own intentions as compared with physical causality, but a region in
the right STS was more active in adults than in adolescents (Blakemore et al. 2007).
Significant behavioral improvements in mentalizing, particularly in the domain of
perspective taking, have recently been reported (Dumontheil et al. 2010).
• Basic emotions (e.g., disgust, fear) do not require an understanding of mental states,
but social emotions (e.g., embarrassment and guilt) do. In a functional magnetic
resonance imaging study in which participants read scenarios that described either
social emotions (guilt or embarrassment) or basic emotions (fear or disgust), the ac-
tivity in the dorsal medial PFC was greater in adolescents during social relative to
basic emotions (Burnett et al. 2009). As in the contrast between intentional and
physical thinking in the study discussed in the preceding point, the increase in me-
dial PFC activity for social emotion in adolescence was matched by the opposite de-
velopmental pattern in the left temporal pole.
• The processing of facial affect stimuli also appears to engage the adolescent
amygdala more than the adult (Guyer et al. 2008) or the child amygdala and PFC
region (Hare et al. 2008; Yurgelun-Todd and Killgore 2006). Hare et al. (2008) re-
ported greater amygdala reactivity to fearful faces in adolescents than in younger or
older participants during a go/no-go task involving fearful, happy, and calm facial
expressions, and this correlated with reaction time delays to fearful compared with
happy expressions. In contrast, ventral PFC activity did not differ with age, suggest-
ing that increased limbic activation relative to ventral PFC regulation could con-
tribute to the increased emotional reactivity and poor decision making associated
with adolescence.
• Similar implications arise from a study that compared high and low resisters to peer
influence. Adolescents who showed more coordinated activity across premotor and
prefrontal regions when viewing angry faces also were above average in resisting
peer influence (Grosbras et al. 2007). This study is noteworthy not simply because
it offers a plausible mechanism that might account for being able to resist peer in-
fluence (engaging the executive processes in response to socially relevant stimuli),
but also because it implies that taking an individual differences (developmental psy-
chopathology) approach can illuminate mechanisms of typical development.
Thus, although it appears that PFC activity during mentalizing and face process-
ing tasks decreases with age, suggesting increased competence with these types of tasks,
processing centers in the same region involved with emotion regulation exert increas-
ing top-down control. Regions such as the amygdala, which are involved in the initial
emotional response to a stimulus, may be more active and less selective in the adoles-
cent years. Thus, what we earlier considered as a likely account of adolescent-onset
psychopathology in terms of remodeling of the dopamine system (Casey et al. 2008;
Steinberg 2008), increasing the salience of social rewards (e.g., peer approval), or the
gonadal steroid release, increasing sensitivity to social stimuli in adolescence, via effects
on oxytocin receptors, we could also see in terms of emerging mentalizing in adoles-
cence as young people become more aware of the importance of succeeding in social
situations and of the social costs of failure (i.e., brain development might underlie the
sensitivity to rejection that is characteristic of adolescence). Testing alternative models
is vital for the development of intervention programs, and the accelerated longitudinal
design of the proposed program would provide an ideal testing ground. Should em-
phasis be on the affective and cognitive-regulatory nodes of a social processing network
or on the reward value of positive social feedback from peers in reducing risk of ado-
lescent psychopathology?
Adolescent brain reorganization in the PFC and interconnected regions may gen-
erate declines in aspects of executive function, response inhibition, effortful attentional
control, and emotional self-control (Casey et al. 2000; Dahl 2001; Luna et al. 2001;
Pine et al. 2002). The mesocorticolimbic brain regions, which also undergo dramatic
change during adolescence, constitute critical components of the stress-sensitive cir-
cuitry implicated in modulating risk taking, novelty seeking, and social behavior (Le
Moal and Simon 1991) and in attaching hedonic affect (Volkow et al. 2002) to natural
rewards, particularly social stimuli and reciprocity. The attenuation in mesolimbic
dopaminergic activity in adolescence has been linked to a “reward deficiency syn-
drome” (Gardner 1999) characterized by actively seeking environmental stimulation,
including drug abuse and other stimuli with addictive properties, in an attempt to re-
mediate the reward deficiency. But addictive substances and activities, such as drugs,
self-harm, or food bingeing, may interfere with the development of the reward system
and thus further impair the social-emotional functioning that is associated with re-
wards for social reciprocity and effective mentalizing.
Evidence thus points to neurodevelopmental changes in adolescence affecting and
likely generating disturbances in the regulation of mood or affect and impulse or action
by cognitive, controlled mentalizing. Developmentally, this capacity lags behind.
These changes suggest the possible neurodevelopmental context that makes adoles-
cence a time of increased vulnerability to adaptive breakdown and, in the case of pre-
disposed and at-risk individuals, to psychiatric disorders, particularly to the core
struggles of affect dysregulation and impulsive dyscontrol that characterize BPD.
Emerging Borderline Personality

Disorder in Adolescence
As described in earlier chapters, Fonagy and Bateman’s (2006a, 2007, 2008; Fonagy
and Target 2006) attachment-mentalization theory of BPD proposes that constitu-
tional vulnerabilities (Koenigsberg et al. 2002; New et al. 2008; Ni et al. 2007, 2009;
Siever et al. 2002; Skodol et al. 2002) and exposure to neglect and invalidation in early
attachment relationships (Battle et al. 2004) lead to enfeebled mentalizing capacities in
attachment contexts that discourage a coherent discourse concerning mental states
(Fonagy and Bateman 2008). A complex developmental cascade crucially involves the
development of disorganized attachment in infancy, linked to a vulnerability to affect
dysregulation associated with a weakened capacity to represent internal states of emo-
tional arousal in attachment relationships.
The childhood markers of this vulnerability include oppositional, controlling, coercive

behavior toward attachment figures; a hostile or suspicious view of the world; a proneness
to outbursts of inappropriate and intense anger; impulsivity; and a poorly defined sense of
self. For such vulnerable children, encountering abuse and neglect in attachment relation-
ships leads to a devastating vicious cycle: trauma activates the attachment system and efforts
to seek proximity, reciprocity, and protection. However, attachment also activates intense
distress, in both children and their caregivers, and this escalating distress, and the associated
increase in the chances of further trauma, intensifies the activation of attachment. The re-
sult is a “ready triggering” of the attachment system “manifested in a rapidly accelerating
tempo of intimacy in interpersonal relationships,” catastrophic responses to such instantly
intimate attachments, “along with a vulnerability to the transient loss of mentalizing when
attachment needs are activated, as they are often likely to be, given the hyperactivation of
the attachment system” (Allen et al. 2008, p. 277).
Children reaching adolescence with an enfeebled capacity to mentalize in the con-
text of attachment are less able to withstand the developmental challenges of adolescence.
That is, they are less able to integrate a vastly changed body, to manage increased sexu-
ality and affective intensity, and to deal with a greater capacity for abstraction and sym-
bolization in a reorganized sense of self while also meeting the pressures for an increased
focus on peer-directed norms and interactions, the psychosocial demands of achieving
autonomy and separation, and the assumption of distinct adult roles. All this takes place
in the neurodevelopmental context of mentalizing brain circuits that are undergoing
pruning (and thus are less able to modulate affect and arousal) and a limbic system that is
generating a hunger for novelty and stimulation. We suggest that this psychobiosocial
storm that takes place in adolescence converges to precipitate the adaptive collapse we
identify as emerging BPD in adolescence. As Baird et al. (2005) aptly described it, the ef-
fect of neurodevelopmental changes in youngsters vulnerable to BPD is “like attaching a
330 horsepower motor to a cardboard box” (p. 1046). The cardboard box in question is
the fragile capacity to mentalize, a capacity that is precipitously lost when the “330 horse-
power motor” of emotional arousal and attachment needs is activated. We further
hypothesize that vulnerable adolescents’ intense despair leads them to develop psycho-
logical defenses, first appearing in adolescence, that actively inhibit mentalizing and thus
enable them to avoid accessing their own helplessness and vulnerability and their sense of
others’ malevolent feelings toward them (Fonagy and Target 2006).
In summary, we propose that adolescence is the point at which early developmental
difficulties join hands with neurodevelopmental changes, weakening mentalizing and
mentalizing-mediated affect regulation, and with intense psychosocial and develop-
mental pressures that place greater demands on the capacity to represent the self and
regulate affect, creating the conditions for the symptomatic expression of BPD.
Structured interviews and questionnaires specifically developed for adolescents
and adult measures adapted for adolescents (e.g., the Personality Disorder Examina-
tion [Garnet et al. 1994; McManus et al. 1984], the Childhood Interview for DSM-IV
BPD (Zanarini, unpublished manuscript, 2003), and the Personality Disorder Features
Scale for Children [Crick et al. 2005]) include age-appropriate items that have provided
an accumulating body of evidence on the validity of the BPD diagnostic construct in
adolescence. Several studies documented symptomatic features similar to those of adult
BPD (Becker et al. 2002; Bradley et al. 2005), particularly among adolescent girls,
whereas boys who meet BPD criteria show more aggressive, disruptive, and antisocial
symptoms (Bradley et al. 2005).
Large community samples, such as the ones studied by Chabrol et al. (2001) and
Bradley et al. (2005), show that approximately 90% of the adolescents meeting criteria for
BPD have paranoid or dissociative symptoms. Also common are inappropriate and in-
tense anger; suicidality and deliberate self-harm; and vulnerability to overwhelming anx-
iety in anticipation of abandonment, separation, or rejection. Only slightly less common,
in the range of 75%, are dramatic displays of impulsivity and impulsive aggression.
The following vignettes illustrate how these youngsters appear when seeking clin-
ical attention:
Jenny
The parents of a 15-year-old girl, Jenny, described her as “depressed, anxious, irritable,
and moody” throughout her life, always comparing herself negatively with an older
brother she referred to as “the golden child.” After an argument with her boyfriend, she
appeared devastated and “hysterical” and overdosed with benzodiazepine, which led to
the first of four acute psychiatric hospitalizations over the next 3 months, each triggered
by an overdose.
Jenny’s mother tearfully shared her sense that the “entire family is dysfunctional”
because they could never find a way to “fit in all four” of the members of the family and
“had” to exclude one who would be “left out,” feeling rejected and ignored, a position
most frequently occupied by Jenny. Both parents agreed that they differed significantly
in their views about how to raise their children, with the mother being inclined to re-
spond to “misbehavior” with stern discipline and the father apt to be more lax and “un-
derstanding” of the children’s sensitivities. They frequently became embroiled in bitter
disputes about their parenting standards but had come to believe that Jenny was adept at
exploiting their differences and pitting one parent against the other. The parents felt
“manipulated” by Jenny, who seemed to “enjoy” the chaos and distress that would follow
her reports that she had, once again, overdosed. When her parents agreed on anything,
however, Jenny would grow enraged and “impulsive.”
Jenny stated that she could not understand how “minor disappointments” would
trigger affective storms of uncontrolled emotion, filled with insults, self-cutting, destruc-
tion of furniture, physical assaults on her mother, and running away.
Binge drinking, largely on weekends, and daily cannabis smoking had resulted in
several blackouts and one arrest when police stopped her and other peers and found open
containers of liquor and several marijuana joints in the car. Her parents discovered that
Jenny’s boyfriend had been beating her up when, on one occasion, the police were called
by neighbors as the boyfriend was punching her in the face and stomach. Jenny refused to
let the police in, worried that her boyfriend, who had previously had encounters with the
law, would have his probation revoked.
Admission to the Menninger Clinic was prompted by a fight between Jenny and her
brother in which he yelled that she “did not belong in this family,” leading Jenny to grab
a knife and run out of the house. The police were called, and after a chase culminating in
Jenny being tackled by a policeman whom she bit and kicked, she was taken to a psychi-
atric unit where she received the diagnosis of bipolar disorder and was referred to Men-
ninger for further assessment and treatment.
Maria
Maria, a 14-year-old girl, was the oldest of three children born to Mexican immigrants.
She was referred to the Menninger Clinic from the acute psychiatric unit where she was
admitted after a school nurse noted the many fresh scars, burns, and lacerations criss-
crossing her arms. On questioning her, the nurse found that Maria felt severely depressed
and was contemplating suicide by first overdosing and then hanging herself. Maria had
hated her body since she was little. She remembered looking at her reflection in the mir-
ror and feeling disgusted by her stomach. She had been purging every day for the last
year and found that vomiting provided “wonderful” relief from the enormous dread and
anxiety that tormented her. “Vomiting gets rid of the feelings,” explained Maria. She had
been hospitalized for “refeeding” 2 years earlier when her weight dropped to 80 pounds
(she is 5 feet 3 inches), which was close to what she considered her “ideal weight” of
75 pounds. She had been depressed for at least 5 years, feeling despondent and hopeless,
lacking energy, and being overwhelmed with panic. She thought of harming herself “all
the time” and had begun burning herself with iron curlers and cutting herself with scis-
sors, blades, or paper clips. Her mother “shadowed her” and slept with her in a frantic ef-
fort to prevent self-harm. Maria felt that sleeping with her mother, who was “the only
one who understands me,” served to relieve the panic and voices that haunted her when
she was alone. She also felt, however, that she “protected” her mother from the distress
she experienced because of desperately missing her family in Mexico. Maria also believed
that her mother felt emotionally abandoned by her husband and was overwhelmed by the
demands of the other children.
On her first day in the hospital, Maria told her mother that 6 months earlier, she
“might” have been raped by a stranger in a park near their house, although she could not
tell for sure if this trauma had actually happened or had been one of the nightmares that
disrupted her sleep. Her mother panicked and demanded that Maria be tested for HIV,
convinced that she “could not go on living” if she did not find out immediately if Maria
had been infected and had passed on the viral infection to the other children with whom
she shared a hairbrush and towels. She insisted, however, that Maria not be told that she
was being tested for HIV because she feared that Maria could not withstand the stress of
waiting for the results.
Jason
Jason, a 15-year-old boy, was the only child of a very busy neurosurgeon and a mother
who had achieved considerable prominence in the theater. His mother had marveled at
Jason’s own dramatic gifts since very early childhood, noting his capacity for imperson-
ation of others, including show-business personalities or family members, and his pen-
chant for dressing up in flamboyant and elaborate costumes. Psychological testing
indicated a verbal IQ of 150, significantly ahead of his performance IQ, which was nev-
ertheless very good. Jason never appeared to be at a loss for words or ideas, and his so-
phisticated language made him sound like a miniature grown-up from the time he started
elementary school. However, when things did not go his way or he failed to capture the
limelight, he became anxious and provocative and wreaked such havoc that he had been
expelled from four schools before reaching the sixth grade.
The arrival of puberty marked the emergence of new and more severe symptoms.
Jason stated that during the 4 years before his admission to the clinic, his “rage and self-
loathing” had become unbearable. He had begun drinking to intoxication at age 12, and
at admission, he was smoking marijuana on a daily basis and abusing Vicodin, Oxy-
Contin, and benzodiazepines. In fits of rage, he had destroyed his bedroom, and on sev-
eral occasions, he had punched his father in the face. He reported that when alone in his
room, he came in contact with terrifying creatures that sought to compel him to die. He
experienced convulsions that had prompted repeated visits to the emergency department
and diagnostic assessments at specialized centers. These had rendered inconclusive evi-
dence about the nature of his “seizures.” Jason had become increasingly absorbed in
pedophilic Web sites, which he spent hours viewing every day. He spoke disparagingly of
his parents, whom he addressed by their first names, claiming that his father “probably
has Asperger’s” because he was utterly incapable of understanding anyone’s feelings or
the cruelty implied in his dismissal of others’ concerns. His mother, on the contrary, was
always trying to “get inside” his head. He took some satisfaction when his mother con-
ceded to Jason’s therapist that she did attempt to manipulate Jason’s thoughts and feel-
ings to “shield him” from the pain she believed he would be exposed to because of his
“unique” sensitivity. On admission, he spoke sadly of his hopelessness and his failure to
connect with others, while rather proudly describing his talent for telling others what
they wanted to hear and his conviction that he was able to trick even the most skillful
“and famous” therapists.
These three vignettes highlight what the studies discussed earlier point out, which
is the emergence of several core features associated with BPD during adolescence.
These core features are discussed below.
First, adolescents with BPD show a vulnerability to dissociation, which is triggered
by stress, loss, rejection, or the failure of interactive partners to “match” the youngster’s
state of mind (Stiglmayr et al. 2008; Zanarini et al. 2008). These triggers evoke an over-
whelming state of hyperarousal, subjective dyscontrol, and a sense of fragmentation
(“falling apart”) that is unbearably painful and leads to psychosis-like states of hearing
voices or seeing things, derealization, or depersonalization.
Second, adolescents begin to anticipate or conjoin this vulnerability to dissociation
with active defensive efforts to dissociate, which they identify as “distracting” or
“numbing” of themselves, with a variety of addictive or addictive-like patterns such as
deliberate self-harm (Coid 1993), purging, drug use, promiscuity, or escape into the
pretend world of the Internet or video games. However, addictive, numbing actions
tend to increase psychophysiological dysregulation and exacerbate the drift toward de-
viant peer groups (Fergusson and Horwood 1999). Involvement with deviant and anti-
social peers leads to further alienation from better adjusted peers and the prosocial
“pull” afforded by school and other adaptive opportunities.
Third, such dissociative efforts provide a measure of relief and an illusory sense of
control but also intensify the youth’s disconnection from his or her own subjectivity
and sense of intentionality and self-directedness (Barnow et al. 2005; Bradley et al.
2005). Thus, they find themselves falling into a dark despair, in which their experience
resists naming or comprehension and their behavior “happens” to them, compelled by
powerful forces of raw affect to enact rigid patterns of response not amenable to inter-
pretation.
Fourth, dissociation also compromises access to other people’s internal, subjective
experience and leads to an even greater sense of aloneness: the loss not only of the pres-
ence of or relationship with another person but also of the mentalizing means with
which to achieve a sense of connection and reciprocity with other human beings.
Fifth, aloneness intensifies distress and hyperactivates attachment, fueling the
young person’s need to coercively evoke, through physical, nonmentalistic, teleologi-
cal, and manipulative behavior, “matching” responses from others, including parents.
This “matching” provides the concrete assurance of reciprocity and counters feelings
of aloneness and self-fragmentation.
Sixth, coercive, manipulative behavior arouses intense emotions in others and
leads parents to feel increasingly out of control, immobilized, and unable to mentalize
(Diamond and Liddle 1999; Solomon and George 1996). As parents become more anx-
ious, worried, enraged, and helpless, they try ever more desperately to control their
children and squelch their “manipulation,” which reinforces and exacerbates the ado-
lescents’ own retreat from mentalizing. Thus, in a tragic transactional sequence, the
attempts made by adolescents to cope with loneliness and loss of control through in-
hibition of mentalizing and addictive coercive behavior evoke nonmentalizing
responses from parents and others. These responses lead to self-perpetuating and self-
reinforcing vicious coercive cycles of nonmentalizing. Coercive cycles foster nonmen-
talizing and leave families feeling “stuck,” exhausted, and engaged in an arms race of
nonmentalizing that reinforces the adolescents’ path to persistent maladjustment.
Nonsuicidal deliberate self-harm is a particularly potent and pernicious instance of
nonmentalizing behavior. Deliberate self-harm has been associated with emotional ne-
glect (Sar et al. 2006) and intense inner pain and dissociation prompted by rejection,
abandonment, or misattunement (Stiglmayr et al. 2008). Adolescents who engage in
nonsuicidal, deliberate self-harm also frequently have other features of BPD, in con-
trast to teenagers who attempt suicide but do not engage in nonsuicidal, deliberate self-
harm (Jacobson 2008) and who are more likely to present with a major depressive dis-
order. Other studies of adolescents engaged in deliberate self-harm (Nock et al. 2006;
Wright et al., unpublished study, 2009) report, however, a very significant overlap be-
tween nonsuicidal, deliberate self-harm and suicidal behavior, including instances of
unintended, accidental death or near death in the course of deliberate self-harm. In the
group with overlapping suicidality and nonsuicidal, deliberate self-harm, a very high
percentage (88%–97%) qualify for a wide range of Axis I psychiatric disorders, a rate
that appears greater than those who qualify for an Axis II personality disorder, includ-
ing BPD (Hog 2002; Nock et al. 2006; Polewka 2005; Portzky 2005).
These studies, and previously cited retrospective and longitudinal data, support
the view that deliberate self-harm is a common feature of BPD in adolescence. From a
diagnostic perspective, however, it is neither necessary (because many youngsters, par-
ticularly boys, meet criteria for BPD without engaging in deliberate self-harm) nor suf-
ficient (because some youngsters engage in deliberate self-harm, by some estimates
15%–20%, but do not meet criteria for BPD and qualify for other psychiatric diag-
noses).
Deliberate self-harm, however, is highly addictive because it releases opiates that
relieve the pain and sensitivity to abandonment, rejection, or misattunement associated
with the reduced opiates shown to be implicated in self-injurious behavior in BPD
(Stanley et al. 2010). Deliberate self-harm is also a sensitive marker of mentalizing col-
lapse, strongly associated with dissociation, and evocative of intense emotional re-
sponses in others—responses that can culminate in acute hospitalizations and frantic
efforts of parental control, mixed with feelings of guilt, shame, rage, helplessness, and
despair that fuel the escalation of the coercive cycles described earlier. Deliberate self-
harm is thus not only a signal of profound pain and distress in young people experienc-
ing a breakdown of mentalizing capacities but also a strong indicator of risk for BPD
and pervasive maladjustment. Therefore, one of the authors (T.R.) selected deliberate
self-harm as the key criterion for admission to the intensive outpatient MBT-A pro-
gram described later in this chapter (see section Mentalization-Based Treatment for
Adolescents) and a core focus of therapeutic intervention.
The co-occurrence of an Axis I diagnosis noted in samples of adolescents with
BPD is consistent with the epidemiological data obtained in adults with BPD (e.g.,
Grant et al. 2008; Zanarini et al. 2008) that show comorbid prevalence rates in the
range of 50% for substance use disorder, 50%–60% for anxiety disorders, 30%–50%
for posttraumatic stress disorder, 30%–50% for eating disorders, and 10%–30% for bi-
polar I and II disorders (Kutcher et al. 1990; Lewinshow et al. 1997; Muratori 2003).
The comorbidity of BPD and Axis I disorders in adolescence raises the question of
differential diagnosis. The differentiation between BPD and mood disorders is partic-
ularly complex because mood disorders are themselves poorly clinically characterized
in adolescence. Clinical descriptions of adolescent mood disorders portray moody, ir-
ritable, affectively labile youngsters with explosive anger and a low tolerance for frus-
tration. Many clinicians assessing adolescents with BPD focus on their mood
symptoms, prompting a diagnosis of bipolar II or rapid-cycling bipolar disorder. In-
deed, it has been proposed that “borderline” should be considered a variant of bipolar
disorder (Akiskal 2004). However, the affective shifts of BPD oscillate between anger
and dysphoria rather than elation and depression and tend to be rapidly reversible and
exquisitely reactive to the relationship context rather than endogenously driven and ep-
isodic (Henry et al. 2001; Koenigsberg et al. 2002).
A more episodic presentation, lasting days or weeks, of exuberant, elevated affect;
loud giggling; high-flown thinking; increased activity and energy; recent onset of angry
outbursts; disinhibition; impulsivity; and decreased need for sleep should point to a bi-
polar disorder, particularly in the presence of genetic antecedents of bipolarity. The
acute onset of a depressive episode, particularly an episode characterized by hypersom-
nia, psychomotor retardation, and psychosis in an adolescent with a family history of
bipolar disorder, is also predictive of a bipolar course.
The 10%–30% co-occurrence of bipolar disorder and BPD in adults supports the
view that most individuals with BPD do not have bipolar disorder, and most of those
who have a bipolar disorder do not develop BPD. Furthermore, the natural history of
BPD tends toward decreased affect instability in middle age, whereas episodes of bipolar
disorder tend to become more frequent and severe without treatment in adulthood.
However, the significant comorbidity of bipolar disorder and BPD symptoms sug-
gests a complex transaction between the two (and perhaps other neuropsychiatric vul-
nerabilities, such as to ADHD or anxiety disorders) and the disturbances in attachment
undermining mentalizing at the heart of the developmental trajectory leading to BPD.
Temperamental vulnerabilities may result in affective signals that are more difficult for
caregivers to mentalize and “mark,” particularly for caregivers who share similar tem-
peramental vulnerabilities and histories of neglect, emotional abuse, and attachment
disorganization. Adolescents with developmental disturbances in attachment and men-
talizing that compromise protective and regulatory capacities are more vulnerable to
the expression of internalizing and externalizing symptoms and neuropsychiatric dis-
orders under conditions of stress. Symptoms of depression, substance abuse, eating dis-
order, anxiety, suicidality, and deliberate self-harm, in turn, fuel affective dyscontrol,
interpersonal storms, family dysfunction, and educational or social impairment, further
compromising mentalizing capacities in young people with BPD and their families and
their capacity to trust and engage in treatment.
A Mentalizing-Based Treatment
Framework for Adolescent Breakdown
and Borderline Personality Disorder
The clinical implications of this model of adolescent breakdown and BPD involve a
therapeutic focus on promoting the teenager’s and his or her family’s capacity to men-
talize in the context of emotional arousal in attachment relationships. Focusing on the
promotion of mentalizing provides a conceptual framework that can hold together a
range of therapeutic interventions in a coherent treatment model.
A coherent narrative is crucial to parents, patients, and clinicians alike. It offers a

clear sense of direction and gives meaning to the struggles of patients and their families
and to the inevitable challenges that treatment will engender. The focus on enhancing
mentalizing is made more compelling by explicitly articulating the overarching goal of
enhancing real mastery and control for both parents and teenagers, mastery that results
from exercising the central disposition of human beings to turn around passivity, help-
lessness, and lack of reciprocity and create agency and human connection through the
reflection and elaboration of intentional mental states in oneself and in others.
Clinicians working with adolescents in turmoil are sorely in need of a coherent
framework to guide their interventions and help them manage the coercive pressures
they encounter. Because attachment is activated in treatment, it evokes the very signals
of danger to which adolescents are vulnerable.
First, to maintain such a framework requires consideration of the vulnerability of
adolescents in general, and adolescents with BPD in particular, to a breakdown of men-
talizing when experiencing intense emotional arousal triggered by challenging inter-
personal situations. Therefore, a critical principle of treatment is to provide a social
“scaffolding” (Masten 2007) to support the young person’s mentalizing capacities to
bridge the transition to greater mentalizing competence. This principle highlights the
inappropriateness of therapeutic interventions that “load” adolescents with mentalistic
explanations of complex and challenging internal states, well beyond their capacity to
process them. Such mentalizing demands run the risk of tipping adolescents into tele-
ological states or psychic equivalence—the terrifying state in which thoughts and fan-
tasies feel like real events—or into pretend mode, in which thoughts are believed to be
disconnected from reality and inconsequential. Jason, for example, began treatment in
the hospital brimming with the insights he had acquired during several years of inten-
sive psychotherapy. These “insights,” including remarkable verbal cleverness and ex-
ceptional ability to conjure evocative images and play with words, were quite at odds
with his difficulties engaging with others and solving problems in reality. When he
spoke of how he had traced the “roots of this self-loathing” to childhood experiences,
he appeared to use language more as a tool for exhibitionism and manipulation, a de-
fense against shame and vulnerability, and a weapon to control, intimidate, and keep
others (and his own feelings) at a distance.
Second, the normal scaffolding for adolescents’ fragile mentalizing is provided by a
secure attachment to parents and others who provide a containing, supportive, and limit-
setting mentalizing context in which the adolescent can safely explore connecting
thoughts and feelings and tolerate emotional arousal without needing to turn off men-
talizing. But coercive, nonmentalizing cycles in families of adolescents with BPD main-
tain, reinforce, and exacerbate nonmentalizing in teenagers and parents and lead to
parental rejection, criticism, punishment, or disengagement. Thus, a second key princi-
ple of this treatment framework is to aim to help families shift from coercive, nonmen-
talizing cycles to mentalizing discussions that can promote trust, security, attachment,
and effective communication and problem solving. Such an aim requires minimizing the
parents’ experience of incompetence or of being blamed or shamed for their children’s

problems. To achieve this aim, parents are provided with a mentalizing formulation, dis-
cussed in more detail later. The formulation examines the youngster’s problems in the
context of mentalizing breakdowns, as responses to threats to the continuity and safety of
the self and attachment. However, this response is doomed to give rise to coercive pat-
terns of behavior and to undermine collaboration and effective use of treatment.
The notion of coercive cycles, driven by emotional arousal and mentalizing break-
down, helps parents appreciate the transactional nature of the problems experienced by
their adolescent and themselves. It defines a crucial goal: enlisting the parents as partners
in a treatment designed to shift from discussing behaviors that need to be controlled or
eliminated—the “dialogue of the deaf” between caregivers who bemoan their children’s
“out of control” behavior and the teenagers who bristle and reject their parents’ efforts to
control them—to a mentalizing conversation that enables family members to grasp one
another’s point of view and convey their own perspective. Shifting away from coercive cy-
cles aims at rekindling curiosity, respect, empathy, mutuality, and agency in all family
members. However, empathy does not preclude limit setting. A mentalizing framework
for adolescents recognizes that attachment processes conducive to mentalizing are built
on a foundation of trust in effective and responsive caregiving. Such caregiving entails
connectedness and support that includes effective containment of destructive or self-de-
structive behavior, a combination associated with a decrease in adolescent deviance and
substance abuse (Fletcher et al. 1995; Schmidt et al. 1996).
Framing the goals of treatment along these lines focuses the therapeutic process on
first assisting the parents in achieving or maintaining mentalizing in the face of the very
pressures that have prompted their own retreat from mentalizing, so that they can sup-
port their children’s mentalizing. Such an approach involves inviting parents to collab-
orate in identifying what experiences and interactions lead to their feeling buffeted by
emotional turmoil and unable to adopt a mentalizing position with respect to them-
selves, the other parent, and their children. A major focus of the work with the parents,
therefore, is to identify stressors impinging on the parents that affect their mentalizing
and parenting capacity and to help them access support and treatment for themselves.
Mentalizing capacities are also affected by neuropsychiatric disorders. Arguably,
all psychiatric disorders of adolescence involve a dysfunction of mentalizing: inevitably,
adolescent psychiatric disorders entail an impaired capacity to interpret self and others
and maladaptive, nonmentalizing modes of perceiving, feeling, thinking, coping, com-
municating, and relating to others. This impairment can be persistent, as in autism
spectrum disorders; episodic, as in depression or bipolar disorder; or intermittent and
context-dependent, as it has been described in BPD.
However, the relationship between mentalizing impairment and neuropsychiatric
disorders is bidirectional: mentalizing deficits make neuropsychiatric problems worse by
interfering with the capacity to collaborate and use treatment effectively. Thus, a third key
principle of a mentalizing framework for adolescent BPD is to assess and provide specific
psychotherapeutic, educational, or pharmacological treatment for the neuropsychiatric
disorders that have symptoms that emerge during acute psychobiological decompensa-
tion and trait vulnerabilities representing an enduring diathesis to dysfunction.
Several treatment approaches, focusing on enhancing affect regulation, have shown ef-
fectiveness with BPD in adolescents (Davidson et al. 2006; Denaro 2008; Linehan et al.
2006). Dialectical behavior therapy, combining acceptance with a challenge to change, and
well-manualized skills training have proven particularly efficacious in reducing impulsive
aggression and self-harm and improving affect regulation (Linehan 1993b).
Pharmacotherapy targets states and traits of dysregulation of arousal, cognition,
affect, and impulse and Axis I disorders such as depression and ADHD that contribute
to the inhibition of mentalizing (Bleiberg 2001; Soloff 1998), thus facilitating mental-
izing-based individual or family therapy.
Substance misuse and eating-disordered behavior are targeted with psychoeduca-
tion, support groups, and specific therapeutic interventions, such as motivational en-
hancement (O’Leary and Monti 2004), and can be indications for inpatient or partial
hospital treatment, particularly in relation to extreme severity, comorbidity, or suicidal
risk (Gowers and Bryan-Waugh 2004; Sigman 2003; Simkin 2004).
The mentalizing framework described earlier is designed for the treatment of BPD
in adolescents and their families. We argue in this chapter, however, that promoting
and enhancing mentalizing in adolescents and their families are core, if not the core,
mechanisms underlying the effectiveness of all treatments in adolescents; promoting
and enhancing mentalizing are thus proposed as a general framework to organize ther-
apeutic efforts to assist young people and their families. In the following sections, we
describe two complementary applications of mentalizing-based treatment with adoles-
cents: an inpatient and partial hospital model, developed at the Menninger Clinic by
Efrain Bleiberg and Laurel Williams, and an intensive outpatient model, developed in
London by Trudie Rossouw and Peter Fonagy.
The Adolescent Treatment Program of

the Menninger Clinic
The adolescent treatment program of the Menninger Clinic is a mentalization-based
inpatient and partial hospital program for adolescent BPD, severe psychiatric disor-
ders, and adaptive breakdown. It comprises two distinct yet linked programs: a 2- to 8-
week inpatient assessment and stabilization program and a 6- to 12-week partial hos-
pital (5 days a week, 8 hours daily) program.
Admission to the inpatient program is indicated when adolescents present with be-
havior that is dangerous to themselves or others and elicits destructive responses from
the environment (school, peers, family) calling for an interruption of coercive, nonmen-
talizing cycles; when their symptomatology, which may include substance abuse, suicide
attempts, potentially life-threatening and out-of-control eating-disordered behavior,
runaway behavior, and other destructive and self-destructive behavior, is not contained
by outpatient interventions; and when their presenting problems appear so complex and
multifaceted that intensive and comprehensive assessment in a controlled environment
becomes necessary. Exclusionary criteria include mental retardation, autism with sig-
nificant language impairment, medically unstable problems requiring stabilization in a
medical unit, and indications of severe antisocial problems, such as a pattern of serious
theft or destruction of property or a pattern of physical and/or sexual violence. A review
of 53 consecutive admissions (Sharp et al. 2009) found that 38% (n=20) met diagnostic
criteria for BPD.
Admission to the inpatient program initiates a 2- to 3-week comprehensive assess-
ment and stabilization protocol that leads to recommendations for further treatment.
These recommendations can include an additional 4–6 weeks of inpatient treatment in
the adolescent treatment program, step down to the partial hospital program, or refer-
ral for treatment elsewhere. Of the patients, 30% are admitted from the local commu-
nity, and the rest come from across the United States and other countries.
The 2- to 3-week inpatient assessment process provides a detailed evaluation,
grounded in a coherent attachment-mentalizing conceptual framework. The assess-
ment is integrated with the young person’s and the family’s active involvement in indi-
vidual, group, and family mentalizing interventions, as well as leisure, school, and peer
activities. This immersion allows for a naturalistic clinical evaluation of both the young
person’s and the family’s mentalizing strengths and vulnerabilities, particularly in rela-
tion to the challenges brought about by engagement in the different attachment con-
texts of individual, group, and family sessions and in seeking to develop a collaborative
relationship with the treaters.
The goal of the assessment protocol is to arrive at a diagnostic formulation that does
the following: identifies the adolescent’s psychiatric diagnosis and symptom severity;
assesses the presence of emerging features of personality disorder, including criteria for
BPD and antisocial and psychopathic features; describes the adolescent’s psychological ca-
pacities mediating treatment response, including measuring cognitive capacity, executive
functioning, and mentalizing capacity; and evaluates the adolescent’s social-transactional
context of family functioning, including stressors impinging on the parents and the par-
ents’ mentalizing capacity. This assessment integrates clinical evaluation with a formal set
of measures (see Table 18–1) that cover the previously mentioned domains.
For example, Jason and his parents were provided with a formulation that pointed
to a diagnosis of major depression. This diagnostic picture was consistent with the boy’s
self-report and the mother’s view, yet at odds with the perspective of the father, whose
view of a spoiled, provocative, angry, attention-seeking brat contrasted with the
mother’s perception of a desperately miserable, sensitive, and tormented youngster
afraid of losing control. The formulation invited both parents to enter a collaborative
endeavor with each other, with the family as a whole, and with the diagnostic and treat-
ment team, suggesting that exploring the differences in their views of their son was a
step for each of them to consider alternative or additional ways to make sense of Jason’s
TABLE 18–1. Diagnostic assessment for the adolescent treatment program of the
Menninger Clinic
Axis I: Severity
Diagnostic Interview Schedule for Children (DISC)
CRAFFT screening tool to screen adolescents for high-risk alcohol and other drug use disorders
Youth Self-Report (YSR)
Child Behavior Checklist (CBCL)
Strengths and Difficulties Questionnaire (SDQ)
Deliberate Self-Harm Inventory (DSHI)
Peer Conflict Scale (PCS)
Trauma Symptom Checklist for Children (TSCC)
Emerging personality disorder
Millon Adolescent Clinical Inventory (MACI)
Hare Psychopathy Checklist (PCL)
Childhood Interview for DSM-IV Borderline Personality Disorder (CI-BPD)
Borderline Personality Disorder Features Scale for Children (BPFSC)
Antisocial Process Screening Device (APSD)
Inventory of Callous–Unemotional Traits (ICU)
Family functioning
Child Attachment Interview (CAI)
Security Scale (SS)
Stress Index for Parents of Adolescents (SIPA)
Reflective Function Questionnaire (RFQ–Parent)
Experiences in Close Relationships—Revised (ECR-R)
Alabama Parenting Questionnaire (APQ)
Adolescent’s characteristics
Cognitive capacity
Wechsler Intelligence Scale for Children (WISC)/Wechsler Adult Intelligence Scale (WAIS) (IQ)
Peabody Picture Vocabulary Test (PPVT)
Peabody Expressive Vocabulary Test (PEVT)
Woodcock-Johnson Tests of Cognitive Abilities, 3rd Edition (WJ-III)
Executive functioning
Behavior Rating Inventory of Executive Function (BRIEF)
TABLE 18–1. Diagnostic assessment for the adolescent treatment program of the
Menninger Clinic (continued)
Adolescent’s characteristics (continued)

Mentalizing capacity
Basic Empathy Scale (BES)
Avoidance and Fusion Questionnaire for Youth (AFQ-Y)
Movie for the Assessment of Social Cognition (MASC)
Reflective Function Questionnaire (RFQ–Adolescent)
Working Alliance Inventory (WAI)
Emotion regulation capacity
Difficulties in Emotion Regulation Scale (DERS)
Cognitive Emotion Regulation Questionnaire (CERQ)
and their own plight, which, currently, had them locked in a cycle of mutual recrimi-
nation either for “spoiling” Jason or for failing to be “sensitive” to him.
Jason also presented emerging features of borderline or narcissistic personality dis-
order, suggesting that he was very vulnerable to developing a highly maladaptive pat-
tern of regulating affect and coping with intense emotions and relationships. Crucially,
this pattern involves a disposition to dissociating and losing contact with reality in the
face of intense arousal, stress, and feelings of vulnerability.
Cognitive testing documented a verbal IQ of 155, significantly different from Ja-
son’s high-average performance IQ of 110. This very substantial difference could have
shaped, and been shaped by, the youngster’s disposition to seek to escape from vulner-
ability into a “pretend” world of words and disembodied, Web-based images, sustained
by efforts to numb himself with drugs while failing to connect to real affects and pro-
cedural experience. Assessment of executive functioning and mentalizing capacity fur-
ther pointed out how vulnerable he was to impulsive action and breakdowns in
mentalizing whenever he felt vulnerable and in need of help. At such times, Jason
would quickly escalate to feeling out of control and feeling enormously ashamed and
humiliated. Yet the more out of control he felt, the more desperate he was to “switch
off” mentalizing, so as not to notice how helpless he felt and how others either failed to
“get” him—leaving him feeling lonely and alienated—or “got” him too completely—
putting him at risk for losing control of his own mind and sense of self. His “solution”
was to go into pretend mode, seeking to “trick” others, and ultimately himself, with the
illusion that he could control his own feelings and mind and the availability and reac-
tions of others.
Assessment for substance abuse identified a pattern of alcohol and marijuana de-
pendence and opiate and benzodiazepine abuse, in addition to an addictive-like depen-
dence on the Internet, that contributed enormously to the breakdown of his capacity to
mentalize and further alienated him from real relationships and genuine feelings.
The diagnostic formulation provides a springboard for outlining a treatment path-
way that highlights the specific ways in which treatment interventions can help the ad-
olescent and his or her family to gain a sense of control, based on communication and
rekindled hope. This remoralization is supported by interventions that aim to remediate
the specific neuropsychiatric and addictive disorders that exacerbate mentalizing prob-
lems and are made worse by breakdowns in mentalizing. These two steps serve as the
launchpad for longer-term rehabilitation of the mentalizing capacities that generate
agency, reflection, and connections with others and promote more effective means to
manage stress, adversity, and vulnerability (Bateman and Fonagy 1999).
The following types of adolescents, illustrated in the vignettes presented earlier, often
require a more extended hospitalization (3–6 weeks beyond the initial 3 weeks of inpatient
assessment) and 6–12 weeks of partial hospital treatment to achieve the goals of remoral-
ization and remediation and to initiate the process of rehabilitation of mentalizing capacity:
• Borderline adolescents who have extensive comorbid neuropsychiatric disorders,

such as ADHD, bipolar disorder, anxiety disorders, depression, and a traumatic his-
tory (or current maltreatment), and who have a predominance of dissociative and
self-destructive responses
• Borderline adolescents who have severe and out-of-control addictive or eating dis-
order problems
• Borderline-narcissistic adolescents who appear mistrusting and become disorga-
nized, impulsive, and destructive when their efforts to achieve a sense of control
through maladaptive means are challenged
For these young people, a mentalizing inpatient and partial hospital program provides
a framework to organize individual, group, family, pharmacological, school, recreational,
and skill-building interventions; spiritual activities; interventions aimed at substance abuse
and other addictive problems; and specific approaches for eating disorders and trauma (see
Figures 18–1 and 18–2) into a coherent and well-integrated treatment.
The mentalizing treatment framework is made up of psychoeducational modules
provided in groups for the adolescents and separately for the parents. The modules are
similarly described by Allen et al. in this volume (see Chapter 7), as explicit mentalizing
educational groups. These groups use a discussion and role-playing format to explain the
process and components of mentalizing and nonmentalizing practice; how one recog-
nizes mentalizing and nonmentalizing; the skills and attitudes involved in mentalizing,
such as curiosity, openness, agency, and reflection; the relation of mentalizing and attach-
ment; how mentalizing breaks down under stress, with heightened arousal, and when the
sense of self is threatened; and how to use treatment to promote mentalizing in the par-
ticular situations in which it fails or is inhibited. The treatment team participates in a sim-
ilar mentalizing training and uses weekly team meetings as opportunities to discuss
488
ATP Schedule
Time Monday Tuesday Wednesday Thursday Friday Saturday Sunday
730 WAKE UP WAKE UP WAKE UP WAKE UP WAKE UP WAKE UP WAKE UP
8 Breakfast Breakfast Breakfast Breakfast Breakfast Breakfast Breakfast
830 YOGA Mindfullness Exercise Muscle Relaxation Team MEDITATION YOGA Mindfullness Exercise Muscle Relaxation Free Time Free Time
9 Agenda Agenda Rounds Agenda Agenda Agenda
930 9.10-9.45 9.10-9.45 8.30- 9.10-9.45 9.10-9.45 Team Meeting 9.10-9.45 AM MEETING AM MEETING
10 Mentalization Family Dynamics 10.30am Affect Regulation Self-Esteem Grp 9.30- 11.00am Trauma Current Events Team Building
1030 10.00-10.50am 10.00-10.50am 10.00-11.00am 10.00-10.50am 10.00-10.50am 10.00-10.50am 10.00-10.50am
11 Free Time Free Time Free Time Free Time Free Time Lunch Lunch
1130 Lunch 11.20am Lunch 11.20am Lunch 11.20am Lunch 11.20am Team Lunch 11.20am Free Time Free Time
12 Free Time Free Time Free Time Free Time Meeting Free Time
1230 ACADEMICS ACADEMICS ACADEMICS ACADEMICS 11.30-1.30pm ACADEMICS Teen Chpl 12.30-1.00pm
Team

1 12.30-3.20pm 12.30-3.20pm 12.30-3.20pm 12.30-3.20pm 12.30-3.20pm GYM TIME Readiness Group
130 Rounds 1.00-2.00pm 1.00-2.00pm
2 1.00- POOL or Crafts GYM/Spirituality
230 3.00pm ALL STAFF MEETING 2.00-3.00pm
3 2.30-3.30pm Free Time Free Time
330 Free Time Group Psychotherapy DBT Group Psychotherapy COMMUNITY MTG
4 3.40-4.40pm 3.40-4.40pm 3.30-4.30pm 3.30-4.30pm Healthy Lifestyles Wellness Group
430 Free Time Free Time Free Time Free Time 4.00-4.45pm 4.00-4.45pm
5 Dinner Dinner Dinner Dinner Dinner Dinner Dinner
530 Free Time Free Time Free Time Free Time Free Time Free Time Free Time
6 AEROBIC ACTIVITY/GYM AEROBIC ACTIVITY/GYM AEROBIC ACTIVITY/GYM AEROBIC ACTIVITY/GYM AEROBIC ACTIVITY/GYM Agenda Agenda
630 6.00-7.00pm 6.00-7.00pm 6.00-7.00pm 6.00-7.00pm 6.00-7.00pm 6.00-6.45pm 6.00-6.45pm
7 Free Time Free Time Addictions Educ Free Time Free Time Free Time Free Time
730 Creative Pursuits Pt Government 7.15-8.00pm Leisure Education GOALS Group Group Activity Addict Group
8 7.30-8.30pm 7.30-8.30pm GYM TIME 7.30-8.15pm 7.30-8.15pm 7.30-8.30pm 7.30-8.30pm
830 12 Step Group Free Time 8.00-8.50pm Craft Room Movie Time with Free Time Free Time
9 8.30-9.30pm Free Time 8.30-9.15pm Personal Snacks
930 Relaxation Time Relaxation Time Relaxation Time Relaxation Time Relaxation Time Relaxation Time
10 BEDTIME BEDTIME BEDTIME BEDTIME BEDTIME BEDTIME BEDTIME
FIGURE 18–1. Mentalization-based inpatient treatment program schedule for adolescent borderline personality disorder, severe
psychiatric disorders, and adaptive breakdown.
Adolescent Breakdown and Emerging Borderline Personality Disorder
Time Monday Tuesday Wednesday Thursday Friday
730
8
830 Check-In Check-In Check-In Check-In Check-In
9 WEEKEND REVIEW YOGA/PMR/MEDITATION YOGA/PMR/MEDITATION YOGA/PMR/MEDITATION YOGA/PMR/MEDITATION
930 9.00-9.45am AGENDA-nursing AGENDA-nursing AGENDA-nursing AGENDA-nursing
10 Mentalization in Families Affect Regulation Trauma Group Skills Practice Group Patient Government
1030 10.00-11.00am 10.00-11.00am 10.00-11.00am 10.00-11.00am 10.00-11.00am-nursing
11 Lunch- Diff for ED track Lunch- Diff for ED track Lunch- Diff for ED track Lunch- Diff for ED track Lunch- Diff for ED track
1130 ACADEMICS ACADEMICS ACADEMICS ACADEMICS ACADEMICS
12 11.30-2.30pm 11.30-2.30pm 11.30-2.30pm 11.30-2.30pm 11.30-2.30pm
1230
1
130
2 Community Meeting
230 GOALS/Wellness Group CD Step Group Life Management CD Education Group 2.00-3.00pm
3 2.30-3.15pm 2.30-3.15pm 2.30-3.15pm 2.30-3.15pm Weekend Planning
330 DBT Skills Group Group Therapy Aerobic or Pool Time Group Therapy Check-Out
4 3.30-4.30pm 330-4.15pm 3.30-4.30pm 3.30-4.15pm 3.00-4.00pm Nursing
430 Check-Out Check-Out Multi-Family Check-Out
5 Mentalization Group
530 4.45-6.00pm
Family CD Education Creative Expression*
6.00-7.00pm 4.45-6.00pm Wednesdays
*PHP Teens in Creative Expression while parents in

Mentalization Group-FF
FIGURE 18–2. Mentalization-based partial hospital program schedule for adolescent borderline personality disorder, severe psy-
chiatric disorders, and adaptive breakdown.
489
situations in which staff members’ own mentalizing has broken down and to role-play
ways of restoring a mentalizing stance. These meetings involve some staff members play-
ing the role of the teenager or parent with whom their mentalizing failed while other staff
members role-play the staff member who experienced the mentalizing break.
The psychoeducational module offers parents an opportunity to reflect on the co-
ercive, nonmentalizing cycles in which families with troubled teenagers get “stuck” and
the ways that other parents can appreciate their particular dilemmas and promote con-
sideration of other perspectives. Through role-playing, parents can practice how to
attempt to regain mentalizing after it has collapsed: for example, when a teenager ex-
plodes with a barrage of “fuck you’s” at a crowded department store after a parent com-
ments on the “inappropriateness” of the swimming trunks he has just chosen. The aims
of these explicit mentalizing groups are to convey the following principles: 1) treatment
offers patients and their families an invitation to join with the treaters in a collaborative
relationship designed to address the problems of patients and their families; 2) the pur-
pose of this collaboration is to promote the capacity to mentalize, a capacity that un-
folds in the give-and-take of reciprocity, respect, and mutuality rather than in coercive
interactions; and 3) this treatment model is based on the premise that mentalizing
makes problems amenable to change, which results from the enhanced capacity of pa-
tients and their families to make choices about how they use treatment; relate to and
communicate with one another; and respond to stress, adversity, and vulnerability, in-
cluding neuropsychiatric vulnerabilities.
An aspect of the explicit mentalizing groups is to review the “contract” between
the families and the treaters. As Gunderson (2001) suggested, the “contract” refers
to an agreement about practical issues, such as the anticipated duration of treatment
(2–3 weeks for the inpatient assessment and stabilization phase, 4–6 weeks for the in-
patient program following the assessment, and 6–12 weeks for the partial hospital pro-
gram) and the structure and components of treatment (displayed in Figures 18–1 and
18–2), specifying that, in addition to the basic structure of groups and school, the in-
patient program includes two sessions of individual mentalizing therapy, two sessions
of implicit group treatment, two sessions of mentalization-based family treatment and
one individual round, and one medication management meeting with the treatment
team per week, and the partial hospital program comprises one individual session of
mentalization-based therapy (MBT); two sessions of implicit group treatment, one ses-
sion of mentalization-based family treatment, and weekly medication management. In
addition, the “contract” also spells out the families’ rights and responsibilities as vol-
untary patients and the basic rules of behavior that patients, staff, and families are ex-
pected to follow, such as respect for confidentiality; the exclusion of violence, drugs,
sexual relations, or access to the Internet; or the requirement that the patients’ levels of
restriction on freedom will be contingent on the approval of the treatment team.
These restrictions and rules are discussed as conditions that can enable the estab-
lishment of a safe and respectful environment that has as its outcome the development
of a collaborative relationship between the teenagers, the parents, and the treatment
team and of a sense of agency and control in the patients and their families based on an
enhanced mentalizing capacity.
In this model, fostering collaboration and agency results from the synergy of indi-
vidual, group, family, educational, and pharmacological interventions all seeking 1) to
enhance mentalizing, 2) to strengthen impulse control and self- and affect regulation,
and 3) to promote awareness of others’ mental states.
Enhancing Mentalizing
How does one go about enhancing adolescents’ mentalizing? A critical precondition
for treatment in all adolescents, but particularly in those with BPD or those experienc-
ing an adaptive breakdown, is the “scaffolding” provided by an environment that offers
clear and consistent containment of impulsive, destructive, or self-destructive behavior
(as outlined in the rules and expectations) and where it is safe, and encouraged, to ob-
serve, label, and communicate mental states, including the associated physiological re-
actions, thus introducing a mentalizing perspective that links behavior to underlying
mental states. The clinical staff’s interventions focus on largely conscious or precon-
scious mental states, such as beliefs, desires, thoughts, and feelings emerging in the mo-
ment-to-moment interactions that take place in rounds; individual, group, or family
sessions; and educational or leisure activities with peers. At the same time, in all con-
texts, staff do not aim to burden the adolescents with the mentalizing demands involved
in linking thoughts and feelings in the present to dissociated or repressed experiences
or in exploring how thoughts, feelings, wishes, fantasies, fears, and conflicts in the
present are “transferred” from important figures and relationships in the past.
In this respect, the overall approach pursued reverses the psychoanalytical focus on
opening paths to the experience of repressed, unconscious thoughts and repudiated af-
fects. In contrast, adolescents who are prone to breakdowns in their capacity to men-
talize and to the defensive inhibition of mentalizing, in the face of threatening internal
and interpersonal cues, need help with learning to use their ideational capacity of con-
trolled mentalizing to modulate their emotional experience and automatic mentalizing.
In individual and group interventions, the adolescents are encouraged to consider
and communicate moment-to-moment changes in their mental states and to under-
stand the thoughts, interactions, and circumstances that lead to certain feelings. For ex-
ample, Jason could focus on how he felt angry when he thought he had no control over
how long he would stay in the hospital and how quickly feeling angry and out of control
led to feelings of self-loathing and shame. Jenny could make sense of the outbursts she
had at a family session when she looked at how she felt misunderstood and put down
when her mother compared her with her brother, the “golden boy” whom her mother
was so proud of.
In connecting their feelings, thoughts, and actions, teenagers are helped to appre-
ciate the choices they make in terms of ignoring or approaching and communicating or
concealing certain mental states in particular circumstances. Jenny, for example, was
able to speak of how she actively dissociated by “distracting” herself and then feeling
that she could literally make her mind go blank. Likewise, Maria would comment on
how purging “gets rid” of her feelings of anger or hurt. Appreciating that an element of
choice is involved in these phenomena promotes the young person’s sense of agency
and helps lay the foundations for the development of stronger control of attention and
mentalizing in the service of increased impulse control and self- and affect regulation.
Strengthening Impulse Control and Enhancing

Self- and Affect Regulation
The previous subsection highlights the close link between enhancing mentalizing and
managing the impulsive, automatic, and addictive responses triggered by a breakdown
or an inhibition of mentalizing.
A perspective conveyed in individual, group, and family interventions—and explic-
itly discussed with parents and teenagers in the mentalizing psychoeducational mod-
ule—is the appreciation of the relief and illusory control, safety, and sense of
connection provided by impulsive, automatic, and addictive patterns. This was some-
thing that Maria recognized when describing how “wonderful” it was to “get rid” of
negative feelings by purging and that Jason acknowledged when he described how
“numbing” himself with drugs or “losing” himself in the Internet “helped” when he felt
out of control and humiliated. Such a perspective allows for an articulation of the un-
derstandable reluctance to interrupt impulsive, nonmentalizing, addictive patterns. It
also paves the way for discussions, in individual and group sessions, of the pain and
adaptive price associated with impulsivity, nonmentalizing, and addictive behaviors and
the courage required to change and seek real mastery. An explicit recognition of the
choice between mentalizing and nonmentalizing facilitates introduction of specific in-
terventions to manage suicidal, parasuicidal, and other harmful or impulsive behaviors
such as substance abuse, bingeing and purging, or fits of angry, threatening behavior.
It is important to appreciate the automatic, procedural nature of these impulsive,
addictive, nonmentalizing patterns to explain the use of skill-building strategies and an
entire treatment environment designed to contain and manage impulsive, addictive be-
havior. Enhanced impulse control and self- and affect regulation thus can be promoted
with psychoeducational interventions and support groups. Specific dialectical behavior
therapy skills (Fleischhaker 2006) promote affect regulation and curb suicidal and para-
suicidal behavior. Crisis and relapse prevention plans help to identify “triggers” of im-
pulsive, addictive behavior, such as feeling alone or being ignored, and define steps that
help manage the impulsive urge and avoid the loss of the capacity to mentalize.
Psychoeducation focuses on neuropsychiatric vulnerabilities—trait vulnerabilities
and states of acute decompensation—as well as Axis I psychiatric disorders. It provides
both the young people and their parents with a cognitive framework to make sense of
factors affecting impulse control and self- and affect regulation. This framework intro-
duces the possibility of examining the implications of particular vulnerabilities on the
adolescents’ experience of themselves and others, on their ability to hold on to a mental-
izing stance and to regulate their affects and impulses, and on relationships within the
family. It also offers a rationale for the use of medications, which can target both acute
states and enduring diatheses to dysfunctions of cognition, impulse, arousal, and affect.
Promoting Awareness of Others’ Mental States

Through individual, group, and family interventions, the adolescent is encouraged to
become aware of, and consider, other people’s mental states and perspectives. The first
aim is to promote an awareness of the idea that there may be more than one way of
looking at things, particularly when he or she is feeling stressed or vulnerable. How-
ever, it is not uncommon for adolescents actively to resist such awareness because it
challenges patterns of experience and relationships, particularly within the family, that
serve to avoid feelings they find unbearable. For example, Maria initially felt that family
sessions that challenged the family to “stand” and hear one another’s perspectives, and
the scheduling of separate sessions in which the parents discussed their own relation-
ship and efforts at joint parenting without Maria being present, threatened to “ruin”
what she described as “my perfect family.”
“Practicing” awareness of the mental states and perspectives of staff and peers, in
individual and group interventions, helps the family to engage in mentalizing ex-
changes. Role-playing themselves or other family members in individual sessions, or
mentalizing group exercises, prepares for mentalizing exchanges in family sessions.
The opportunity to take a playful, humorous stance in general, and particularly
while role-playing, can help to promote mentalizing and the awareness of other peo-
ple’s mental states because role-playing requires holding in mind the “pretend” and the
actual simultaneously and engaging in a moment-to-moment reading of the state of
mind of the other person involved in the role-playing. This use of pretend, humor, and
role-playing offers a way to take a “step back” from overwhelming, threatening inter-
personal exchanges that feel unmanageable. By promoting awareness of multiple per-
spectives, these exchanges prepare the adolescent to maintain a mentalizing stance in
the emotional cauldron of family sessions.
Often, adolescents and their parents need individual coaching before they are able to
engage in mentalizing conversations involving emotionally loaded issues. Such coaching is
designed to make explicit “the content and style of what is to be said, prepare for potential
reactions by other participants, and solidify a mini-contract that challenges the participants
to follow through as planned once the interaction begins” (Liddle and Hogue 2000, p. 274).
Focusing on enabling adolescents and their parents to appreciate each other’s points of
view while also gaining a clear sense of their own perspectives and motivations helps teen-
agers and parents to take the first steps toward restoring mentalizing in the very interactions
in which it most frequently breaks down. Such coaching enabled Jason to practice how he
would discuss with his parents that he had been “making it up” about having “seizures”
rather than admitting to them—and himself—how anxious and out of control he felt.
A concerted focus on enhancing mentalizing, strengthening impulse control and
self- and affect regulation, and promoting awareness of others’ mental states may result
in the following indications that a patient could be ready to end treatment within the
adolescent inpatient and partial hospital treatment program:
• Both the young person and the parents show an ability to effectively engage with the
treatment by sustaining collaborative relationships with treaters that help them to
solve problems when mentalizing breaks down. In addition, they establish that they
can begin using this collaborative stance to resolve impasses and interrupt coercive
cycles inside and outside of sessions.
• The young person shows a capacity to interrupt addictive and destructive cycles of
self-harm, suicidality, eating-disordered behavior, or substance misuse. The adoles-
cent has planned how he or she will recognize triggers of relapse in the future and
what strategies he or she will use to cope with stress and vulnerability that do not in-
volve deployment of addictive, nonmentalizing, coercive strategies but do involve
self-initiated approaches to ask for help.
• The young person’s symptoms of comorbid Axis I disorders, such as anxiety, depres-
sive, attention-deficit, or manic disorders, are abating.
• The young person and the parents have a sense of rekindled hope, a remoralization
that results from an increased capacity to experience themselves as intentional be-
ings—agents capable of making choices, asking for help and support, and conceiving
of themselves and others as real human beings.
The attainment of these markers signals the initiation of the process of rehabilitation of
mentalizing (Bateman and Fonagy 1999).
for Adolescents
Background of the Model
The MBT-A program is derived from the adult MBT model with modifications
based on developmental factors and the importance of the family context. Currently,
the model is being tested in a randomized controlled trial (RCT) to establish its effi-
cacy. A detailed discussion of the RCT is beyond the scope of this chapter, but once it
is completed, we plan to publish the results.1 The model, which we describe in this sec-
tion, has been developed for young people who harm themselves. The hypothesis un-
derlying our decision to target this particular population group is that self-harm is a risk
indicator for BPD in adolescence. Preliminary, unpublished results of an initial cross-
TABLE 18–2. Demographics of a self-harm group compared with a clinical non-

self-harming group and a nonclinical school group
Self-harming Clinical School

Demographic group control group control group
Number of participants 59 19 65
Age (y)
Mean (SD) 15.15 (1.31) 15.03 (1.29) 16.6 (1.25)
Range 11.92–17.50 12.25–17.17 13.33–18.42
Sex, n (%)
Male 9 (15.3) 10 (52.6) 26 (40.0)
Female 50 (84.7) 9 (47.4) 39 (60.0)
Living arrangements, n (%)
With parents 26 (44.8) 8 (44.4) 34 (77.3)
With mother 21 (36.2) 6 (33.3) 6 (13.6)
With mother and her partner 5 (8.6) 3 (16.7) 4 (9.1)
With father 2 (3.4) 0 0
Other 4 (6.9) 1 (5.6) 0
Source. Wright et al., unpublished study, 2009.
sectional part of the study, in which a self-harm group was compared with two control
groups, a clinical non-self-harming group and a nonclinical school group, indicated
that the self-harm group showed significantly more borderline pathology on all mea-
sures used (see Tables 18–2 and 18–3 for preliminary results). These findings strongly
support the hypothesis that self-harm can be used as a risk indicator for adolescent
BPD, which creates the opportunity for treatment programs to target this population
for the purposes of early intervention and prevention of further morbidity.
Structure of the Treatment Program

MBT-A is a year-long program involving weekly individual MBT-A sessions and
monthly Mentalization-Based Family Therapy (MBFT) (Figure 18–3). The MBT-A
1
Preliminary results thus far indicate effectiveness of the MBT-A model in terms of reduction
in self-harm, emotional distress, and borderline functioning after a year’s treatment. Thus far, it
proves to have better results than treatment as usual, but it is too soon to draw conclusions
because the study is not complete yet.
TABLE 18–3. Percentages of participants meeting the three levels of diagnostic

criteria for borderline personality disorder in the child version of the
Diagnostic Interview for Borderline Patientsa
Group Definitely present Probably present Absent

Self-harm 73.08 10.44 15.66
Clinical control 0 17.64 82.32
Nonclinical control 3.62 3.62 92.31
Note. Results were similar when the Borderline Personality Disorder Features Scale for Children
(BPFSC; Crick et al. 2005) was used. The BPFSC found significantly more borderline features in the self-
harm group than in both control groups through pairwise comparisons. In agreement with the pairwise
comparison analysis, planned contrasts also found no significant differences between the control groups
on this measure (t129 =1.79; P<0.0008; partial η2 =0.024) and highly significant differences between the
school group and the self-harming group (t129 =7.96; P<0.001; partial η2 =0.33).
aSemistructured
interview adapted from the Revised Diagnostic Interview for Borderline Patients
(Zanarini et al. 1989).
sessions are 50 minutes long. The individual sessions are held on a weekly basis at the
same time and place. The MBFT sessions tend to be at the same time and day, and the
dates are known to the family well in advance to ensure attendance.
The model is currently being used and tested in our service, which is a large child
and adolescent mental health service in North-East London, covering a catchment area
with a population of 1 million. The service is based in three outpatient clinics. Twenty-
two therapists, all child and adolescent mental health workers from different profes-
sional backgrounds such as child psychiatry, psychology, psychotherapy, family therapy,
nursing, and social work, underwent training in MBT-A and MBFT.
Training of the therapists is a crucial starting point of the model, but the corner-
stone of the program is ongoing weekly group supervision (see Figure 18–3). Group su-
pervision provides a platform for continuous learning; it creates a forum for
containment and understanding of the patients and a structure to help with patient risk
management.
In our model, supervision of MBT-A is done in groups and on a weekly basis. The
MBFT supervision is done once a month. Supervision is conducted in a mentalizing
framework. In the supervisory sessions, the group members reflect on their emotional
experience while listening to the clinical material, seeking to mentalize what went on in
the session. This mentalizing stance in supervision not only enhances continuous
learning from experience about the model but also creates a nonpersecutory supervi-
sory context that is far more facilitating of the enhancement of mentalization in the
work of all the group members.
The treatment begins with an assessment phase, which lasts for a few sessions.
These sessions conclude with the development of a formulation, which is given to the
patient in writing and includes a treatment plan and a crisis plan. The formulation is
MBT-A
Training of therapists
Weekly supervision
Weekly MBT-A Monthly MBFT

sessions for 1 year sessions for 1 year
FIGURE 18–3. Structure of mentalization-based treatment for adolescents (MBT-A).
MBFT=Mentalization-Based Family Therapy.
not discussed with the parents, but the parents do receive a copy of the treatment plan.
The family therapy sessions have an assessment phase in the beginning, which is fol-
lowed by feedback and educational input.
The assessment phase is followed by the initial therapeutic phase, in which great
emphasis is placed on the establishment of a therapeutic alliance. The cornerstone of
establishing a therapeutic alliance, both in the individual work and in the family work,
is the therapist’s ability to be empathically attuned with the patient and to maintain a
mentalizing stance. Once the alliance is achieved, the next phase is the working (mid-
dle) phase, followed by the consolidation (final) phase before the end of treatment.
Assessment Phase
The assessment phase (Table 18–4) is used to gain an understanding of the young per-
son and the difficulties he or she faces. During the assessment phase, the therapist also
hopes to get an idea of the young person’s style of managing difficulties and ability to
mentalize and the particular situations in which the young person’s ability fails. This
usually takes two to three sessions. In our RCT, we are helped during this phase by
some of the results of the psychometric tests conducted on the young people prior to
entry into the research. The Millon Adolescent Clinical Inventory (Millon and Davis
1993; Millon et al. 1993) is particularly useful when the results are incorporated into
the formulation given to the young person. In MBFT, similarly, the therapist tries to get
to know the family and the different family members and their mentalizing ability in
the first session.
Formulation
Once the assessment is complete, the clinician gives the young person the formulation
to read and to discuss with the clinician. An example of a formulation is given below:
Background. Bob, a 15-year-old, presented to our service with a history of depression

and emotional distress, leading, at times, to self-harming behavior. Bob is an only child
and has grown up in a family dominated by conflict between his parents. He also ex-
perienced emotional and physical abuse from his mother. The constant conflict and
hostility in the family home left him feeling anxious, torn, unsure of what might happen
next, and also very alone, as if no one noticed his distress or was able to help him cope
with it.
When things at home go wrong, children and young people often blame them-
selves and feel that it is their fault. It appears that this happened for Bob to some extent,
and it has left him feeling that he is bad. As a result, Bob developed low self-esteem and
an inability to notice his own good qualities.
Coping skills. Given the family conflict and Bob’s sense of isolation in the home, he
had to learn, very early on in life, how to cope with pain, stress, anxiety, uncertainty, and
angry feelings. He did this by trying to look after the needs of those around him, put-
ting his own needs last. This left him feeling resentful and empty, however, and at times
led to intense feelings of anger. Bob coped with these feelings by expressing them, by
taking them out on someone else, or by harming himself. Because of Bob’s lack of con-
trol over his environment, he tried to cope by having some form of control in a practical
sense; for example, by trying to control his weight and his food.
Personality style. Bob is a warm and caring person who is very intelligent and artic-
ulate. However, he often feels unhappy and expects life to be distressing. He expects to
be let down and hurt in life, and he does not expect to get many rewards. This keeps
him on his guard and makes him unusually quick to distance himself from negative ex-
periences. He often holds himself back from others for fear of being hurt. Unfortu-
nately, this distance isolates him and prevents him from getting more positive feedback.
Bob often relates to others in a self-sacrificing manner and sometimes even allows
others to take advantage of him. He also presents himself in a negative light to others.
He often experiences fluctuations in his mood: he has periods when he feels very
down, with no energy, and other periods when he feels energetic and happy or quite an-
gry. Bob is able to form passionate attachments to others but then can become suspi-
cious and anxious that he will be rejected. In relationships, he sometimes feels a roller
coaster of love, rage, and guilt. At times, he feels empty inside. He also goes through
periods of hating himself and wanting to harm himself.
Sometimes when he feels overwhelmed with emotions, Bob makes himself numb,
but this makes him feel a sense of unreality.
TABLE 18–4. Mentalization-based treatment for adolescents: assessment phase
Getting to know:
The patient
The patient’s history
The patient’s relational context
The meaning of the reason for referral
The patient’s coping strategies
The patient’s mentalizing abilities
Formulation
Background
Personality style
Engagement in therapy
Self-harm in context
Mentalization
Treatment plan
Crisis plan
Engagement in therapy. Bob is likely to engage well in therapy but also likely to feel
anxious that the therapist will not really be interested in what Bob feels inside. He would
also be sensitive and worried that he will be judged or rejected. The end of sessions some-
times may be difficult, too, and it may feel like a long wait until the next session. To help
with this, Bob has a number that he can call when he feels that he is in an emotional crisis.
Self-destructive behavior. Bob uses self-harm as a way to manage his feelings. At

times, it feels as if it is the only thing he can do to cope with his feelings. Now that he
is in therapy for the first time, it might help him to understand himself and his feelings,
and this may help him to find different ways of coping.
Sensitive mentalizing. Bob often shows a great ability to understand what is in the
mind of others, such as an awareness of what his father feels or an understanding of his
mother’s feelings (even though he does not agree with her, he can still understand her
feelings). Bob also tries to understand his own thoughts and feelings and sometimes is
able to do it but at other times finds it harder not to fall into familiar patterns (see next
subsection) of judging himself.
Nonmentalizing. Bob often falls into a pattern of hateful thoughts and feelings in-
stead of trying to understand his underlying thoughts or feelings. This leaves him with
TABLE 18–5. Written crisis plan for “Bob”
Bob, when you feel that you cannot cope and you want to harm yourself, you could try
one of the following alternative techniques:
1. Write down what you feel and everything that happened in the past hour, then bring it
to therapy or call the clinic and request that I call you back, and I will do so when I am
free.
2. Do something physical and strenuous, such as going for a run.
3. Place an elastic band around your wrist, and when you have an urge to hurt yourself,
flick your wrist with the elastic band.
4. Draw on your wrist with a pen.
5. Delay the urge to hurt yourself, such as by saying to yourself, “Let me wait for 10
minutes,” and then distract yourself for 10 minutes with a video game or something
similar. It may make the urge go away.
It will be good to become familiar with the trigger factors over time. Thus far, we have
identified the following triggers: arguments between your parents, disputes with your
friends, thoughts that your girlfriend is abandoning you, feelings of anger, attacking
yourself, and anxieties about what other people think.
For you, risky feelings are those that involve a sense that you do not care about yourself
and, on occasion, that lead to suicidal thoughts. When you have these feelings, it is
important to recognize that they are risky feelings. When you feel like that, tell your
parents or contact the clinic at [number]. The clinic will get in touch with me, and I will
call you back when I am free. If I am not available, someone else will call you back. We
will talk about the crisis on the telephone and then decide whether to offer an urgent
session before your next session.
Sometimes the telephone conversation may be enough, but if the risk is high, you may
need to be seen for an urgent appointment. When people are feeling very depressed, it
is sometimes necessary to consider medication or to admit people to the hospital for a
short time. Other times, social services is contacted if families need more support.
If it is after hours and you think that you can wait until the morning, then contact the
clinic in the morning. If you feel that it cannot wait, then you could go to the emergency
room, where you will be seen by the duty doctor, and the duty doctor will then contact
the consultant on call, who will decide what needs to happen next.
Signed:
Patient: __________________________________________________________
Parent: ___________________________________________________________
Therapist: ________________________________________________________
TABLE 18–6. Mentalization-based treatment for adolescents: initial phase
• Provide formulation and psychoeducation

• Use empathy, empathy, empathy!
• Establish emotional contact
• Establish a positive alliance
horrible feelings, and then he believes that the only way to manage the feelings is to
turn them into an action (e.g., self-harm). This means that a feeling becomes some-
thing concrete; the feeling is transformed into blood, and then concrete care is applied
to take care of it. This is an example of how a feeling ended up being a concrete action,
but the actual feeling and what may have caused it are not understood.
Treatment plan. Bob has committed himself to a treatment program of weekly indi-
vidual therapy sessions with Dr. T on Fridays at 4:00 P.M. at Loxford Hall. Bob and his
parents will see a social worker once a month on a Friday at 5:00 P.M. at Loxford Hall.
Bob is not taking any medication at the moment. Bob’s treatment will last for 1 year,
and once a term, Dr. T will meet Bob’s parents and Bob to review the treatment. Bob
and Dr. T also agreed on a crisis plan (see next subsection). Bob’s parents will get a copy
of the crisis plan and a copy of the treatment plan, but they will not get a copy of the rest
of his formulation.
Crisis plan. Sometimes Bob feels a desire to hurt himself. This usually happens when
he is overcome with strong feelings that he finds difficult to manage, such as anger, sad-
ness, or negative feelings about himself. The crisis plan (shown at left, in Table 18–5)
has been developed to help him when he feels like that. The plan is also to help his par-
ents when Bob feels like harming himself.
In the first instance, it may help Bob’s parents to know that when Bob harms him-
self, he does so in an effort to escape difficult feelings. He does not harm himself with
the intention of killing himself.
Initial Phase of Treatment

Although the initial phase is described after the assessment phase, in reality, many as-
pects of the initial phase start with the assessment because the main focus of the initial
phase is the establishment of a therapeutic alliance and the engagement of the young
person in therapy (Table 18–6). It is quite common for young people to have difficulties
engaging in a therapeutic relationship, especially one that is sustained over a longer
term. In our study, we found that the highest likelihood of dropout was in the time be-
tween the assignments to treatment and the start of treatment. Once MBT began, the
dropout rate became very low (much lower than for treatment as usual). The mental-
izing stance of the therapist adopting a nonjudgmental, curious, and non-all-knowing
attitude is emphasized throughout but especially in the beginning.
In the adult MBT model, once the assessment is completed, the therapist discusses
the diagnosis with the patient, and this is followed by psychoeducation. In the devel-
opment of our model, this created a lot of debate. There was a strong view that it would
be too reductive, and potentially detrimental, to inform young people that they have
BPD or emerging BPD. This view is partly supported in some of the studies quoted in
the beginning of this chapter, which found that there is not always a link between BPD
in adolescence and BPD later, and hence it may be misleading to assign the diagnosis at
too young an age. For this reason, instead of giving a BPD diagnosis, we speak to young
people about the “blueprint of their coping mechanisms” and the trigger points in in-
teractions, and we incorporate that into the formulation. When the formulation is
given to the young person, much of the session is used to discuss it, and in this session,
the feedback, which has a psychoeducational function, is incorporated.
Because all of the above is done within the context of a mentalizing stance, and with
a strong emphasis on empathy and establishing real emotional contact with the patient,
it fosters a positive alliance from the start. With a positive alliance in place, the rest of
the initial phase follows. This involves slowly getting to know the young person’s emo-
tional landscape, vulnerabilities, ways of coping, and particular nonmentalizing mech-
anisms deployed. It is critical to gain an understanding of the adolescent’s relational
context and to help him or her to develop an understanding of when his or her men-
talizing abilities fail and of the particular emotions that lead to the failure, as well as the
events and emotions that preceded the moment.
The following is an example of a first session with a very anxious 14-year-old who
presented to the service following a suicide attempt. She took an overdose in an attempt
to escape from a torturous inner world dominated by anxiety, panic, and constant feel-
ings of emptiness. The example illustrates the therapist’s efforts to engage with the pa-
tient and make emotional contact with her. It also shows the therapist’s efforts to
ameliorate the patient’s anxiety by not allowing uncomfortable silences:
THERAPIST: Welcome. I am glad you came; from what your mom said on the phone, it
sounded as if it was difficult for you to come. So, that tells me you must have been
quite brave to come.
PATIENT: [silent, looking down]
THERAPIST: Is it okay to be here?
PATIENT: It’s awkward to talk to people.
THERAPIST: I understand that, especially now, because I am still a stranger to you. If you
think, at any stage, that I say something that makes you feel that I don’t under-
stand, please tell me. Would you mind just giving me an idea of what happened and
how you came to be here?
PATIENT: I had problems at school... [silence]
THERAPIST: I am sorry to hear that; what happened?
PATIENT: I was bullied by some kids, and I’m worried about the exams. I’m scared of
what people think of me.
THERAPIST: Tell me more.
PATIENT: I’m worried that I will do badly on the exams and that the teacher will be angry.
THERAPIST: Do you have a horrible teacher?
PATIENT: She sometimes takes marks off just to make me feel bad so that I work harder.
THERAPIST: Gosh, how does that make you feel?
PATIENT: It upsets me, and then I feel angry, and I think I didn’t work hard enough.
THERAPIST: It sounds to me that when the teacher does that, you get cross with yourself,
but she is the one who is doing something wrong, not you, so why should you get
cross with yourself?
PATIENT: I always get cross with myself.
THERAPIST: Do you think you just feel cross, or do you feel other things, too?
PATIENT: I think I feel sad.
THERAPIST: What do you think is making you sad?
PATIENT: I try so hard.
THERAPIST: Yes, I understand that. And when she takes marks off like that, do you feel as
if she does not notice how hard you try?
PATIENT: Yes. [cries]
THERAPIST: I wonder if that feels quite cruel to you.
PATIENT: Yes.
THERAPIST: Is she just a horrible, cruel woman? Why do you think she does that?
PATIENT: She says she does it to help me, to motivate me to work harder.
THERAPIST: But that isn’t the way it makes you feel, is it? It sounds to me like you feel
that nothing you do is good enough.
PATIENT: Yes.
THERAPIST: Do you think she knows how you suffer?
PATIENT: No, I think she thinks it is a game.
THERAPIST: If people play games with my feelings, I sometimes get angry.
PATIENT: I am very bad with anger.
THERAPIST: What do you mean?
PATIENT: I get worried when I get angry that I have ruined everything.
THERAPIST: Do you feel like that with your family, too?
PATIENT: Yes, I do with my dad.
THERAPIST: Tell me more....
Middle Phase of Treatment

The middle phase is the longest treatment phase and contains the bulk of the work
(Table 18–7). Now that the mentalization deficits and their particular emotional con-
text have been understood, this phase aims to enhance the patient’s mentalizing abili-
ties. The emphasis in the initial treatment phase was on the alliance and on mentalizing
the patient (i.e., opening up and exploring feelings, responses, and, in particular, re-
sponses in a relational context). The middle phase brings in specific challenges of non-
mentalization, as illustrated below.
Nonmentalizing Forms of Thinking

Concrete thinking. The following is an example of a session with a 15-year-old boy
who was referred to our service with a history of cutting himself, taking overdoses, and
having great difficulty managing relationships at school.
Peter also had a strong history of violent outbursts and impulsive behavior, and on one
occasion, he had been reprimanded by the police for attacking another boy. He grew up
with his mother and two half-siblings from different fathers. His mother has a history of
drug abuse. Peter experienced life as unpredictable when he was growing up, surrounded
by volatile relationships and inconsistent boundaries, which had left him with very little
ability to manage his own feelings, and hence he frequently fell back on concrete ways of
trying to reassure himself of his safety and concrete ways of managing his feelings.
This small vignette of a few minutes of a session with Peter illustrates his concrete men-
talizing and the therapist’s attempts to mentalize his feelings:
PETER: I broke up with Michelle. You remember that I wanted to see her last
Friday, and she said she was busy. Later, I found out that she was only busy
for one hour, and I could have seen her. So, on Saturday, I thought I’m not
having this; I may as well end it with her rather than wait around for her.
THERAPIST: What did you feel on Friday?
PETER: I sent her a text Saturday and said, “If you don’t call me by 5 o’clock, it’s
over.” I used to think that she wasn’t answering her phone because it was
broken, but, funnily enough, just after I sent the text, she texted straight
back saying, “I am sorry, but I am a happy person, and you are always
moaning, and it brings me down.” So, I thought, okay, whatever, and just
left it.
THERAPIST: Gosh, you must have felt very hurt.
PETER: No, I tried to convince myself that I felt nothing. I just don’t understand;
I was always happy when I was with her. I don’t see how she could say that
I am always moaning. The only thing I moaned about was that she just
never answered her phone. Any boyfriend would want that, right?
THERAPIST: So, when she didn’t answer her phone, what did that feel like?
PETER: It felt as if she didn’t care. Jenny always answered her phone, and that is
how I knew she cared.
THERAPIST: And when you felt that she didn’t care, how did that make you feel?
PETER: Anxious, and then I would phone her nonstop, and I would text and
leave messages. It’s not right to ignore me like this.
THERAPIST: So, the more she didn’t answer, the more anxious you would get.
PETER: Sometimes I would call her 20 times, and she would ignore me.
THERAPIST: And when you were anxious, what thoughts did you have, and what
were you anxious about?
PETER: I think that she’s met someone else. And I sort of saw it coming, so Fri-
day evening, when I went dancing, I flirted with people, and then I met
this new girl. She’s not really new; she is a sort of a friend. So, I thought
TABLE 18–7. Mentalization-based treatment for adolescents: middle phase
• Engage in bulk of the work

• Address nonmentalization
• With patients in emotionally aroused states, pause, go back, and explore feelings and trig-
ger factors
• With patients in affective storms, stay calm, avoid complex or transference interpretations,
keep interpretations simple and nonthreatening, stay emotionally attuned, and avoid
silences
• Address misinterpretations
• Explore alternative possibilities
• Open feelings up to explore more subtle feelings underneath
• Help patients to mentalize others
that I’d like to take her out, so I pretended to be drunk, and then I told her
that I would like to take her out. I thought that if I pretended to be drunk
and she said no, then I would just say the next day that I was drunk and that
I don’t remember anything. Then I won’t have to feel embarrassed. So, she
didn’t do that but said that she’d like to go out with me. On Saturday, when
I dumped Michelle, I already had the other one lined up, so I didn’t really
care about Michelle anymore. Now life has moved on, and this weekend I
will go out with her for the first time. And this week I felt really happy.
This girl is really special. We have so much in common; she is pretty....
THERAPIST: Can I just slow things down a bit to try and catch up?
PETER: Yes, it is a bit fast, isn’t it? I always do that—I always have one in reserve.
The minute I see trouble coming, I get one in reserve.
THERAPIST: It seems to me that all of this action about phoning her so many
times and getting another girl in reserve are ways in which you try and
manage a terribly anxious feeling inside you.
PETER: Yes, but now I don’t feel it because the new girl answers her phone all the
time, just like Jenny did, so it helps me.
THERAPIST: You said that when Michelle didn’t answer her phone, you got anx-
ious. Is that all you felt, or did you have other feelings, too?
PETER: I felt anxious that she was seeing another guy. and then I phoned again
and again.
THERAPIST: If I thought that someone I like was seeing someone else, it would
make me feel angry.
PETER: Yes, I felt like I could smash my phone up. I wanted to break her door
down.
THERAPIST: So, part of phoning her so many times was also an angry thing.
PETER: Yes, I suppose it was a bit smothering; maybe that is why she said that I was
moaning. But any guy would be upset if he was ignored....
Teleological thinking. Common examples of teleological thinking in adolescence are

a young person who believes that he or she is being cared for only if the care is ex-
pressed in an act, as opposed to being present in abstract form; a young person who cuts
himself or herself to receive physical care; or a young person who suddenly “knows”
that her boyfriend does not love her anymore because she did not get a text from him
(the text is treated as the concrete representation of his love). For example:
During one session, a 16-year-old patient described being upset because of an argument
with his girlfriend. Gary was very angry, threatening to break it all off, and filled with an
urge to act out impulsively. He was convinced that his girlfriend was unfaithful to him
and tried to muster all sorts of evidence to support his conviction. Then he received a text
from her in the session and read it. The text expressed something about her wish to be
with Gary and went on to say that she would break off her relationship with her previous
boyfriend to reassure Gary of her love for him. She ended the text with the sentence,
“I will tell him that.”
Gary read the text to the therapist and then threw the phone on the floor, saying,
“See, that’s what I told you.” The therapist felt a bit confused and said that she did not see
what he meant. Gary said: “She is with him now; that’s what.” Still confused, the therapist
said that she did not hear that in the message, so what made him think that? He picked up
his phone and read it again and then said: “It is in her saying, ‘I will tell him that’; because
she used those words, it meant that she was with him.” The therapist still did not get his
point and asked for further clarification. Gary then said: “If she said, ‘I will tell him that
when I see him,’ it would have meant that she was going to see him in the future, but her
saying ‘I will tell him that’ meant that she was with him.” In Gary’s mind, if she was with
the ex-boyfriend, then she was unfaithful to him.
In his rage, and driven by his impulsivity, Gary wanted to send her an immediate text
to tell her never to contact him again. With careful work, the therapist stopped him from
acting out, slowed him down, and helped him to see his distortion and how, in his dis-
tortion, he missed the true message of the text, which was the girl’s love for him.
Trying to mentalize the girl and wondering what she might have been feeling about
him when she sent the text calmed Gary down. Only after he calmed down and was less
impulsive and more in touch with her, as a person with feelings toward him, was it pos-
sible to explore his deep fear that she would leave him or get tired of his impulsive moods.
These nonmentalizing forms of thinking are present in nonmentalizing modes,

which are described below.
Pseudomentalization. The first mode, pseudomentalization, can be further broken

down into concrete mentalization, intrusive mentalization, and misuse of mentalization.
Concrete thinking, in the context of adolescence, is exemplified by a young woman
who, after an overdose, says that she does not know why she took the overdose and that
she just gets suicidal from time to time: it comes out of the blue, it just happens to her,
and it has no meaning. Very careful work and understanding later identify the complex
emotional and interpersonal struggles that led to the overdose. In the moments pre-
ceding the event, layers of misperception eventually result in an emotional escalation,

which becomes unmanageable for the young person; hence the impulsive flight into a
concrete solution.
Intrusive mentalization is commonly seen in family therapy. Examples would be par-
ents incorrectly ascribing mental states to a child’s behavior, without attempting to un-
derstand what the child is actually feeling. For instance, one mother complained that
her child was deliberately behaving in an angry way because the child’s father is aggres-
sive (and hence the child is like his father); only very careful work determined that the
child’s anger was in fact related to feelings of being blamed and misunderstood by his
mother and to his sense that whatever he did seemed to aggravate her. In a few sessions
alone with the therapist, the mother expressed her unresolved anger at her ex-husband
for leaving her for someone else and her deeper feelings of humiliation and rejection.
Once she understood her feelings, she was more able to notice how she confused her
son in her mind with her ex-husband.
Misuse of mentalization, which occurs when someone has the ability to mentalize the
feelings of another but then abuses that for his or her own manipulative purposes, is of-
ten seen when parents are going through a divorce or marital dispute, and the feelings
of children are used and distorted as ammunition against the other parent (as discussed
by Asen and Fonagy in Chapter 5 of this volume).
Pretend mode. In this nonmentalizing state of mind, the person appears to be men-
talizing and provides ample information and detail, but the interaction is emotionally
empty and disconnected or overly intellectual. Therapeutically, it is easy to fall prey to
this, misperceiving it as mentalization or good therapeutic work, the danger being that
the person will feel emotionally isolated and empty underneath the pseudocontact and
hence remain at risk for impulsive acting out. In this state, it is important for the ther-
apist in the first instance to be aware that it is pretend mode and then to try and make
deeper emotional contact with the patient by either stopping the excess flow of detail
and trying to bring the patient back to his or her feelings or commenting or inquiring
about the patient’s affect, such as: “You speak a lot about your friends and what you did
with them today, and, although it sounds important, I can’t help but notice that your
tone of voice is rather flat, and I wonder what you are feeling.”
Working With Nonmentalizing

The first therapeutic challenge is to be able to notice nonmentalization when it hap-
pens, both in the family setting and in the individual setting. When a patient is in a non-
mentalizing state, it is important to notice it, pause, be aware that this is an indication
that the patient is emotionally aroused and will easily misperceive what is said, and
avoid overarousing the patient by making complex observations or interpretations—
especially interpretations that may be perceived as persecutory by the patient. Patients
are very much helped, in this state, if the therapist can be emotionally in touch with
them and help them to realize what they are feeling and to understand the emotional
intricacies that preceded the aroused state.
The technique is about understanding emotional states, understanding how they
arose in the interpersonal context, preventing acting out, understanding feelings cor-
rectly, addressing misperceptions and distortions, and exploring alternative possibilities.
All these elements lead toward containment of the aroused mental state, which returns
the young person’s ability to mentalize. Technically, the work is about doing this again
and again and again, like building a house, brick by brick.
The technique also involves helping people reflect and mentalize the behavior of
those close to them. In this sense, misperceptions or pseudomentalization about others
is addressed and challenged by helping the young person to adopt a mentalizing stance
himself or herself and to appreciate that mental states define behavior.
As discussed by Bateman and Fonagy in Chapter 3 of this volume, in terms of work
within the transference, it is vital for the therapist to be aware of the transference at all
times. Awareness of the countertransference is useful, too, because countertransference
feelings are often the first place where one becomes aware of the pretend mode in op-
eration in the room. Countertransference feelings also can be helpful in informing the
therapist of the patient’s emotional state. Awareness of the transference and interpre-
tations of the transference are useful, but the emphasis in this technique, unlike anal-
ysis, is that interpretations of the transference should be limited to those that reflect the
patient’s emotional response to the analyst and that are consciously available to the pa-
tient. Interpretations referring to deep, unconscious anxieties are not used in this tech-
nique.
The cornerstone of the success of the technique lies in the therapist’s ability to
make emotional contact with the young person, to maintain a mentalizing stance, and
to have a positive alliance with the young person. It is also important for the work to be
playful at times because humor takes place in the realm of symbolism, which can lift
someone out of the realm of the concrete.
The technique of MBFT is not discussed here because it has already been ad-
dressed in Chapter 5.
Final Phase of Treatment

The final phase occurs in the last 2 months of treatment. The aim is to increase inde-
pendence and responsibility (Bateman and Fonagy 2006a), to enhance social stability,
to work through the pending separation, and to consolidate the gains made during
therapy (Table 18–8). In some cases, it may be best to taper the therapy by offering
reduced sessions after a year, such as twice monthly for a period followed by monthly
sessions. At the end of therapy, the young person receives an outcome formulation.
This is similar to the work that occurs in the last 2 months of MBFT.
TABLE 18–8. Mentalization-based treatment for adolescents: final phase
• Increase independence and responsibility

• Enhance social stability
• Work through pending separation
• Consolidate gains
• Taper treatment over longer time when needed
• Develop outcome formulation
Crisis Management
Each patient has a crisis plan with contact details and alternative options in crisis times
(see Table 18–5). When in crisis, brief telephone contact is offered, not to provide a ses-
sion by telephone but to arrange an alternative time to meet and to do a bit of a risk as-
sessment on the telephone. At times, a psychiatric referral is necessary if the risks are
high, or a short crisis admission may be necessary.
In a session when the patient has an “affect storm,”2 key techniques are to stay em-
pathically attuned to the patient, to resist making complex interpretations, to continue
talking, to try to clarify the feeling, and to try to clarify misperceptions. Deep interpre-
tations or transference interpretations should be avoided.
Finally, in terms of crisis management, the use of supervision and the team is crucial
because it is a forum in which risk can be collectively shared and thought about and in
which therapists get help with understanding the meaning of the pressures put on them
and the strong countertransference feelings therapists all experience from time to time.
Suggested Readings
Bleiberg E: Treating Personality Disorders in Children and Adolescents: A Relational Approach.
New York, Guilford, 2001
Sharp C, Williams LL, Ha C, et al: The development of a mentalization-based outcomes and
research protocol for an adolescent inpatient unit. Bull Menninger Clin 73:311–338, 2009
Williams LL, Fonagy P, Target T, et al: Training psychiatry residents in mentalization based
therapy, in Handbook of Mentalization-Based Treatment. Edited by Allen JG, Fonagy P.
New York, Wiley, 2006, pp 223–232
2 This term has been introduced by Bateman and Fonagy (2004), and the management referred
to here is the management they suggested.
Glossary
affect focus an intervention in mentalization-based treatment in which the therapist
focuses on an affect shared between therapist and patient. The affect is one that de-
termines the interaction either between patient and therapist or between group
members. It is covert or preconscious.
alexithymia the condition of lacking words for feeling; a significant trait in eating
disorders and substance abuse. Disconnection between subjective feeling compo-
nents of emotion and language.
alien self in which the child, unable to “find” himself or herself accurately repre-
sented in the mind of the caregiver as an intentional being, internalizes a represen-
tation of the other into the self with distorted agentive characteristics. Internalized,
this can lead to attacks against the self (e.g., self-harm); externalized, it is lodged in
another person, leading to an addictive bond, and terror of loss of the (abusing) per-
son develops.
anaclitic personality style in which patients have difficulties related to dependency

and neediness.
attachment the process by which individuals seek proximity to a caregiver for pro-
tection and a feeling of security when they are fearful, vulnerable, or ill. In children,
physical proximity is sought; in adults, mobile telephone contact, vocalization, or
photographs may suffice to restore a feeling of security. Attachment provides not
only a safe haven of security but also a secure base for exploration, including explo-
ration of the mind of self and others. See hyperactive attachment.
attachment trauma trauma in attachment relationships, mediated, in part, by men-

talizing failures in the caregiver. These failures are traumatizing by virtue of under-
mining the development of mentalizing in the child and thus impairing capacities
for secure attachment and emotion regulation.
Adapted from Allen et al. 2008, with thanks to Jon Allen.
511
borderline personality a disorder characterized by emotional dysregulation, prob-

lems in interpersonal relationships, impulsivity, and paranoid sensitivity.
challenge an intervention aimed to bring nonmentalizing to an abrupt halt. The in-

tervention lies outside the normal therapeutic dialogue. For example, a female pa-
tient in the midst of a nonmentalizing rant said to the therapist, who had looked
away briefly, that he should look at her and listen to her. The therapist stated that
he could listen while looking elsewhere at the same time and that he could multitask
because he was a man.
clarification a goal of interventions that enhance mentalizing by restructuring a pa-

tient’s material and increasing awareness of what he or she is communicating.
combined therapy in which the same therapist conducts both the group and the in-
dividual sessions. Mentalization-based treatment has been organized as a combined
therapy, but the initial research used a CONJOINT THERAPY framework.
concrete mentalizing a failure to appreciate and pay attention to feelings of self or

others as well as the relations between thoughts, feelings, and actions; interpretation
of behavior (one’s own or others) in terms of the influence of situational or physical
constraints rather than feelings and thoughts.
concurrent therapy in which group and individual therapy are provided simulta-
neously.
conjoint therapy in which the individual therapist is different from the group therapist.
contingent responsiveness a high but imperfect level of caregiver responsiveness

to infant behavior that facilitates the infant’s attention to the caregiver’s mental
states and thereby lays the developmental foundation for mentalizing.
dimensions or facets of mentalizing mentalizing considered as consisting of a

range of processes—self and other, cognitive and affective, automatic or implicit and
controlled or explicit, and internal and external focus. Other poles may include am-
biguous and unambiguous and here and now versus there and now.
effortful control the ability to attend to a subdominant mental process and simulta-
neously suppress a dominant mental process so that the individual is able to focus
attention when distractions occur. This is crucial for emotion regulation.
egocentrism the default mentalizing mode of equating others’ mental states with
one’s own.
e-imagination or enactment imagination a process whereby an individual not

only supposes his or her feeling state but also tries to enact the state itself. Links with
EMPATHY.
Glossary 513
embodied mentalizing in which the body is used to fill in moments of mentalizing

failure. The term is elaborated to cover mental states related a person’s physical be-
ing, including perceptions and cognitions about bodily function and sensorimotor
perception.
emotional intelligence a multifaceted assessment pertinent to mentalizing emotion

that includes competence in perception and expression of emotion as well as emo-
tion understanding and emotion regulation.
empathy as Simon Baron-Cohen defines it, identifying others’ emotional responses

and responding with appropriate emotion; broadly conceived, mentalizing is more
inclusive than empathizing in encompassing empathy for the self and others.
excrementalizing slang for distorted mentalizing; mentalizing but doing a very

poor job of it, for example, when trashing oneself in a depressive state.
explicit mentalizing group a psychoeducational/process group used to increase

understanding of attachment, mentalizing, and personality disorder as well as allied
topics. Sometimes known as introductory mentalization-based treatment. Contrast
with IMPLICIT MENTALIZING GROUP.
hyperactive attachment high sensitivity and easy triggering of the attachment sys-
tem, leading to the core symptoms in borderline personality disorder. The stimula-
tion of the attachment system undermines mentalizing.
hypermentalizing using thoughts, reflections, and fantasies as a way of avoiding

current reality. It is associated with hypervigilance, unquestioned assumptions, and
excessive inference.
implicit mentalizing group a group that serves as a training ground for mentalizing
between participants. Contrast with EXPLICIT MENTALIZING GROUP or psychoeduca-
tional group.
intentionality the distinguishing feature of mental states—namely, that these states

are representational or about something.
intergenerational transmission the interactive process whereby patterns of behav-

ior are learned and reenacted across generations; for example, as the intergenera-
tional transmission of trauma is perpetuated by mentalizing failures that cascade
across generations.
introjective personality style in which patients primarily present with issues re-
garding autonomy and self-definition.
joint attention interactions in which infant and caregiver jointly attend to a third
object; a significant contributor to the development of mentalizing in cultivating the
sense of multiple perspectives, including another’s perspective on the self when the
infant is the object of attention.
marked emotion a characterization of emotional mirroring that denotes the care-

giver’s modified expression of the infant’s emotion back to the infant; for example,
alloying the reflection of the infant’s distress with an expression of concern; pro-
motes the infant’s capacity to develop self-representations of emotional states.
mentalizing imaginatively perceiving and interpreting behavior of oneself and oth-

ers as conjoined with intentional mental states, shorthand for which is “holding
mind in mind.”
mentalizing emotion identifying emotional states and their meaning, modulating

the intensity of emotion, and expressing emotion outwardly and inwardly; crucial
for emotion regulation. Includes mentalizing while remaining in the emotional state
(mentalized affectivity).
mentalizing region an area in the medial prefrontal cortex overlapping the anterior
cingulate that consistently shows activation in neuroimaging studies when partici-
pants are engaged in mentalizing tasks.
mentalizing stance an exploratory attitude of inquisitiveness and curiosity about

mental states that mentalizing interventions aspire to promote.
mentalizing the transference more specifically exploring the relationship between

the therapist and the patient to develop collaboratively an alternative perspective.
The intervention does not seek to develop insight.
metacognition a facet of mentalizing, namely, thinking about thinking; serves the

function of monitoring and regulating cognitive processes.
mindblindness Simon Baron-Cohen’s term for the absence of mentalizing in au-

tism, which can be extended to more transient and dynamic mentalizing failures, as
evident, for example, when experiencing threats to attachment relationships.
mindfulness a Buddhist concept referring to attentiveness to the present; mentaliz-

ing entails mindfulness of mind in particular.
mind-mindedness a term used by Elizabeth Meins and colleagues to refer to care-

givers’ recognition of their children as mental agents and proclivity to refer to their
children’s mental states in their speech.
mindreading a term widely used in the theory-of-mind literature to refer to inter-

preting others’ mental states; sometimes used synonymously with MENTALIZING.
Glossary 515
mirror neurons neurons activated by observing an action or emotion and when per-
forming an action or experiencing an emotion; a potential neurobiological substrate
of empathy.
misuse of mentalizing in which understanding of the mental state of the individual

is not directly impaired, yet the way this understanding is used is detrimental. Often
exampled by self-serving distortion of the other’s feelings and self-serving empathic
understanding (e.g., in antisocial personality disorder). An individual may exagger-
ate or distort another person’s feelings in the service of his or her own agenda.
moments of meeting as characterized by Daniel Stern and colleagues, poignant

moments of intersubjective contact in psychotherapy that have a potentially power-
ful therapeutic effect; in their spontaneity, moments of meeting exemplify the artful
nature of mentalizing.
not-knowing stance an aspect of the mentalizing stance that respects the opaque-
ness of the patient’s mental states, as contrasted with making unwarranted assump-
tions and interpretations.
oxytocin a neuroactive hormone synthesized in the hypothalamus influencing brain

areas that are associated with emotions and social behaviors (e.g., amygdala and cin-
gulate cortex). It plays a role in attachment and prosocial behavior in animals and is
associated with trust, generosity, and observing emotional states in humans.
parental metaemotion philosophy a term used by John Gottman and colleagues to

refer to parents’ awareness of their children’s emotional states and an interest in cul-
tivating children’s emotional awareness; consistent with a parental mentalizing
stance.
pedagogy a term used by George Gergely and colleagues to refer to the uniquely hu-
man capacity to teach and learn cultural information, including information about
mental states; a foundation for mentalizing; and, through MARKED EMOTION, a means
of learning about one’s own emotional states in particular.
prementalizing modes ways of thinking and interacting that are developmental

precursors to mentalizing, including the PSYCHIC EQUIVALENCE, PRETEND, and TELEO-
LOGICAL modes.
pretend mode one of the PREMENTALIZING MODES of thinking; unlike in PSYCHIC EQUIV-
ALENCE, mental states are decoupled from reality yet, unlike in MENTALIZING, are not
flexibly linked to reality; in psychotherapy, pretend mode is evident in PSEUDOMEN-
TALIZING, intellectualizing, using psychobabble, or—to use philosopher Harry
Frankfurt’s term of art—bullshitting.
pseudomentalization a tendency to express absolute certainty without recognizing

the inherent uncertainty that knowing someone else’s mind entails. Capability to
conceive mental states, but only as long as these have no connection with actual re-
ality. Can be intrusive (disrespecting separateness or opaqueness of minds) or over-
active (excessive energy being invested in thinking about how people think) or
destructively inaccurate denial of objective realities that undermines the subjective
experience of the person described (“You provoked me”). Linked to PRETEND MODE
functioning.
psychic equivalence mode one of the PREMENTALIZING MODES of thinking in which re-
ality is equated with mental states, and the sense of representingness of mental states
is absent; examples are dreams, posttraumatic flashbacks, and paranoid delusions.
psychological mindedness a term originating from literature about treatment suit-

ability for psychodynamic therapy. Broadly, it is a disposition or proclivity to men-
talize and is often conceived of as a trait rather than a psychological activity.
psychological unavailability emotional neglect, referring to a lack of attunement to

a child’s mental states; exemplifies a critical mentalizing failure.
reenactment unwittingly repeating past traumatic relationship patterns in current

relationships; a mentalizing failure that entails retraumatization and puts patients at
risk for posttraumatic symptoms.
reflective functioning Peter Fonagy and colleagues’ operationalization of mental-

izing capacity as exemplified by their Reflective Functioning Scale used in research;
used synonymously with mentalizing in some research and clinical literature.
representingness a term used by Radu Bogdan to capture the sense one has of men-
tal states as representing something in a particular way; the sense of representing-
ness of mental states is lost in the psychic equivalence mode, for example, when the
depressed patient cannot appreciate that self-condemnation is a reflection of de-
pressed mood rather than indicative of objective reality.
secure base a facet of secure attachment in which the attachment relationship serves
as a platform for exploration; a secure base in attachment promotes exploration of
mental reality as well as external reality and thus is conducive to mentalizing.
self-agency the agentive self. Seen as rooted in the attribution of mental states, this
capacity emerges through interactions with the caregiver, in the context of an at-
tachment relationship, via a process of contingent mirroring. The child finds him-
self or herself through the attention of the caregivers: I am because you think of me
and represent me.
Glossary 517
social cognition an extensive domain of research pertaining to mental processes

that mediate social relationships and, accordingly, a large body of knowledge perti-
nent to mentalizing.
systemizing as defined by Simon Baron-Cohen, the antithesis of empathizing—

namely, a rule-based way of understanding and predicting the behavior of a system;
some persons with autism exemplify exceptional systemizing ability coupled with
profoundly impaired empathizing.
teleological mode one of the PREMENTALIZING MODES; in this mode, mental states are
expressed in goal-directed actions instead of explicit mental representations such as
words—for example, when self-cutting is used as a way of communicating extreme
emotional pain.
theory of mind a domain of extensive research bearing on the development of an

understanding of the representational nature of mind, as exemplified explicitly in
the ability to interpret behavior as stemming from false beliefs; prominent theories
to explain theory-of-mind development include the theory-theory, simulation the-
ory, and modularity theory.
transference tracers indicators in the patient-therapist dialogue about the signifi-

cance of their relationship. Within them are indicators of things to come within the
therapeutic relationship: “Maybe if all your relationships have lasted about three
months, we need to be careful in this relationship at around that time!” There is an
urbane hint about transference but no further exploration unless the patient responds.
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Index
Page numbers printed in boldface type refer to tables or figures.
Access, to treatment for borderline Adult Attachment Interview (AAI), 47, 51,
personality disorder, 231–232 52, 56, 60, 352, 388, 405
Accountability, and mentalization-based Affect. See also Affect regulation; Negative
family therapy, 111 affect
Act With Awareness subscales, 55 antisocial personality disorder and, 291–
Acute inpatient care, for borderline 292
personality disorder, 229–231 basic principles of mentalization and, 4
Acute stress disorder, 421 borderline personality disorder in
Adaptive flexibility, 20–21 adolescents and “storms” of, 509
Addiction, as stress regulation disorder, 311 mirroring of, 4, 7–8, 36, 265
Adherence, and eating disorders, 369. See Affect focus, in mentalization-based
also Compliance treatment, 74–76, 99–100, 511
Adolescents. See also Children Affective attunement, and
characteristics of borderline personality countertransference in mentalization-
disorder in, 466–480 based treatment, 78
characteristics of in popular and clinical Affective mentalization
literature, 463 antisocial personality disorder and, 293
diagnosis of personality disorders in, 464– assessment of, 63
465 multidimensional construct of
eating disorders and, 350, 353 mentalization and, 29–31
elevation of rate of psychiatric disorders Affect labeling, 57
in, 464 Affect regulation. See also Emotion
impulsivity, risk taking, and peer-focused regulation
interactions in adaptive fitness of, basic principles of mentalization and, 4
464 borderline personality disorder in
mentalization-based treatment of adolescents and, 492–493
borderline personality disorder in, eating disorders and, 352
480–509 mentalization-based therapy for children
personality disorders and substance abuse and, 152–154
in, 446 transactional model for development of
self-harm as early risk marker for social cognition, 7–8
borderline personality disorder in, Agency, and borderline personality disorder
465 in adolescents, 467
571
Aggression, and antisocial personality mentalization with regard to self versus

disorder, 297–298 others in, 25, 64
Alabama Parenting Questionnaire (APQ), prementalistic modes of functioning and,
485 292–293
Alcohol abuse. See also Substance abuse sense of self and, 293–296
disorders structured assessment of mentalization
mentalization-based treatment in partial and, 53
hospitalization setting and, 217 substance abuse and, 446, 450
psychiatric characteristics of mothers Antisocial Process Screening Device
with, 334 (APSD), 485
suicide attempts and, 448 Anxiety. See also Anxiety disorders
Alexithymia, 31, 377–378, 511 antisocial personality disorder and, 300
Alien self brief treatment and, 166
antisocial personality disorder and, 293– mentalization-based family therapy and,
296 112–113
definition of, 33, 511 substance abuse and, 453
mentalization-based therapy for children Anxiety disorders, comorbidity of with
and, 141 borderline personality disorder in
traumatized patient and, 433 adolescents, 479
Allen, Jon G., 370–371 APT (Addiction Prevention and Treatment)
Aloneness, and experience of mentalizing, Foundation, 334
163 “Argument Rules and Regulations,” and
American Psychiatric Association, 82. See also mentalization-based family therapy, 126
DSM-IV-TR Arousal. See also Dual arousal systems
Amphetamine, 320 assessment of mentalization and levels of,
Amygdalocentric model, of posttraumatic 50
stress disorder, 428 automatic mentalization and, 21–22
Anaclitic personality style, 511 effect of on mentalizing in traumatized
Analyst-centered interpretations, and affect patient, 432–433
regulation, 152 as trigger for failure of mentalization, 16–
Animated Theory of Mind Inventory for 17
Children, 57 Art therapy. See also Drawings; Music
Anorexia nervosa. See Eating disorders mentalization-based treatment in partial
Anticipatory mentalizing, and brief hospitalization setting and, 211–212
treatment, 175, 177 psychodynamic therapy and, 251
Anti-mentalizing, and eating disorders, 371 Ascription, and antisocial personality
Antisocial personality disorder disorder, 299
clinical features of, 289 Asperger’s disorder, 134
developmental roots of violence in, 296– Assessment. See also Diagnosis
300 borderline personality disorder and, 235–
dimensions of mentalization in, 290–292 236, 483, 485–486, 497–501
externally focused mentalization and, 23 characteristics of good mentalization and,
failures of mentalizing and, 7 58–59
mentalization-based treatment of, 300– individual differences in attachment,
307 mentalization, and stress, 44–51
Index 573
internal-external distinction in Attitudes, exaggeration of by therapist, 151

mentalization and, 22–23 Attunement task, and emotional regulation
of maternal reflective functioning in late in brief treatment, 183
pregnancy, 321 Authenticity
relationship-specific mentalization and mentalization-based treatment for
interpersonal nature of borderline personality disorder and,
mentalization, 51–52 282–283
of sensorimotor regulatory capacities in transference in mentalization-based
children, 145 treatment and, 76
structured forms of, 52–53, 55–57 Autism
unstructured forms of, 54, 59–64 diagnosis-specific anomalies of
Attachment. See also Deactivation; mentalization and, 10
Hyperactivition mindblindness in children and, 134
antisocial personality disorder and, 297– Automatic mentalization
298 assessment of, 63
assessment of individual differences in, functional polarities of mentalization and,
44–51 19–20
attentional control and, 9 individual differences in attachment and
basic principles of mentalizing and, 4 stress, 45–46
borderline personality disorder in Avoidance
adolescents, 473–474 depression and, 405, 409
brief treatment and, 164–165, 182–183 traumatized patient and, 432
broaden and build cycles of, 48, 49, 393 Avoidance and Fusion Questionnaire for
definition of, 511 Youth (AFQ-Y), 486
depression and, 390–394, 405–406 Avoidant personality disorder, 367
description of process of, 511
family or couples therapy and, 259–260, Background dimension, of psychoanalytic
262 process in patients with personality
mentalization-based therapy for children disorders, 249
and, 132, 133, 136 Basic Empathy Scale (BES), 486
psychotherapy and, 34–39 Basic layer, and borderline personality
self and development of capacity for disorder, 249
mentalization, 25 Bayley Scales of Infant Development (BSID
strategies, 44–51 II), 320
substance abuse and, 344, 451–453 Beck Depression Inventory (BDI), 329, 336
transactional model for development of Behavior, and mentalization-based treatment
social cognition, 11–16, 17–19 in partial hospitalization setting, 206.
trauma in, 426–429, 511 See also Aggression; Intentional
Attentional control behavior; Self-destructive behavior;
basic principles of mentalizing and, 4 Violence
development of social cognition and, 8–9 Behavior Rating Inventory of Executive
Attentional fixation, and brief therapy, 164 Function (BRIEF), 485
Attention-deficit/hyperactivity disorder, 134 Beliefs About Emotions Scale, 55
Attention regulation, and mentalization- Benzodiazepines, 337
based therapy for children, 143, 145– Biobehavioral switch model, 45
152, 157 Bion, W. R., 85–86, 253, 318
Bipolar disorder, and borderline personality structured assessment of mentalization

disorder in adolescents, 479, 480 and, 53
Body awareness, and eating disorders, 372– subjective experience and, 32
373 substance abuse and, 446, 455–461
Body image, and eating disorders, 348, 354, symptoms of, 200
361–362 trauma history and, 18
Body scanning, and mentalization-based treatment duration for, 228–229
family therapy, 125 validation interventions in dialectical
“Borderline child,” 133–134, 135 behavior therapy and, 52
Borderline personality disorder (BPD) Borderline Personality Disorder Features
acute inpatient care for, 229–231 Scale for Children (BPFSC), 485
in adolescents, 467–509 Borderline personality organization (BPO).
attachment hyperactivation and See also borderline personality disorder
deactivation strategies in, 49 198, 248–250, 252, 254–255
automatic and controlled mentalization Boredom, and mentalization-based
in, 21, 49 treatment of borderline personality
brief treatment and, 166, 181 disorder, 283
children and diagnosis of, 133, 134 Boundaries, in mentalization-based therapy,
concurrent group and individual 113–114, 153
psychotherapy for, 82 Bowlby, John, 34, 297
consistency in treatment of, 228 Brain. See Neurobiology
countertransference experiences in, 79 Brainstorming, and mentalization-based
crisis interventions for, 231 family therapy, 124
definition of, 512 Breuer, J., 34
demands on mental health services system Brief Symptom Inventory (BSI), 320
and, 227 Brief treatment. See also Mentalization-based
depressed patients with features of, 388– treatment
389 education about mentalizing and, 165–
dual arousal systems and, 9–10 167
experimental outpatient program for mentalizing challenges for clinicians in,
treatment of, 235–241 191–195
failures of mentalizing and, 4 mentalizing exercises for, 167–183
features of effective treatments for, 199 mentalizing perspective on, 161–165
group therapy for, 234 potential value of, 161
impairments in self-identity and, 25 problem formulation in, 183–190
internally and externally focused therapeutic alliance and, 160, 161
mentalization in, 22, 23 Broaden and build cycles, of attachment,
mentalization-based treatment for, 198, 48, 49, 393
273–288, 480–509 Bruch, Hilde, 360–361, 362, 370, 371,
psychodynamic therapy and, 249, 250, 375
267 Bulimia. See Eating disorders
self-harm in children and adolescents as Buprenorphine, 320, 455, 456, 460
early risk marker for, 465
social cognitive functions and, 7 Cannabis, 334, 337
staff and teams working with patients for, Capgras’ syndrome, 7
233 Cartoon task, and eating disorders, 359
Index 575
Case examples egocentrism of, 27

of antisocial personality disorder, 295 mentalizing in parents with personality
of borderline personality disorder in disorders and, 180–183
adolescents, 475–477, 504–505, 506 self-harm in as early risk marker for
of brief treatment, 167–168, 173–177, borderline personality disorder, 465
185–187, 188–189, 194 Children in the Community Study, 466
of eating disorders, 354, 355, 356, 357 Chronic fatigue syndrome, 391
of group therapy, 84–85, 91–97, 101–104 Cocaine, 334, 337, 447, 450, 451
of mentalization-based treatment for Codes of conduct, and group therapy for
borderline personality disorder, 230, antisocial personality disorder, 303–304
239–240 Coercion, and misuse of mentalization,
of mentalization-based treatment in 114
partial hospitalization setting, 223 Coercive cycles, and borderline personality
of posttraumatic stress disorder, 434, 436, disorder in adolescents, 482
440–441 Cognitive-behavioral therapy (CBT). See also
of psychodynamic therapy, 259–260 Cognitive-evolutionary therapy;
of reflective functioning in mothers with Mentalizing cognitive therapy (MCT)
substance abuse, 324, 326 changes in brain and in mentalization
of substance abuse disorders, 454 related to, 35
of treatment programs for mothers with for depression, 394
substance abuse, 337, 339–341 for eating disorders, 348
Case formulation. See also Problem effective mentalization-based
formulation interventions and, 40–41
for borderline personality disorder in for posttraumatic stress disorder, 419
adolescents, 484, 487, 498–499, 501 Cognitive Emotion Regulation
for eating disorders, 364–366 Questionnaire (CERQ), 486
Centralized pattern, of relationships, 49 Cognitive errors, in depression, 403
Challenge, as high-risk intervention in Cognitive-evolutionary therapy, 83
mentalization-based treatment, 73–74 Cognitive mentalization
Chameleon effect, 26, 28 antisocial personality disorder and, 293
Changeability, and mentalization-based assessment of, 63
family therapy, 111 depression and, 410
Characteristic play, 144 multidimensional construct of
Checking for consensus, and mentalization- mentalization and, 29–31
based family therapy, 118, 119 Cognitive perspective-taking system, and
Child Attachment Interview, 15, 51, 53, 485 emotional contagion system, 29–30
Child Behavior Checklist (CBCL), 485 Cognitive processes, and functional
Childhood Interview for DSM-IV polarities of mentalization, 19–20
borderline personality disorder, 474, Coherent approach, to mentalization-based
485 treatment in partial hospitalization
Children. See also Adolescents; Development; setting, 218
Family; Family therapy; Mentalization- Collaboration, and transference in
based therapy for children; Parent(s) mentalization-based treatment, 77
and parenting Collaborative Assessment and Management
diagnosis of borderline personality of Suicidality (CAMS), 163
disorder in, 133, 134, 135 Combined therapy, 512
Comorbidity, with other psychiatric Controlled mentalization

disorders assessment and, 63
antisocial personality disorder and, 301 failure of in depression, 398
borderline personality disorder in functional polarities of mentalization and,
adolescents and, 479, 480 20–22
of borderline personality disorder with hyperactivation strategies and, 46
other Axis I diagnoses, 465 Conversations With Anorexics (Bruch 1988), 370
of depression with borderline personality Coping skills, and borderline personality
disorder, 389 disorder in adolescents, 498
of depression with pain and fatigue, 391, Corticotropin-releasing hormone receptor I
397 (CRHR1) gene, 391
of eating disorders with personality Countertransference. See also Transference
disorders, 350 borderline personality disorder and, 233–
of personality disorders with substance 234, 285–288, 508
abuse, 446–448 eating disorders and, 379
Complementary countertransferences, 78, group therapy and, 102–104
102 mentalization-based therapy for children
Complex posttraumatic stress disorder, 425– and, 139
426 mentalization-based treatment and, 77–
Compliance, and eating disorders, 378. See 80, 233–234
also Adherence; Pseudocompliance substance abuse in mothers of infants and,
Complex interpretive mentalizing, and 333
mentalization-based therapy for Covert feelings, and eating disorders, 378–
children, 155–156 379
Concordant countertransferences, 78–79, CRAFFT screening tool, 485
102 Creative therapy, and mentalization-based
Concrete mentalizing, 512 treatment in partial hospitalization
Concrete thinking, and borderline setting, 211. See also Art therapy;
personality disorder in adolescents, 504, Writing therapy
506–507 Crisis plans
Concurrent therapy, 512 antisocial personality disorder and, 301
Conduct disorder, 134 borderline personality disorder and, 231,
Confrontation, and treatment of depression, 500, 501, 509
395 mentalization-based treatment in partial
Conjoint psychotherapy, 81, 207–208, 512 hospitalization setting and, 205–206
Consistency, of approach in mentalization- Criticism, directed at therapist, and
based treatment, 218, 228 treatment of antisocial personality
Contact, mentalization-based therapy for disorder, 304–305
children and ability to make, 149–150 Csibra, G., 146
Containment, and treatment Cultural issues, and eating disorders, 374
of posttraumatic stress disorder, Curiosity, and mentalization-based family
434–436 therapy, 110, 121–122
Context, of mentalization in depressed Curiosity Box Paradigm, 329
patients, 388
Contingent responsiveness, 512 Day hospital treatment programs, and group
Continuous Performance Test (CPT), 9 therapy, 83
Index 577
Deactivation, and attachment strategies, 46– understanding behavior of others as

47, 49–51, 262, 393, 407, 408–411 achievement of, 4
Death of violence in antisocial personality
as living theme in eating disorders, 376– disorder, 296–300
377 Developmental trauma disorder, 425
leading causes of in adolescents, 464 De Viersprong Center of Psychotherapy
Decathexis, and mentalization-based therapy (Netherlands), 197, 198, 206–207
for children, 131 Diagnosis. See also Assessment; Comorbidity;
Deliberate Self-Harm Inventory (DSHI), Differential diagnosis; DSM-IV-TR;
485 Dual diagnosis
Dependency, in traumatized patients, 432 of personality disorders in adolescents,
Dependent/sociotropic individuals, and 464–465
depression, 407–408, 409, 413 of posttraumatic stress disorder, 420–425
Depression. See also Major depression Diagnostic Interview for Borderline Patients,
antisocial personality disorder and, 301 466, 496
attachment and, 390–394, 405–414 Diagnostic Interview Schedule for Children
brief treatment of, 166 (DISC), 485
case for mentalization-based approach to, Dialectical behavior therapy
386–389 borderline personality disorder in
diagnosis-specific anomalies of adolescents and, 483
mentalization, 10 borderline personality disorders and
impaired and distorted mentalization in, validation interventions in, 52
396–402 concurrent mentalization-based
implications of mentalization-based treatment and, 82
treatment of, 414–416 Differential diagnosis, and borderline
long-term negative impact of, 386 personality disorder in adolescents,
outcome of treatment for substance abuse 479–480
in mothers and, 338 Differentiation, of internal states of mind, 31
phenomenology of, 402–406 Difficulties in Emotion Regulation Scale
prevalence of, 385 (DERS), 486
relapse rates in, 386, 394, 415 Disembodiment, and eating disorders, 360, 373
theoretical perspectives on mentalization Disentangling feeling states, in
in, 389–396 mentalization-based family therapy, 121
Depressive realism, 400–401 Disorganized attachment strategies, 47, 48
Development. See also Children Displacement, and mentalization-based
attachment trauma and, 426–429 therapy for children, 140
of awareness of internal mental states, 24 Disruptive behavior disorder, 134
borderline personality disorder in Dissociation
adolescents and, 468–473 borderline personality disorder in
mentalization-based therapy for children adolescents and, 477–478
and, 130–133, 148 cognitive and affective aspects of
parent’s capacity for reviewing of, 319 mentalization and, 30
posttraumatic stress disorder and, 423 responses to trauma and, 423
transactional model for social cognition Distributed relationship pattern, 49
and, 6–19 Dopamine and dopaminergic system
substance abuse in mothers and, 332–333 arousal and, 16
Dopamine and dopaminergic system Eating disorders

(continued) body image and, 348, 354, 361–362
attachment and, 44, 451 as clinical challenge, 349–350, 351, 374–
depression and, 399 381
drug abuse and, 313 comorbidity with personality disorders,
Dose-response relationship, of trauma in 350, 479
posttraumatic stress disorder, 421 embodied mentalizing in, 349, 359–360
Drawings, and brief treatment, 169, 171. See impairments in mentalizing and, 7, 348,
also Art therapy 351–352
Dropouts, and group therapy for borderline interoceptive confusion and self-deficits
personality disorder, 234 in, 360–361
Drug abuse. See also Substance use disorders mentalization-based therapy for, 362–
dopaminergic pathways and, 313 374, 375
mentalization-based treatment in partial minding the minds of others, 358–359
hospitalization setting and, 217 therapeutic alliance and, 349
DSM-IV-TR Edinburgh Pre-postnatal Depression Scale
borderline personality disorder and, 133, (EPDS), 320
134, 198, 236 Education, about mentalizing in brief
comorbidity of eating disorders with treatment, 165–167. See also Parent
personality disorders and, 350 Education Program; Psychoeducation;
personality disorders in adolescents and, Training
464–465 Effortful control, 512
posttraumatic stress disorder and, 420– Egocentrism, 27, 512
421 Electromyography of facial mimicry, 57
Dual arousal systems, and transactional Embodied mentalizing, and eating disorders,
model for development of social 349, 359–360, 513
cognition, 9–10 Emergency services, and mentalization-
Dual diagnosis, of personality disorders and based treatment in partial
substance abuse, 448–450, 453, 459–461 hospitalization setting, 206. See also
Dual focus schema therapy (DFST), 449 Crisis plans
Dual liability, and trauma, 419–420, 427 Emergent personality disorder, 133
Dual-process model, of arousal and stress Emotion(s). See also Affect; Negative
regulation, 45 emotionality
Dunedin Multidisciplinary Health and brief treatment and regulation of, 183
Development Study, 423, 464 emotional closeness in mentalization-
Duration, of treatment based treatment sessions and, 68–70
for borderline personality disorder, 228– logic of in patients with borderline
229 personality disorder, 276
for substance abuse in mothers of infants, Emotional contagion system, and cognitive
316, 343 perspective-taking system, 29–30
Dynamic body expressions, 57 Emotional intelligence, 513
Dynamic deconstructive psychotherapy Emotion regulation, and attachment, 427.
(DDP), 449 See also Affect regulation
Dynamic Interpersonal Therapy (DIT), 184, attachment and, 427
415 co-occurrence of personality disorders
Dysregulation, and eating disorders, 353 and substance abuse, 447
Index 579
Empathic listening, and brief treatment, Falsehoods, brief treatment and

169, 176 identification of, 169
Empathising System, The, 29–30, 31 Family, brief treatment and mentalizing in
Empathy relationships of, 169, 179–180, 181.
antisocial personality disorder and, 299– See also Children; Parent(s) and
300, 306–307 parenting
definition of, 513 Family therapy, mentalization-based (MBFT)
Empathy for pain in others task, 57 basic clinical model for, 127
Empathy Quotient, 55 borderline personality disorder in
Enacting problem scenarios, and adolescents and, 495
mentalization-based family therapy, difficulties in mentalizing and, 111–114
121, 122 five-step loop for therapeutic work in,
Enactive imagination (e-imagination), 299, 117–120
300, 512 hypotheses and formulations in, 116–117
Enactments, and traumatized patient, 429– intersession activities and tasks in, 125–
442 126
Enmeshed family, 113 mentalization-based treatment in partial
Evolutionary perspective, on mentalization hospitalization setting and, 213
and depression, 395–396 mentalization-enhancing activities and,
“Excrementalizing,” 513 123–125
Exercises, in mentalizing for brief therapy, mentalizing the moment in, 119, 120–122
167–183 objectives of, 108, 109
Experiences in Close Relationships–Revised psychodynamic therapy and, 258–264
(ECR-R), 485 session structure for, 115–116, 117
Expert/student paradox, in brief treatment, strengths of mentalizing in relational
191–192 context and, 109–111
Explicit mentalization. See Controlled trajectory of, 117
mentalization Fantasy, and play in mentalization-based
Explicit mentalizing groups, for eating therapy for children, 153
disorders, 364, 513 Fatigue, comorbidity of with depression,
Expression, of internal states of mind, 31 391, 397
Expressive-supportive continuum, and Feeling and doing activity, and
treatment of borderline personality mentalization-based family therapy,
disorder, 237 123–124
Externalization, of alien self, 433 Feeling finer game, and mentalization-based
Externalizing subtype, of posttraumatic family therapy, 123, 179
stress disorder, 424 Feeling hot-potato game, and brief
Externally focused mentalization, 22–25 treatment, 169, 179–180
Fibromyalgia, 391
Face morphs, 56 Fight-flight-freeze reactions, 17
Facial affect stimuli, and borderline Finland, and residential program for
personality disorder in adolescents, pregnant and parenting women, 312
472 Five-step loop intervention technique, in
Facial expressions, exaggeration of by mentalization-based family therapy,
therapist, 151 117–120
False beliefs, 11–12 Flashbacks, and traumatized patient, 430
Follow-up treatment, and mentalization- interventions for high-risk mothers of

based treatment in partial infants and, 344–345
hospitalization setting, 203, 213–214, in partial hospitalization setting, 207–208,
215 209
Forgiveness, and mentalization-based family preparation of patients for, 88–89
therapy, 110 problem formulations in, 185–187
Freud, Anna, 432 structural elements of, 89
Freud, Sigmund, 34, 37–38, 85, 86, 137, 146, substance abuse disorders and, 460–461
253, 360 therapist activity and dependency, 89–90
Frozen statues game, and mentalization- “Growing: birth-to-three” method, 318
based family therapy, 123 Guessing games
Frustration, and impairment of mentalization-based therapy for children
mentalization, 28–29 and, 138
Functional analysis, of mentalization-based mentalization-based family therapy and,
treatment for borderline personality 124
disorder, 241–242, 243 Guided imagery, and brief treatment, 164
Guiding, of child’s attention in
Gender, and posttraumatic stress disorder, mentalization-based therapy, 146
423 Guilt, and depression, 395
Generalizing, and mentalization-based
family therapy, 119–120 Hare Psychopathy Checklist (PCL),
Genetics 485
depression and sensitivity to stress, 391 Heroin, 451, 456, 457
risk for development of posttraumatic Holding environment, and treatment of
stress disorder and, 423 substance abuse disorders, 316, 457
Genocide, and trauma, 443 Holding Tight program, 312–326, 342
Gergely, G., 146 Hope, and treatment of traumatized patients,
Give-and-take, and mentalization-based 442–443
family therapy, 111 Hopelessness
Global Severity Index (GSI), 336 group therapy and, 101–102
Grounded imagination, 12 mentalization-based family therapy and,
Group therapy, and mentalization-based 113
treatment Hopkins Symptom Checklist-90 (SCL-90),
antisocial personality disorder and, 301, 237
303–304 Hume, D., 253
borderline personality disorder in Humility, and mentalization-based family
adolescents and, 495 therapy, 111
concurrent individual psychotherapy and, Humor
82–85 as coping strategy in depression, 393–394
countertransference and, 102–104 mentalization-based family therapy and,
discussion of group material in, 97–102 111
eating disorders and, 357–358, 363–364, Hyperactivation, and attachment strategies,
365, 380–381 38, 46, 49–51, 262, 393, 407, 411–413,
group analysis and, 86–88 431–432, 513
group anxieties and mentalizing in, 85–86 Hyperarousal, in traumatized patient, 432–
illustration of approach for, 91–97 433
Index 581
Hyperembodiment, and eating disorders, concurrent group therapy and, 82–85,

360, 372–373 207–208
Hypermentalization eating disorders and, 363
children of parents with schizophrenia mentalization-based interventions for
and, 112 high-risk mothers of infants and, 344
definition of, 513 mentalization-based treatment in partial
depression and, 388, 401, 402 hospitalization setting and, 204, 207–
disorganized attachment strategies and, 208
48 Individual resonating intervention, and
eating disorders and, 355 mentalization-based family therapy, 121
as form of pseudomentalization, 30 Information processing, and depression, 387
internal mental states and, 25 Inhibition, of mentalizing in drug addiction,
paranoid disorder and, 291 454
Hypomentalizing phase, of depression, 401, Inpatient setting, and treatment of
402 borderline personality disorder in
Hypothalamic-pituitary-adrenal (HPA) axis, adolescents, 483–484. See also Acute
and stress, 390, 391, 392 inpatient care; Residential programs
Inquisitive stance, in psychotherapy, 40
ICD-10, and BPD in children, 133, 134 Integration, between cognitive and affective
Identification aspects of mentalization, 30, 31
of affect focus in mentalization-based Intellectualization, and depression, 410
treatment, 75–76 Intentional behavior, and mentalization-
with aggressor by traumatized patient, based therapy for children, 150–151
432 Intentionality, definition of, 513. See also
Imagination. See Enactive imagination; Intentional behavior
Grounded imagination Intentionality Scale, 56
Imaginative and symbolic mentalizing Intergenerational transmission, 513
exercises, in brief treatment, 169, 170– Internalizing subtype, of posttraumatic stress
172 disorder, 424
Imitative behavior, capacity to inhibit, 28 Internally focused mentalization
Impact awareness, and mentalization-based definition of, 19–20
family therapy, 110 multidimensional construct of, 22–25
Implicit mentalization. See Automatic reemergence representation of internal
mentalization states and, 32–33
Implicit mentalizing groups, 363, 513 Internal states, and treatment of antisocial
Impulse control, and borderline personality personality disorder, 306–307
disorder in adolescents, 492–493 Internal State Lexicon, 56
Impulsivity, and co-occurrence of personality International Affective Picture System, 56
disorders and substance abuse, 447 Interoceptive confusion, and eating
Individual psychotherapy. See also disorders, 361
Mentalization-based therapy for Interoceptive sensitivity, 57
children Interpersonal-affective focus, in dynamic
antisocial personality disorder and, 301, therapy, 184
302 Interpersonal psychotherapy, for depression,
brief treatment and, 187–190 394–395
Interpersonal Reactivity Index–Perspective Making a story, and mentalization-based

Taking subscale, 55 family therapy, 126
Interpersonal security, and treatment of Malnourishment, as metaphor in eating
posttraumatic stress disorder, 434–436 disorders, 374–376
Interpretation, and treatment of depression, Manipulating body consciousness task, 57
395 Marked emotion, 514
Interpretive mentalizing, and mentalization- Marking, and mentalization-based family
based therapy for children, 155 therapy, 121
Intervision, for staff in mentalization-based Maternal accuracy paradigm, 57
treatment in partial hospitalization Maternal Mind Mindedness Scale, 53, 57
setting, 222–223 Mayer-Salovey-Caruso Emotional
Introductory sessions, and mentalization- Intelligence Test, 55
based treatment, 204, 236, 301 McDougall, W., 85
Introjective personality style, 513 Medical management, of eating disorders,
Intrusive mentalization, and borderline 366–367
personality disorder in adolescents, 507 Medication. See also Medication hour
Inventory of Callous-Unemotional Traits for borderline personality disorder in
(ICU), 485 adolescents, 483
Inverted role activity, and mentalization- for depression, 399
based family therapy, 123 Medication-assisted treatment (MAT),
for opiate dependence, 455–456,
Jacob, Pierre, 298–299 460
Jacobson, Edith, 433 Medication hour, and mentalization-based
Joint attention, 513–514 treatment in partial hospitalization
setting, 213
Kentucky Inventory of Mindfulness Skills, 55 Memories, of traumatized patients, 437–
Kernberg, O., 198 439
Klein, M., 442 Menninger Clinic, 483–494
Kleinian theory, and group therapy, 86 Mentalization, and mentalizing. See also
Assessment; Automatic mentalization;
Latency, and mentalization-based therapy for Cognitive mentalization; Controlled
children, 131–132, 144 mentalization; Embodied mentalizing;
Leadership, and mentalization-based Externally focused mentalization;
treatment in partial hospitalization Hypermentalization; Internally focused
setting, 220–221 mentalization; Mentalization-based
Levels of Emotional Awareness Scale, 55 treatment; Pseudomentalization
Life Events and Difficulties Schedule basic principles of, 4–5
(LEDS), 401 benefits of consciously attending to
Linehan, M. M., 160 process of, 160
Lived body, and eating disorders, 373 definition of, 290, 514
Log keeping, and brief treatment, 169, 177 as form of social cognition, 4
impaired or distorted forms of in
Major depression. See also Depression depression, 396–402
mentalization-based family therapy and, as multidimensional construct, 19–31
112 phenomenology of depression and, 402–
substance abuse and, 448 406
Index 583
psychotherapy and changes in brain and, psychodynamic therapy and, 254–258

33–39 of substance abuse disorders, 453–461
reemergence of prementalistic Mentalization-based treatment in partial
representation of internal states and hospitalization setting (MBT-PH)
inhibited forms of, 32–33 development and initial trials of, 197–198
theoretical perspectives on depression goals of, 199–200
and, 389–396 mentalizing environment in, 214–218
transactional model for development of patient population for, 198
social cognition and, 6–19 principles of service development for,
in traumatized patient, 429–430 198–199
Mentalization-based therapy for children research on, 223–225
(MBT-C) staff selection and team functioning in,
developmental considerations in, 130– 219–223
133, 148 structure of treatment in, 200–214
failure of and need for peer supervision, training and team supervision for, 218–
136–137 219
frame of therapy for, 135–136 treatment plans and, 200
overall goal of, 130, 131 Mentalization dimension, of psychoanalytic
target population for, 133–135 process in patients with personality
techniques in, 142–157 disorders, 249
therapist stance toward child and Mentalization Stories Test for Adolescents,
significant others in, 137–142 53, 55
Mentalization-based treatment (MBT). See Mentalized affectivity, 37
also Brief treatment; Family therapy; Mentalizing cognitive therapy (MCT), 210–
Group therapy; Mentalization-based 211
therapy for children; Mentalization- Mentalizing as a Compass for Treatment (Allen
based treatment in partial et al. 2003), 165
hospitalization setting; Mentalizing Mentalizing and core issues exercise, in brief
cognitive therapy; Outpatient settings treatment, 185–187
affect focus in, 74–76 Mentalizing emotion, 514
of antisocial personality disorder, 300– Mentalizing hand, and mentalization-based
307 family therapy, 120
of borderline personality disorder, 273– Mentalizing the moment, in mentalization-
288, 480–509 based family therapy, 119, 120–122
characteristics of therapists in, 275 Mentalizing profile, 43–44, 60, 62
comprehensive formulation as significant Mentalizing region, 514
component of, 183 Mentalizing stance, and brief treatment, 160,
contrary moves in, 70, 71 162, 514
of depression, 414–416 Mental representations, and treatment of
of eating disorders, 362–374 substance abuse in mothers of infants,
emotional closeness in therapy sessions 327, 330–331, 335–336, 338
and, 68–70 Mental States Measure and Grille de
focus on process rather than content of l’Élaboration Verbale de l’Affect, 56
patient’s thoughts and feelings in, 68 Metacognition, and cognitive-behavioral
intervention process in, 71–80 therapy for depression, 394, 514
of posttraumatic stress disorder, 430–444 Metacognition Assessment Scale, 56
Metaphors Naïve realism, 27

brief treatment and, 169, 172 Naïve stance, and eating disorders, 370–371
eating disorders and, 371, 374–376 Naming, of internal states of mind, 31
Methadone, 334, 450, 455, 456, 460 Narcissistic personality disorder, 134, 291
Millon Adolescent Clinical Inventory Narrative, development of about trauma,
(MACI), 485, 497 437–439. See also Story telling
Mindblindness Narrative coherence, and brief treatment,
in children, 134 164
definition of, 514 National Institute of Child Health and
depression and, 408–410 Human Development (NICHD), 297
Mind-brain scanning, and mentalization- National Institute on Drug Abuse Cocaine
based family therapy, 124–125 Psychotherapy Study, 450
Mindful Attention Awareness Scale, 55 National Institute of Health, 422
“Mindful awareness,” and depression, 387 National Institute for Health and Clinical
Mindfulness Excellence (NICE), 82
approaches to treatment of depression National Institute of Mental Health
and, 394 Treatment of Depression Collaborative
attachment strategies and, 48 Research Program, 394
definition of, 514 NCAST (Nursing Child Assessment Satellite
parental attributes and, 12 Training), 329, 336
“Minding the Body” project, and eating Negative affect, 12
disorders, 367, 371–372 Negative automatic thoughts, in depression,
Mind-mindedness, 514 403
Mindreading, 514 Negative emotionality, and co-occurrence of
Mirroring, of affect, 4, 7–8, 36, 265 personality disorders and substance
Mirror neurons, 515 abuse, 447
Misunderstandings, in brief treatment, 193– Negative social reinforcement theory, of
194 depression, 387
Misuse, of mentalization, 114 Negotiating non-negotiables, and eating
Monitoring, of mentalizing as exercise in disorders, 379–380
brief treatment, 169, 177–179 Neurobiology. See also Dopamine and
Moods, brief treatment and understanding dopaminergic system; Norepinephrine;
of, 168 Serotonin
Mothering From the Inside Out (MIO), activation of attachment and deactivation
326–341, 342, 343 of mentalization, 17
Motivation, and mentalization-based amygdala and antisocial personality
treatment in partial hospitalization disorder, 291–292, 298
setting, 201–202 attachment and substance abuse, 451
Motivational interviewing, 162–163 automatic and controlled mentalization,
Movie for the Assessment of Social 21
Cognition (MASC), 57, 486 borderline features in adolescence and,
M-representations, 29 468–473
Multidimensional construct, of cognitive mentalization and, 29
mentalization, 19–31 of depression, and neural circuits, 398
Music, and brief treatment, 169, 171 mentalization with regard to self and
Myths, and family therapy, 260 others and, 25–29
Index 585
neurobiological switch, from controlled Oppositional defiant disorder, 134

to automatic mentalization, 45–46 Oslo University Hospital, 364, 365, 367, 372
posttraumatic stress disorder and neural Ostensive cues, and mentalization-based
circuits of, 428–429 therapy for children, 147, 157
psychotherapy and changes in Outpatient settings, and mentalization-based
mentalization and, 33–39 treatment
Nicknaming, of members in group therapy, experimental program for borderline
306 personality disorder and, 235–244,
NimStim set of facial expressions, 56 245
Nonmentalizing modes. See also Pretend group therapy and, 234
mode; Psychic equivalence mode; principles of service development in, 228–
Teleological mode 234
assessment of, 64 treatment of substance abuse in mothers
borderline personality disorder in of infants, 326–341, 345
adolescents and, 507–508 Outreach, and mentalization-based
Nonverbal techniques, in psychodynamic treatment in partial hospitalization
therapy, 250 setting, 202, 204
Norepinephrine, 16 Oxytocin, and association between
Not-knowing stance mentalization and attachment, 13, 17,
brief treatment and, 193–194 391–392, 515
definition of, 515
mentalization-based therapy for children Pain, and comorbidity with depression, 391,
and, 138, 139 397
mentalization-based treatment for Pair bonding, 451
borderline personality disorder and, Paranoid personality disorder, 291, 446
278–279 Parent(s), and parenting. See also Children;
Nursing staff, and mentalization-based Family; Family therapy
model in psychodynamic therapy, 264– borderline personality disorder in
267 adolescents and, 481–482
brief treatment and understanding of
Object identification, and brief treatment, interactions in, 169, 180–183
169, 171–172 mentalization-based therapy for children
Objective Relations Inventory, 53 and, 135, 141–142
Objective stressor criteria, for posttraumatic outpatient program for substance-abusing
stress disorder, 421 mothers of infants, 326–341
Object Relations Technique, and brief qualities facilitating establishment of
treatment, 170 strong mentalization, 11–13
Object relations theory reflective functioning and, 309–310, 311,
developmental psychopathology and 317–320, 321, 324, 326, 328, 334–
attachment trauma, 426 335, 338
psychoanalytic process in patients with research on substance abuse and, 341–
personality disorders and, 249 345
Observing, and mentalization-based family residential program for substance-using
therapy, 118, 119 mothers of infants, 312–341
Open-mindedness, and eating disorders, 377 stress and, 310–311
Opiate use disorders, 334, 337, 450, 455–459 Parental metaemotion philosophy, 515
Parental Reflective Functioning psychodynamic therapy for, 249, 250,

Questionnaire, 55 258–264
Parent Development Interview (PDI), 23, substance abuse and, 446–450
51, 53, 56,321 Personality Disorder Features Scale for
Parent Education Program (PEP), 333– Children, 475
341 Personality traits
Partial hospitalization. See Mentalization- borderline personality disorder in
based treatment in partial adolescents and, 498
hospitalization setting brief treatment and, 167–170
Patient-therapist relationship. See also vulnerability to depression and, 390
Therapeutic alliance vulnerability to eating disorders and,
brief treatment and, 162 350
mentalization-based therapy for children Perspective taking, and mentalization-based
and, 140, 156–157 family therapy, 110
mentalization-based treatment for Pervasive developmental disorder, 134
borderline personality disorder and, Phase specificity, and treatment of borderline
283–285 personality disorder, 237, 238
residential program for mothers with Phenomenological psychiatry, and
substance abuse and their babies, depression, 397–398
319 Phenomenology, of depression, 402–406
“Pause button” Photographs, interpretation of, 169, 170
brief treatment and, 177–178 Physical activity
mentalization-based family therapy and, depression and, 399, 404
120, 124 eating disorders and, 373
posttraumatic stress disorder and, 430 Physical sensation, and mentalization-based
Peabody Expressive Vocabulary Test therapy for children, 148–149
(PPVT), 485 Piaget, J., 27
Peabody Picture Vocabulary Test (PPVT), Play, and mentalization-based therapy for
485 children, 140–141, 144, 153
Pedagogic stance, in mentalization-based Polysemy, of body, 356
therapy for children, 146–147 Post-group reflection, and mentalization-
Pedagogy, definition of, 515 based treatment in partial
Peer Conflict Scale (PCS), 485 hospitalization setting, 219
Peer influence, and borderline personality Posttraumatic stress disorder (PTSD)
disorder in adolescents, 472 borderline personality disorder in
Perfectionism, and eating disorders, 367 adolescents and, 479
Perinatal period, and substance abuse, 314– cognitive-behavioral therapy for, 419
315 complex form of, 425–426
Personality disorder(s). See also specific diagnostic issues in, 420–425
personality disorders failures of mentalizing and, 7
brief treatment and, 166, 180–183 mentalizing-focused treatment of, 430–
characteristics of severe, 251 444
comorbidity of eating disorders with, 350 substance abuse and, 447
concurrent group and individual Posttreatment, and mentalization-based
psychotherapy for, 82, 85 treatment in partial hospitalization
diagnosis of in adolescents, 464–465 setting, 200, 213–214, 215
Index 587
Power, and treatment of antisocial Problem formulation, and brief treatment,

personality disorder, 304–306 169, 183–190. See also Case formulation
PowerPoint presentations, 191, 192 Problem solving, and mentalization-based
Practicism, and treatment of eating family therapy, 126
disorders, 348 Projection, and mentalization-based therapy
Pregnancy, and substance abuse, 314–315, for children, 141
343–344 Projective identification, 33, 265
Pregnancy Interview (PI), 321 Projective Imagination Test, 57
Prementalistic mental functioning Project MATCH (Matching Alcoholism
antisocial personality disorder and, 292– Treatments to Client Heterogeneity),
293 450
definition of, 515 Pseudocompliance, and eating disorders,370
eating disorders and modes of reality, Pseudomentalization
352–358 assessment of, 62, 64
Prementalistic representation, of internal attachment deactivation strategies and, 46
states, 32–33 borderline personality disorder in
Prerepresentational interventions, in adolescents and, 506–507
mentalization-based therapy for couples therapy and, 262
children, 148 definition of, 516
Presentations, and psychic equivalence in depression and, 410
eating disorders, 353 eating disorders and, 355
Pretend mode hypermentalization as form of, 30
assessment of, 64 mentalization-based therapy for children
borderline personality disorder in and, 152–153
adolescents and, 507 mentalization-based family therapy and,
cognitive and affective mentalization in, 113, 262
30–31 psychotherapy and identification of, 40
countertransference experiences and, 79 Pseudosymbolization, 49
definition of, 515 Psychic equivalence mode
depression and, 401 assessment and, 64
eating disorders and, 354–355 brief treatment and, 164
mentalization-based therapy for children countertransference experiences and, 79
and, 140, 141, 144 definition of, 516
traumatized patients and, 429 depression and, 397
Pretreatment, and mentalization-based eating disorders and, 353–354
treatment in partial hospitalization neural systems and, 27
setting, 200, 201–206 subjective experiences and, 32
Prevalence substance abuse and, 453
of borderline personality disorder, 466 trauma and, 429
of comorbidity in borderline personality Psychoanalytic process, in patients with
disorder in adolescents, 479 personality disorders, 249, 250
of depression, 385 Psychodynamic perspective, in group
Preverbal interactions, of children, 151–152 analysis, 87
Previewing, mothers’ capacity for, 319 Psychodynamic therapy
Prisons, antisocial personality disorder in challenges and problems in, 251–252
inmates of, 289 clinical applications of, 258–267
Psychodynamic therapy (continued) Reading the Mind in Films Task, 56

conceptualizing of psychoanalytic Reading the Mind in the Voice Test, 56
process in patients with personality Reality. See also Naïve realism
disorders, 249, 250 depression and concept of depressive
as distinct from mentalization-based realism, 400–401
treatment, 248 eating disorders and psychic modes of,
introduction of mentalization-based 352–358, 371
treatment and, 252 Reality value, and mentalization-based
models of mentalization in, 253–258 therapy for children, 151–152, 153–154
treatment program for, 250–251 Reasoning errors, 50
Psychoeducation. See also Education Recommendations, for mentalization-based
borderline personality disorder in treatment in partial hospitalization
adolescents and, 487, 490, 492–493, setting, 216–218
502 Reenactments, and treatment of
depression and, 399 posttraumatic stress disorder, 437, 439,
eating disorders and, 364, 365, 367, 374 516
posttraumatic stress disorder and, 435 Reflection, and borderline personality
Psychological function, of disorder in adolescents, 467
countertransference experiences in Reflective contemplation, and mentalization-
mentalization-based treatment, 79 based family therapy, 110
Psychological mindedness, definition of, Reflective functioning, as measure of
516 mentalizing capacity. See also
Psychological Mindedness Scale, 55 Assessment; Reflective Functioning
Psychological unavailability, 516 Scale; Reflective Function
Psychopharmacology. See Medication Questionnaire
Psychosis, and development of capacity for and parenting, 309–310, 311, 317–320,
mentalization, 25. See also Schizophrenia 321, 324, 326, 328, 334–335, 338,
Psychosocial context, of residential program 516
for mothers with substance abuse, 313– Reflective Functioning Scale, 26, 51, 52, 53,
314 60, 61, 388
Psychotherapy. See also Conjoint Reflective Function Questionnaire (RFQ),
psychotherapy; Dynamic deconstructive 53, 55, 485, 486
psychotherapy; Individual Regression, and psychodynamic therapy,
psychotherapy; Interpersonal 251
psychotherapy; Mentalization-based Regulation, eating disorders as disorders of,
treatment 352, 379. See also Affect regulation;
effective mentalization-based Attention regulation; Dysregulation;
interventions and, 39–41 Emotion regulation; Self-regulation
improved mentalization and changes in Rehabilitation, and borderline personality
brain, 33–39 disorder in adolescents, 487
Relapse
Rage, and impairments of mentalization, 28– brief treatment and prevention of, 164
29 rates of for depression, 386, 394, 415
Rationalization, and depression, 410 substance abuse disorders and, 458
Reading the Mind in the Eyes Test, 54, 56, Relatedness, and borderline personality
359 disorder in adolescents, 467
Index 589
Relationship(s). See also Family; Sexual Schiller, J. C. F. von, 37

relationships; Social problems; Schizophrenia. See also Psychosis
Therapeutic alliance diagnosis-specific anomalies of
antisocial personality disorder and, 291, mentalization, 10
293–294 mentalization-based family therapy and,
assessment of mentalization and, 51–52, 112
63 Searching for positives, and mentalization-
depression and, 386–387 based family therapy, 121, 122
exercises for brief treatment and, 169, Seclusion, and psychodynamic therapy, 251
173–175 Secure attachment strategies, 47, 48–49
mentalization-based family therapy and, Secure base, 516
109–111 Security Scale (SS), 485
Relationship recruiting, and attachment, 393 Sedative-hypnotics, and suicide attempts,
Remediation, and borderline personality 447–448
disorder in adolescents, 487 Self
Remoralization, and borderline personality antisocial personality disorder and sense
disorder in adolescents, 487 of, 293–296
Representations. See Mental representations depression and social origin of selfhood,
Representingness, definition of, 516 396
Residential programs, for substance abuse in mentalization and agentive sense of, 10
mothers of infants, 312–341, 345. See mentalization-based therapy for children
also Inpatient treatment and, 130–131
Resilience, and treatment approaches to mentalization with regard to others
depression, 394–395, 406, 415 versus, 25–29, 63
Responsibility, and mentalization-based Self-agency, and eating disorders, 376, 516
family therapy, 111 Self-awareness, and self-consciousness in
Reviewing, and mentalization-based family depression, 396
therapy, 119, 120 Self-critical/autonomous individuals, and
Reward deficiency syndrome, and depression, 407–408, 409
adolescence, 473 Self-description, and brief treatment, 167–
Rewinding, in group therapy, 98–99, 104 168
Risk factors, for posttraumatic stress Self-destructive behavior. See also Suicide and
disorder, 423–424 suicidal ideation
Role playing borderline personality disorder in
brief treatment and, 169, 176–177 adolescents and, 478–479, 495, 499
mentalization-based family therapy and, in children and adolescents as early risk
121, 122 marker for borderline personality
Rules, for mentalization-based treatment in disorder, 465
partial hospitalization setting, 216–218 psychodynamic therapy and, 257–258
Self-disorders, eating disorders as, 351–352
Safety Self-esteem
mentalization-based family therapy and, antisocial personality disorder and, 295–
110 296, 302, 306
psychodynamic therapy and, 250 eating disorders and, 356
St. Ann’s Hospital (London), 207 Self-object relations, and psychodynamic
Sandler, Joseph, 253, 422 therapy, 250
Self orientation, and functional polarities of Somatoform disorders, 25, 49

mentalization, 19–20 Splitting, and mentalization-based treatment
Self-reflection, and group therapy, 86 in partial hospitalization setting, 222–
Self-regulation 223
borderline personality disorder in Staff. See also Nursing staff; Therapists
adolescents and, 492–493 interaction between mentalization-based
eating disorders and, 352 treatment and psychoanalytic
Self-structure, and borderline personality therapy, 255–256
disorder, 4 selection of for mentalization-based
Sensimotor regulatory capacities, assessment treatment, 219–223, 232–234
of in children, 145 Standard experience, and antisocial
Separation anxiety, 33 personality disorder, 299
September 11, 2001, attacks, 426 State, and capacity to mentalize, 4
Serious early pathology, 133 Stepwise intervention, in mentalization-
Serotonin, and arousal, 16 based treatment, 72–73
Sexual relationships, and mentalization- Stockholm model, of mentalization-based
based treatment in partial treatment for opiate-dependent
hospitalization setting, 218 borderline personality disorder patients,
Shame 455–459
antisocial personality disorder and, 295– Story telling. See also Narrative
296 brief treatment and, 169, 170–171
depression and, 395 mentalization-based family therapy and,
Simmering down, and mentalization-based 126
family therapy, 120, 121 Strange Situation Procedure, 393
SMART (Short-Term Mentalization and Strange Stories Task, 57
Relational Therapy), 261 Strengths and Difficulties Questionnaire
Social cognition (SDQ), 485
definition of, 517 Stress
depression and, 387 assessment of individual differences in
eating disorders and, 349, 358–359 attachment, mentalization, and, 44–51
functional polarities of mentalization and, automatic mentalization and, 21–22
19–20 depression and, 387, 390–394
mentalizing as form of, 4 difficulties in mentalizing and, 111–112
transactional model for development of, parenting and, 310–311
6–19 risk factors for posttraumatic stress
Social hour, and mentalization-based disorder and, 424
treatment in partial hospitalization Stress Index for Parents of Adolescents
setting, 212 (SIPA), 485
Social problems, and mentalization-based Structured assessment, of mentalization, 52–
treatment in partial hospitalization 54
setting, 206. See also Relationships Structured Clinical Interview for DSM-IV
Social support, and posttraumatic stress Axis I Disorders (SCID-I), 198
disorder, 424 Structured Clinical Interview for DSM-IV
Social workers, and residential treatment for Axis II Disorders (SCID-II), 198, 235
mothers with substance abuse, 315 Structured Interview for DSM-IV
Somatization, and depression, 404 Personality Disorders (SIDP-IV), 198
Index 591
Subjective stressor criteria, for posttraumatic of eating disorders, 374, 375

stress disorder, 421 Systemizing, 517
Subjectivity
antisocial personality disorder and, 292, Target problem, and mentalization-based
293, 294 family therapy, 116
disturbances of and failures of Team approach, to mentalization-based
mentalization, 4, 32–33 treatment, 83–84
Substance use disorders. See also Alcohol Teleological mode, of thinking. See also
abuse; Drug abuse; Opiate use disorders Thinking and thought disorders
attachment and mentalizing in, 451–453 antisocial personality disorder and, 293
borderline personality disorder in assessment and, 64
adolescents and, 479 borderline personality disorder in
mentalization-based treatment of, 453– adolescents and, 506
461 countertransference experiences and,
outpatient program for treatment of 79
mothers of infants, 326–341 definition of, 49, 517
personality disorders and, 446–450 depression and, 400
research on parenting and, 341–345 eating disorders and, 356–358, 377
residential program for treatment of traumatized patient and, 430
mothers of infants and, 312–326 Telephone accessibility, and crisis plans, 202,
stress and, 311 204, 509
Subtitling, and mentalization-based family Temper tantrums, and mentalization-based
therapy, 121, 122 therapy for children, 140
Suicide and suicidal ideation Temporoparietal junction, and chameleon
borderline personality disorder in effect, 28
adolescents and, 502 Thematic Apperception Test, 57
brief treatment and, 163–165 Theory of Mind (ToM), 29, 30, 31
crisis interventions for patients with cognitive versus affective mentalization
borderline personality disorder and, and, 29, 30, 31
231 definition of, 517
depression and, 399–400 depression and, 387–388
hospital discharge and risk of, 230–231 eating disorders and, 358–359
substance abuse and, 447–448 Therapeutic alliance. See also Patient-
Suicide Status Form, 163 therapist relationship
Supervision brief treatment and, 160, 161
of mentalization-based therapy for eating disorders and, 349, 371
children, 136–137 effective mentalization-based
of mentalization-based treatment for interventions and, 41
borderline personality disorder, 233– mentalization-based treatment for
234 borderline personality disorder and,
of mentalization-based treatment in 238, 240
partial hospitalization setting, 218– outpatient program for substance abuse in
219 mothers of infants and, 329
Symptom Checklist 90-Revised, 388 posttraumatic stress disorder and, 439–
Symptoms 442
of borderline personality disorder, 200 substance abuse disorders and, 456
Therapeutic arguments, and mentalization- mentalization-based treatment in partial

based family therapy, 126 hospitalization setting and, 218–
Therapeutic frame, and family therapy, 260– 219
261 Traits, and capacity to mentalize, 4. See also
Therapeutic home milieu, for substance Personality traits
abuse in mothers of infants, 345 Transactional model, for development of
Therapeutic stance. See also Naïve stance; social cognition, 6–19
Not-knowing stance Transactional space, and psychotherapy,
antisocial personality disorder and, 302– 37
303 Transference. See also Countertransference
borderline personality disorder and, 274 borderline personality disorder in
Therapists. See also Countertransference; adolescents and, 508
Patient-therapist relationship; Staff; depression and, 395
Therapeutic stance; Transference mentalization-based therapy for children
attitude of in treatment of borderline and, 139, 156–157
personality disorder, 277 mentalization-based treatment and, 76–
characteristics of in mentalization-based 77
therapy, 275 mentalizing of, 514
errors in treatment of borderline posttraumatic stress disorder and, 435–
personality disorder, 279–280 436, 442–443
Thinking and thought disorders. See also substance abuse in mothers of infants and,
Negative automatic thoughts; 333
Teleological mode Transference tracers, and borderline
borderline personality disorder in personality disorder, 240, 517
adolescents and, 504–507 Trauma. See also Posttraumatic stress
mentalizing exercises for brief treatment disorder
and, 168–169 antisocial personality disorder and, 297–
failures of mentalizing and, 7 298, 300
Thought pause button activity, and arousal and inhibition of mentalization
mentalization-based family therapy, 124 in, 18
Time, depression and disturbances in attachment hyperactivation and
experience of, 397. See also Duration, deactivation strategies in, 50
of treatment complex psychological form of, 425
Time-frames, and mentalization-based developmental psychopathology and
family therapy, 120–121 attachment-related, 426–429, 511
Time-outs, and mentalization-based family disruption of capacity for mentalizing
therapy, 126 by, 4
Toronto Alexithymia Scale, 55 dual liability and, 419–420, 427
Toronto Structured Interview for extreme attachment experiences and, 13–
Alexithymia, 56 16
Trading places game, and brief treatment, mentalizing in face of, 429–430
169, 180 Trauma Symptom Checklist for Children
Training (TSCC), 485
mentalization-based interventions for high- Traumatic Antecedents Questionnaire
risk mothers and babies and, 343 (TAQ), 321
Index 593
Treatment. See Cognitive-behavioral Vasopressin, 17, 391–392

therapy; Compliance; Creative therapy; Verbal contract, and psychodynamic therapy,
Dialectical behavior therapy; Dual focus 256
schema therapy; Dynamic Interpersonal Verbalization, and mentalization-based
Therapy; Medication; Mentalization- therapy for children, 140
based treatment; Posttreatment; Verbal therapies, and psychodynamic
Pretreatment; Psychodynamic therapy; therapy, 250
Psychotherapy Vicarious experience, and antisocial
Treatment manual, for mentalization-based personality disorder, 299
therapy for children, 131 Videotaping, and treatment of substance
Treatment milieu, for mentalization-based abuse in mothers of infants, 318–319,
treatment in partial hospitalization 331–332
setting, 215–216 Viersprong Institute for Studies on
Treatment plan, for borderline personality Personality Disorders, 198
disorder in adolescents, 501. See also Violence
Crisis plans antisocial personality disorder and, 296–
Trust 300, 303–304
mentalization-based family therapy and, mentalization-based treatment in partial
110–111 hospitalization setting and, 217
mentalization-based treatment of
antisocial personality disorder and, Waiting list, for mentalization-based
303 treatment in partial hospitalization
mentalization-based treatment of eating setting, 201
disorders and, 357 Wechsler Adult Intelligence Scale (WAIS),
Trust Task, 57 485
Wechsler Intelligence Scale for Children
Unit meetings, and mentalization-based (WISC), 485
treatment in partial hospitalization Winnicott, Donald, 37, 253, 256, 433, 457
setting, 212 Woodcock-Johnson Tests of Cognitive
University Psychiatric Hospital of Louvain, Abilities, 3rd Edition (WJ-III), 485
Kortenberg campus (KLIPP), 248 Working Alliance Inventory (WAI), 486
Urine toxicology (UTOX) screens, 337 Working hypothesis, and mentalization-
based family therapy, 116–117
Validation Working Model of the Child Interview
group therapy and, 102 (WMCI), 53, 56, 335
mentalization-based therapy for children Writing therapy, and mentalization-based
and, 153–154 treatment in partial hospitalization
of transference feeling in mentalization- setting, 212
based treatment, 76
Van den Berg, J. H., 397 Youth Self-Report (YSR), 485

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HANDBOOK OF

Anthony W. Bateman, M.A., F.R.C.Psych.

Copyright © 2012 American Psychiatric Association

Manufactured in the United States of America on acid-free paper

Library of Congress Cataloging-in-Publication Data

1 Introduction and Overview . . . . . . . . . . . . . . . . . . . . .3

2 Assessment of Mentalization . . . . . . . . . . . . . . . . . .43

4 Group Therapy Techniques. . . . . . . . . . . . . . . . . . . . 81

5 Mentalization-Based Family Therapy. . . . . . . . . . . . 107

6 Mentalization-Informed Child Psychoanalytic

7 Brief Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . 159

8 Partial Hospitalization Settings . . . . . . . . . . . . . . . 197

9 Outpatient Settings . . . . . . . . . . . . . . . . . . . . . . . . 227

11 Borderline Personality Disorder . . . . . . . . . . . . . . . .273

12 Antisocial Personality Disorder . . . . . . . . . . . . . . . .289

13 At-Risk Mothers of Infants and Toddlers . . . . . . . . .309

14 Eating Disorders . . . . . . . . . . . . . . . . . . . . . . . . . .347

17 Drug Addiction . . . . . . . . . . . . . . . . . . . . . . . . . . .445

Eia Asen, M.D., F.R.C.Psych.

Dawn Bales, M.Sc.

Anthony W. Bateman, M.A., F.R.C.Psych.

Efrain Bleiberg, M.D.

Cindy DeCoste, M.S.

Peter Fonagy, Ph.D., F.B.A.

Catherine Freeman, M.A.

Mirjam Kalland, Ph.D.

Sigmund Karterud, M.D., Ph.D.

Morten Kjolbe, M.D.

Alessandra Lemma, B.Sc., M.A., M.Phil. (Cantab.), D.Clin.Psych.

Benedicte Lowyck, Ph.D.

Patrick Luyten, Ph.D.

Linda Mayes, M.D.

Flynn O’Malley, Ph.D.

Marjukka Pajulo, M.D., Ph.D.

Björn Philips, Ph.D.

Trudie Rossouw, M.B.Ch.B., F.F.Psych.

Finn Skårderud, Prof. Dr. Med.

Nancy Suchman, Ph.D.

Mary Target, Ph.D.

Bart Vandeneede, M.A.

Annelies Verheugt-Pleiter, M.Psych.

Rudi Vermote, M.D., Ph.D.

Jolien Zevalkink, Ph.D.

Second, mentalizing is a developmental construct. This raises questions about the

focus is partly on technique when it is delivered in a particular psychotherapy frame-

Our understanding of the development of antisocial personality disorder takes us

Anthony W. Bateman, M.A., F.R.C.Psych.

M entalizing is a term that has been introduced simultaneously into neuroscience

1. Understanding the behavior of others in terms of their likely thoughts, feelings,

In several publications, we have reviewed evidence in support of these contentions

Need for a Transactional Model

1. That symptoms of the disorder will manifest differently at different developmental

Development of Social Cognition

1. Affect representation and the related affect regulation

Arnsten’s Dual Arousal Systems

lose their explicit mentalizing capacity almost completely. Paradoxically, however, at

Attachment and Mentalization

Quality of attachment and early mentalization. A relation between attachment in

Extreme attachment experiences and attachment trauma. Maltreated children are

Insecure, disorganized maternal attachment

Reduced maternal oxytocin while with infant

Nonmentalizing (unmarked and noncontingent) response to infant distress

Infant fails to internalize representation of self-state