Bonus – Inside Mentalization-Based Treatment: Borderline & Narcissistic Personality Disorders (308)

0:00in principle, all therapists, we're all supposed to be kind of not knowing and inquisitive, right? and ask rather than presume. The problem is when you watch, like a lot of what I'll do, we're training people is we'll watch therapy sessions. It is really hard to stick with a true not knowing stance. So a patient will share, for example, a patient will share, oh, you won't believe what happened at work today. My coworker said this thing and it was horrible. And I, you know, and can you believe that she said that and stuff like that, right? The therapist will then want to say just very naturally, well, it sounds like that made you really angry.

0:38In MBT, we're not allowed to do that. We've got to then say, okay, well, what did that bring up for you? So the kind of the saying that I associate with a not knowing stance is when you want to make a statement, stop. Ask a question. Hope you enjoy a preview of this full episode published exclusively as a bonus for our incredible online neuro nerd community. This group is the backbone that keeps this podcast thriving. And you can find out more at therapistuncensored.com slash join.

1:17Hey, everybody, we are picking up our conversation, a fascinating conversation about challenging personalities, specifically narcissism and borderline personality disorder. This is the second of two sessions that we're going to do, and this one is going to be more clinically focused. So the first one, we encourage you to go back and check it out. It is going to separate myth from reality about what narcissism really is, the subtypes, and borderline personality. So I encourage you to check that out. And in the meantime, on this one, we are going to focus more on the treatment and what to do about this and deep dive specifically into mentalization.

1:56And I've heard some people say mentalization is kind of at the root of mental health, but without it, it's hard to have resilience and this kind of capacity. So can we start by just helping us understand? It seems easy on one level and not on another. What is mentalization specifically? Yeah, it's a great question. And you're absolutely right. Like I'm seemingly sort of simple, but actually there's a lot to it as a concept. So simply define mentalization is the ability to accurately read, access, and reflect on mental states in ourselves and other people. So mental states really is just all the invisible stuff of the mind.

2:38So thoughts, emotions, desires, attitudes, the stuff that we can't see, but we make presumptions about. You know, we're really doing it all the time. You know, we're kind of looking at each other and we're trying to get a sense of what is this person feeling? What are they wanting? We can kind of like introspect and look inward and be like, where am I at at a given moment? So that's the broad idea. But there is a lot to it. Sort of part of it is identifying the way that we define it or I define it in the book and we've talked about elsewhere in the literature is essentially there are three parts to it.

3:17The what, the why, and the how. Yeah, and I want to get into all of those. I have a question. So this is connected to Peter Fonagy and Anthony Bateman's work, I believe. And I think he used to call it reflective function. Is that the same thing as mentalization? And then Dan Siegel talks about mind sight. Are there distinctions here? Are this generally in the same bucket? Yeah, Peter Fonagy was really the person most responsible for kind of bringing the concept of mentalization, like in like a prominent part in kind of mental health thinking. He wrote a really kind of seminal paper in the late 1980s talking about this issue of theory of mind, which, you know, comes out of like research and thinking on autism.

4:05and then what Peter did was really kind of apply that to understand the challenges that people experience with borderline personality disorder and so he wrote a paper about like how does mentalizing relate to borderline and how could there maybe be like challenges with sort of reflecting on mental states specifically in borderline personality disorder and that's what led he ended up partnering with Anthony Bateman they're both kind of psychoanalysts from London And they were both a little kind of discouraged about the ability at the time, psychoanalysis was the treatment of the day. But they were inspired by the work of DBT, which was showing that BPD, borderline personality disorder, was very treatable.

4:49And they were really interested in like, what would it look like to build a therapy that specifically focuses on mentalization? So they kind of partnered together to develop this therapy and then to research it. And in terms of your good question about reflective functioning, there are kind of two ways of saying the same thing. And they do have like a measure for mentalization. It is called the reflective functioning questionnaire. So and that's the measure that we tend to use when we're kind of looking at how does mentalizing, how is it impacted by treatment? So there are kind of two ways of saying the same thing.

5:28Well, I have a quick side story about that, which is that I was in a reading group and there was a footnote. And the footnote, it was about reflective function. And the footnote said something to the effect of that you can teach low-income mothers reflective function or something that had this impact on the babies within the six to eight week thing. and it was just a footnote but I was so excited and inspired by just that little like what you can you don't have to like change attachment patterns and you don't have to have years of therapy and that we started a what ultimately this is short and a very short story but it ended up being the genesis of an organization a non-profit in Austin called Austin in Connection.

6:16I.N.

6:20is and the whole idea was to bring the science to the public. And it really literally all came from Bonagie's little asterisk related to reflective function and the capacity to teach reflective function. So here we are, full circle. This is the next kind of layer of it. So you're taking some of their work and then really with your new book, Mentalization, Utilizing Reflection to Heal from Borderline Personality Disorder, going to really be able to dig in and give us the, okay, what do we do with this now? How do we do it? Totally. I mean, there's tons of research on this, which is maybe this is not a surprise, but it's really this idea that parental mentalization predicts children's capacity to mentalize, predicts secure attachment.

7:06So that's the idea. If we can help parents reflect more on mental states in themselves and their children, that's the idea is that that's going to lead to sort of help kids be better mentalizers. And that's going to help those same kids feel a more solid sense of self and to kind of do better in their relationships. That's so cool you founded that organization. Yeah, I certainly did. And really, I'm not even kidding that it was, that was the genesis of it. It was like, what? Why are we, you know, making people pay a fortune and sit in therapy for years and all of those things? So reflective function, mentalization.

7:40Another way that our audience has heard about this is David Elliott's work on the three pillars of comprehensive treatment for attachment disorders. And one of the pillars is all about mentalization. So you're in wonderful company, but this is definitely the deep dive. So you said parenting, mentalization is a predictor of all of these great things, including secure attachment. So what would it look like if you were a fly on the wall and you saw a parent competently mentalizing with their child? What does it look like? Kind of the hallmark of mentalization is curiosity, you know, and maybe the enemy of mentalization, I don't know if you want to say that word, but is certainty.

8:22I love that. That's so clear. But basically the idea is, is that sort of what would a caregiver who's sort of like mentalizing the child, we'd say it's more about the process than the content. It's like the question, can I ask a question? when that kid said that to you, how did that make you feel? You know, or also sharing one's own feelings. Wow. Oh man, I'm feeling a little nervous about your audition tomorrow, right? This idea of putting words on mental states, which may sound really, it is kind of basic, but at the same time, we can't take it for granted because it's very, very common for a lot of folks, especially with psychiatric challenges to kind of dismiss mental states, You know, to tell a child they shouldn't be feeling a certain way or to feel inhibited themselves.

9:10They don't actually kind of name their own feelings. So this idea of curiosity about what kids are feeling, but also what's leading them to feel that way. The what, the why, and the how is really being curious, but also connected. So it's not, it's not just, I can't just ask my kids, you know, what was your theater camp like today? And then I just kind of like listen, like I actually, you got to care, right? And so that's sort of, I think, a big part of it. And I was actually just thinking about this yesterday because we, one of the things we started doing in my family, we have two kids, one 12, one 14.

9:53And we were do, you ever do like highs and lows? Oh yeah. What's your highlight and what's your low light? Yeah. It sounds like so basic, but I was just thinking it's a mentalizing exercise, right? It's this kind of curiosity. What made you feel the best today? Where were their challenges? And that kind of like, there's some ways like that's a bit of it. Can we infuse that into our relationships with our kids where we're kind of curious with them about their experience? I think it's such a great, great example because the other part of it is you come to know these super minutiae details that you would never have known.

10:29I mean, I think it's a good couples exercise even. Absolutely. Yeah. Because it does cultivate that where you're scanning and telling story and making sense of your narrative. Yeah. So what about treatment though? How does this look in treatment and particularly when people fail to mentalize? Why don't you teach us a little bit about that? Yeah. So it's a good point. And yeah, I guess you're right. Even before getting to the treatment techniques, we should be sort of saying what are problems in mentalizing look like actually. Yeah, it's a really good point. So on the most basic level, you know, a problem in mentalizing can be, and actually I should say, just to let you all know, there's in the book, they're all worksheets on this.

11:10So you, if you sort of get it, you can actually like look through like, how do I identify what, what my problems in mentalizing are, or how do I identify what my patient's problems in mentalizing are? And there's even a, there's a free website too, that has these worksheets that you could do to identify your own problems in mentalizing. So I'll make sure to kind of give this to you. But basically, the most common ones, one, patients can often just struggle to put words on their feelings. They can give one word answers and struggle to elaborate on it. So that's the problem with the what. Also, there can be challenges where they'll presume they know what other people are thinking and feeling, which can lead to tremendous disruptions in relationships, because what happens if we kind of get it wrong or are seeing things in an overly narrow way.

11:57Well, and what's so dangerous about that is that, because I'm thinking about everybody failing to mentalize, you know what I mean, at times. And that when you're in it, you really are in it, you just believe that what you're thinking is true. You're not aware that you're having a thought, just that's the truth. It's not an interpretation of something. This is factual that you no longer care about me because of whatever, right? Or whatever it is. absolutely well that's well said your way of describing it is exactly consistent with in mbt we have these kind of three non-mentalizing modes and you just did i gave they gave a perfect description of of one of them which is called psychic equivalence mode like i think it therefore it's true but you said it in a very nuanced way when we're in psychic equivalence mode we don't even think it's a belief.

12:49Right. It's a, it's a fact. Quick side story again of, I'm looking over the crib at my baby and what I think, fortunately I caught myself thinking this, but I wasn't in the moment, but I'm like, he's totally asleep. And I, and I think, oh, look, he wants me to pick him up. And I remember catching myself like, no, Sue, he is sleeping. I want to pick him up. Right. Like, I love it. But without that second thing, it's like now I'm scooping him up, quote, for him. Yes. And there's a really big difference between what he actually wants and what his needs are. And my impulse to give him love that he's not asking for in that moment.

13:32Wow. No, that's perfect, actually. And there's a whole construct in MBT, not to kind of go too far off track, but it's called the alien self. and the idea is that when parents or even therapists have trouble mentalizing the child and kind of project their own mental states onto the child. It's a common therapeutic mistake, yeah. Absolutely. The child or the patient will take in the other's mind and it's too much of the other's mind and it'll actually not kind of be connected to themselves enough. So that leads to what we call an alien self process where it's like, I'm not, I don't fully know who I am.

14:12It's more about you. And that's a really common problem with specifically with borderline personality disorder. I was just thinking that. Yeah, that's right. Yeah, definitely. So, so yeah, so that's a big problem in mentalizing. Other kinds of problems in mentalizing that are very common in therapy or you see in clinical work are really, it's what we call teleological mode. So basically focusing extensively on visible things and relying on visible things to understand the internal world. So for example, the patient who feels like, oh, my boyfriend didn't text me back for an hour or two, that means he's probably wanting to be with somebody else right or and that's more of a borderline process we also see theological mode with narcissism where it's like oh i don't have a good enough job that means i have no value so where the outside determines the inside if that makes sense so that's one of our big problems in mentalizing and then the the last big one is what's called pretend mode, which is kind of unfortunately named because it implies like some misrepresentation, but really what it is, it's disconnection or dissociation.

15:29So it's really, it's key in therapy and MBT spends a lot of time thinking about this because a lot of times you'll have patients who are very insightful and they have all these ideas about themselves, but they're not really connected to what they're feeling. And similarly, another part of pretend mode is that I can say, oh yeah, I know you're feeling hurt by me, but I'm not actually resonating with that or caring. You know, that's the problems and empathy. So those really are the three main non-mentalizing modes, certainty, external focus, and disconnection. So those are kind of the big focus.

16:10MBT really spends a lot of time trying to help patients with those areas of challenge. Thanks for listening to this preview of bonus content. If you would like to continue with the episode or to support free worldwide access to important material like this, you can join our online community for as little as$5 a month at therapistuncensored.com slash join. Thanks.