Mentalization-based treatment: Learning to think before you act

Mentalization-based treatment helps patients improve their interpersonal relationships

Aditi Surendra

 

Mentalization-based treatment (MBT) is a form of treatment for patients with borderline personality disorder (BPD). It was developed by British psychodynamic therapists, Peter Fonagy, and Anthony Bateman. It aims to restore the capacity to mentalize in those who struggle with insecure attachments.

How are insecure attachments formed?

As infants, we have an ingrained need to feel close to our caregivers, our parents. When we are distressed, we rely on attachment behaviors like smiling, crying, or clinging so that we can receive a comforting response. How our parents react to these behaviors influences the nature and growth of our sense of security.

In simpler words, the comforting responses give us a framework which helps us to self-soothe and self-regulate our emotions and behaviors. It enables us to form a model of relationships that we apply to relationships that we have later in life.

In some cases, for example, when parents fail to respond adequately to the child, an insecure attachment may develop. Although this may not be intentional, this leads to the children not being able to regulate their emotions and upsets their interpersonal relationships as adults. One of the main aspects of this is that they are unable to mentalize.

What is mentalization?

Mentalization refers to the ability to identify our thoughts and feelings about a situation and not just focus on our behavior or those of others. It allows us to reflect clearly on past, present and future events and understand the situation through different perspectives. This helps in the ability to think before acting and improves our interactions and social relationships.

What is mentalization-based treatment?

MBT is a form of talk therapy that encourages the client to narrate incidents from their own life. The therapist then helps the client to validate their thoughts and feelings, and to identify non-mentalizing modes such as thinking in negative extremes or generalizing (for example thinking thoughts like, “I’m a complete failure, they always ignore me”). Targeted intervention by the therapist allows the client to see the incident from different perspectives. They can then engage in mentalization and regulate their own emotions.

For example, a client may complain of abandonment when their friend doesn't answer their phone call. The therapist first helps them identify the thoughts and feelings that followed the incident and then helps them explore the reasons behind their friend not answering the phone call. This helps the patient to see their non-mentalizing mode, regulate their emotions and navigate through the incident.

The more this exercise is performed, the more it becomes second nature for the client to start mentalizing and applying the strategy to interpersonal interactions outside of the therapy space. This results in better regulation of emotions, lesser outbursts, and improved behavior.

Who can benefit from MBT?

While the treatment was developed to help persons living with BPD, it is also used to treat other personality disorders, eating disorders, recurrent depression, self-harm, and addiction. Patients who have suffered from complex trauma can also benefit from this treatment to avoid emotional turmoil while responding to triggers.

How is MBT different from CBT or DBT?

There are some overlaps in all these therapies such as understanding the link between emotions and behavior. Cognitive behavioral therapy (CBT) and dialectical behavior therapy(DBT) focus on changing behaviors through a directive approach; the therapist drives the client to change their behavior.

MBT is more explorative in nature and focuses on restoring the process of mentalization. Once the client is able to reflect calmly on their crisis, they are encouraged to make their own decisions about changing their behavior.

Is MBT practiced in India?

A relatively new method of therapy, MBT is still in its nascent stage in India with the service available only in Bangalore in the form of group therapy.

Each batch of the group attends weekly sessions for a year. Every session is facilitated by a psychiatrist and a co-therapist and lasts 75 minutes. Assessments are conducted by the psychiatrist at the six-month mark and at the end of the year following which the progress of members is monitored every now and then. Sessions are also conducted for family members of the group’s participants so that they can understand the struggles of their wards better.

Why group therapy?

Ideally, MBT is availed as a combination of group and individual therapy, but there aren't enough trained professionals in India to provide individual MBT.

More so, group therapy has many advantages. Patients form connections and interact with people who struggle with similar issues. The purpose of group therapy is for the therapist and group members to see, in real time, where they lose their mentalizing capacity during interpersonal interactions. This safe space allows them to understand and support each other to regain their reflective capacity.

MBT does not replace individual therapy.allows the patient to focus on interpersonal mentalizing and frees up space in individual therapy to focus on trauma and more sensitive issues that may not be discussed in the group.

With inputs from Dr Ashlesha Bagadia, a specialist in borderline personality disorder and mentalization-based treatment.