Mentalisation Based Treatment – a short patient’s guide

 I’ve got borderline personality disorder. I’ve got all sorts of other things – a dog, two jobs and a strange itch on my shin. But I’m only having psychotherapy for my BPD. And it’s not any old psychotherapy. It’s a relatively new, designer therapy, with the Americanish title of Mentalisation Based Treatment. (Or the even more American version – Mentalization etc.) This information piece is about MBT, written in the hope that it will be helpful for other people fortunate enough to be offered or currently having MBT.

I’ve written elsewhere about my having BPD – if you’re interested, you can find it on a website www.brightplace.org.uk/starbpd.html. So I won’t ramble on about it here, other than to say that of the nine qualifying conditions, my five are bunched around mood swings and self-harm. (The whole thing about qualifying conditions feels a bit like the entry conditions for the Euro. But easier to understand and without spawning quirky breakaway political parties.)

What is MBT?

MBT is a type of psychotherapy created to treat people with borderline personality disorder. It’s also been found to be useful for people with other types of mental illness. As the name suggests, it centres on the concept of ‘mentalisation’. I struggled to understand what exactly this is, which could be further evidence of my need for this therapy or just that I’m a bit dim. But I finally grasped that it’s unscarily straightforward. Mentalisation is simply about recognising what’s going on in our own heads and what might be going on in other people’s heads.

So what’s the big deal? Surely we’re all pretty in touch with what we’re thinking and feeling, and have got as good a chance as anyone else of guessing what others are doing? Er, no. Unfortunately those of us with BPD are unlikely to be top scorers in the Minds’ Awareness League. Not great at accurately identifying what’s happening in our own minds and even less likely to correctly work out what’s in other people’s minds. Especially if we’re feeling stressed out.

And there’s an even more fundamental problem here. When we’re feeling crap, we’re likely to shut down (or at best tone down) our ability to ‘mentalise’. Thinking becomes a real effort, and reasoned thinking about thinking nearly impossible. Certainly for me, when things are tough I often self-harm specifically to avoid thinking, as that’s too painful. Self-harming gives us something very concrete to focus on, which links with another aspect of BPD. Apparently, if we’ve got BPD we tend to find it easier to believe things that we can see rather than imagining what might have led to a particular situation. (No money under the pillow, definitely no tooth fairy.)

MBT is intended both to help us sharpen up our ability to mentalise and to be willing to use it, especially when we’re feeling intense emotions. For example, in a session the therapist might ask us to consider what the other person in a difficult situation might have been thinking, and help us move past our initial assumption, especially if it’s a really negative one.

What’s the difference between ‘mentalising’ and thinking and why can mentalising sometimes be better?

Thinking is thinking. Mentalising is thinking about thinking and feeling, our own and other people’s. Obviously it’s often best just to get on and have thoughts. About whether Borat is the funniest film ever made or a shocking and trashy piece of sexist and racist rubbish. About whether there’s something we can do as a non-punitive alternative to self-harming.

I’ve found it helpful looking at mentalising from the perspective of people with autism. Perhaps it’s because I’ve struggled to understand quite what mentalisation is about that it’s been useful to me to consider a group of people with a totally different disability to mine. People with autism live very much in the here and now. They have been described as having no ‘theory of mind’, as most are unaware of their own thinking processes and have even less recognition that other people think or have feelings. Clearly people with autism think. (An inordinate amount of the time, it seems, about Thomas the Tank Engine, at least when they’re kids.) But it’s a very automatic experience, and reflecting on their own thoughts just doesn’t arise. And the way they see the world is such that although they may notice the manifestation of others’ thoughts and feelings, for example they can see that someone is smiling or hear them shouting, they don’t connect that with the emotions that produce those observable responses. People with autism find it almost impossible to imagine themselves ‘in someone else’s shoes’.

For those of us with BPD rather than autism, mentalising is an acquirable skill, and one which can give us valuable extra perspective on a situation. For example, if I’m planning to take an overdose, just thinking about it tends to take me along a route which lets me confirm this is the ‘right’ thing to do. But if I have to mentalise, I have to look at my thinking. It’s hard for me to do this without concluding that I’m not thinking straight. That my thoughts and feelings about the overdose are caused by feeling seriously crap and that I should at least try to hold off any decision til I’m feeling more settled.

And if I then move on to thinking about others’ thoughts and feelings, it takes me to the painful place of knowing how traumatised my friends are if they find out that I’ve taken an overdose. Let alone the impact on them if the next overdose turns out to be fatal.

None of this mentalising necessarily stops me from taking self-damaging action but it at least gives my self-protective side a decent shot at introducing some logic to the situation.

What’s it like having MBT?

You might expect that a therapy with mentalisation at its heart would involve the therapist endlessly asking “And what was in your mind? And what was in their mind?” But, luckily, this hasn’t happened. It’s all much more nuanced than that. Similarly, although the approach is very non-directive, when I ask for advice or need help in practical problem-solving with something I’m wrestling with, my psychiatrist will often respond in a ‘normal’ way and help me out.

I had cognitive behavioural therapy with a psychologist before I ended up being sectioned. At that stage, I was taken on by a personality disorder unit as an outpatient and have had MBT weekly with a psychiatrist for about 18 months. Both types of therapy feel very similar, despite the psychologist and psychiatrist being very different types of people. Both approaches have felt supportive, non-judgmental and focused on what I’m thinking. I’ve been able to see issues, especially painful ones, from a different perspective and to understand what might be fuelling the tough stuff. Both have made me feel like I’m setting the agenda about what we talk about and that I can say anything, however embarrassing or ridiculous I feel it is. And I know that the self-protective part of me, which tries to resist my self-destructive tendencies, gets crucial reinforcement.

The most noticeable difference in style is that my psychiatrist has very ‘high boundaries’, so I know almost nothing about him and his life, other than what I can pick up from clues around his office. (He either rides a motorbike or is excessively worried about getting a head injury when driving his car.)

Perhaps the most tangible difference I experience is that I’ve only once self-harmed after a session with the psychiatrist whereas I used to do so regularly after my previous sessions. This really puzzled me til I read a couple of books about MBT. These made me realise that while the MBT sessions feel quite normal and ‘spontaneous’, they’re carefully designed to be at a level of intensity, or intrusiveness, that I can comfortably cope with. (This relates back to the business about us closing off if things become too painful.) This doesn’t mean that I’m never moved outside my comfort zone – most sessions we cover things which make me cry. But somehow, overall I don’t end up feeling completely jangled or bursting with feelings I don’t know how to or don’t want to deal with.

Does it work?

Well, I’ve been able to survive 18 months of pretty consistent suicidal feelings and still be around to write this. And studies have shown that it certainly works for a lot of, but not all, patients. One very reassuring thing is that it’s been designed as a result of careful research into both the causes of BPD and the impact of MBT. I don’t really understand all the stuff about how BPD develops, but it goes something like this.

If mothers have problems connecting well with their babies, they respond differently to other mothers. One thing that the research shows is that when the babies are really upset, these mothers don’t calm the babies in a way that helps the babies to ‘understand’ or learn what’s their own distress and what’s the mother’s. It’s a bit like the baby’s distress is magnified and bounced back at the little thing rather than being soothed and dissolved by the mother. As well as emotional mishaps like this, it’s been found that many people who develop BPD often have early experiences of abuse or neglect by parents. These things lead to many of us being unable to soothe ourselves in ways that are conventional, or not self-destructive, again reinforcing our tendencies to self-harm.

Another central proposition of MBT is that when we’re babies and our mothers aren’t able to comfort us in an effective way, we sort of bung onto our mother the parts of ourselves we can’t cope with. This results later on in life with us coping particularly badly with the loss of someone close to us, partly because we might have ‘assigned over’ to them the painful parts of ourselves. This contributes in a rather complicated way to our tendencies to self-harm and be suicidal, apparently to feel re-connected to the outsourced part of ourselves.

The quality of ‘attachment’ in our earliest years continues to affect how we feel and think right through our lives, and if they’ve got off to a bad start we’ll have difficulties with other close relationships. Including potentially the one with our therapist.

The MBT therapist, then, will be very aware of this and will be careful that we don’t just slot back into a pattern of feeling overwhelmed by intensely painful feelings which make us close off thinking, especially about our own and the therapist’s thoughts. Feeling understood by someone we trust (the therapist), is a sound place to be able to move into a calmer, safer way of coping with difficult stuff.

More information about MBT

If you want to know and understand more about MBT… unfortunately there isn’t much information out there. And what there is has been written for therapists rather than patients. The most accessible of this limited literature is Mentalization Based Therapy for Borderline Personality Disorder by Bateman and Fonagy. I’ve only been able to find one thing on the Internet, a press release from the Royal College of Psychiatrists which provides a clear but brief explanation of MBT and its effectiveness: http://www.rcpsych.ac.uk/pressparliament/pressreleasearchive/pr748.aspx

There’s much more written about the obscurely titled Dialectical Behaviour Therapy. So it’s time for those of us getting MBT to start writing as well as reading about it.