The Mentalizing Model of Borderline Personality Disorder (BPD)

An underlying failure in mentalizing and its relationship to adversity and attachment has been presented as a model for BPD [8, 11].

Mentalizing develops in the context of attachment relationships throughout childhood and adolescence. Secure attachment processes facilitate robust mentalizing while disorganised and insecure attachment processes, especially in the context of developmental trauma and neglect, undermine the acquisition of stable mentalizing. A core feature of BPD is poor mentalizing, with different problems arising at different stages of the disorder, dependent on the mentalizing profile of the individual [12–14].

The mentalizing profile of a patient with BPD tends to show imbalance in all the dimensions of mentalizing:

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   1. There is often an unstable self-representation and sometimes an over-reliance and acceptance of other representation and a domination of affective processing and automatic mentalizing, and reliance on external mentalizing

   
   
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   2. The attachment system in BPD may be disordered [15], and the problems of the attachment system may create a vulnerability in relation to interpersonal interaction and intimate relationships [16, 17]

   
   
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   3. There is suggestive evidence that mentalizing can protect from the expression of symptoms and it is the failure of that protection (resilience) that makes someone symptomatic [18]

   
   
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   4. Developmentally, the quality of attachment and mentalizing interact in complex causal ways: while a benign attachment context is considered to enhance mentalizing, understanding and overcoming adversity entails the enhancement of mentalizing in the process of overcoming the trauma [19]

Mentalizing in Mood Disorder

In depression the situation is different. The disorder itself impacts on mentalizing and most studies have found that the duration and severity of depression negatively influences mentalizing capacities. Clinical experience and a growing body of research suggest that disturbed mood impairs individuals’ ability to mentalize [20, 21]. When depressed individuals attempt to mentalize, mentalizing is likely to be distorted, with excessive self-preoccupation and ineffective mentalizing modes dominating, for example psychic equivalence in which feeling bad means ‘I am bad’ [22]. Mentalizing is shut down and the individual shows hypomentalizing with poverty of thought, inability to access emotion, and experience of body and mental emptiness. Studies have quite consistently reported impairments in mentalizing, based on a wide variety of tasks, in patients with both unipolar and bipolar disorder [23].

In bipolar disorder mentalizing potentially becomes excessive with over-recruitment of the cognitive processing system leading to hypermentalizing [24]. Beliefs about the self and an understanding of the motives of others are not grounded in reality and become overly complex and intricate. This is a form of pretend mode in which the patient cannot accept difference in self and other representations. Importantly, these changes in mood disorders have been found to predict relapse in major depression and have been demonstrated in euthymic patients, even when basic cognitive dysfunctions associated with depressed mood were controlled for. This finding clearly suggests that mentalizing impairments continue to exist outside depressive episodes and thus may be involved in the onset and recurrence of mood disorders.

Mentalizing in Psychotic States

In psychotic states there is a reliance on low level mentalizing. Mental states lack differentiation and there is a breakdown between self and other, internal and external experience – self and other boundaries become permeable, thoughts become facts (psychic equivalence), mental images have the quality of reality (psychic equivalence), misunderstandings abound (teleological mode). However, phenomenologically, psychosis is defined not solely by symptoms of hallucinations and delusions, but also by a disturbance in mentalizing of self, which can be expressed in a number of different forms of psychotic subjectivity. Normally a sense of self-agency and capacity for self-regulation, established in the context of embodied engagements with caregivers during infancy, gradually fosters control and regulatory capacity over bodily signals, which is essential in establishing a minimal self [25]. The ubiquity and consistency of bodily cues firmly ground the individual’s basic sense of continuity as an integrated continuous being. Dysfunctions within the sensory and self-monitoring processes necessarily alert the individual to attend to and manage states of vulnerability threatening the basis of self-integrity. Self-integrity is manifestly disturbed in schizophrenia and other disorders such as autistic spectrum disorders or other neurodevelopmental conditions [26].

Within this framework, a mentalization-based approach provides a legitimate starting point to address the central problem of psychosis – that of alterations in sense of self. Evidence also suggests that attachment and mentalizing may not represent causal factors in the development of psychosis [27] but rather represent key protective factors that can (a) attenuate the clinical course of emerging psychosis in those at increased risk and (b) sustain recovery in affected individuals. In other words, a mentalization-based approach to psychosis seeks to enhance protective mechanisms in the early part of the disease, and to strengthen the ‘non-psychotic’ part of the personality [28, 29] in affected individuals, to promote resilience to life challenges.

Loss of the capacity to mentalize plays a key role in the development of mental distress, and robust and stable mentalizing increases resilience to social and personal set backs. A focus on generating mentalizing may therefore be helpful in the treatment of a range of psychiatric disorders either as the main target for intervention or as an adjunct to other treatment.

Attitude

The attitude of the clinician is crucial. The psychiatrist’s task is to stimulate a mentalizing process as an essential aspect of any therapeutic interaction. Thinking about oneself and others develops, in part, through a process of identification in which the clinician’s ability to use his mind and to demonstrate a change of mind when presented with alternative views is internalised by the patient, who gradually becomes more curious about his own and others’ minds and is consequently better able to reappraise himself and his understanding of others. 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 narrative contexts is key to a change process, as is the focus of the work on current rather than past experience.

Not-Knowing Stance

The ‘not-knowing or mentalizing stance’ [31] is part of this general therapeutic attitude and is central to ensuring that the psychiatrist maintains his curiosity about his patient’s mental states. A common confusion has been that being a not-knowing clinician is equivalent to feigning ignorance. The clinician has a mind and is continually demonstrating that he can use it! He may hold alternative perspectives to the patient and if so this is a perfect moment for further exploration

In the role of clinician, you are naturally pulled into excess passivity or activity. Mentalizing entails striking a balance in which assumptions are actively questioned, probed and explored. It is especially productive to challenge patients’ unreasonable assumptions about you and it is recommended that this is done through a series of therapeutic steps:

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   1. Empathy in relation to the patient’s current subjective state

   
   
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   2. Exploration and clarification and, if appropriate, challenge

   
   
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   3. Identifying affect and establishing an affect focus

   
   
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   4. Mentalizing the relationship

Detailed discussion of these therapeutic interventions can be found in [31].

Arousal

Arousal undermines mentalizing. It is important to maintain arousal levels in a session within an optimal range – not too high so that mentalizing is overwhelmed, and not too low so that mentalizing becomes severely restricted. The aim is to help a patient manage arousal and become sensitive to levels of arousal and specific contexts that undermine mentalizing. Any intervention that is delivered with the primary aim of de-escalating excess affect and/or decreasing anxiety and/or increasing arousal can be used.

Contrary Moves

Mentalizing is a flexible, responsive process. In contrast non-mentalizing is fixed and rigid. The clinician focusses on increasing the patient’s capacity to use different components of the dimensions of mentalizing in relation to context. For example, in everyday life it might be appropriate to use more cognitive aspects of mentalizing, in an important negotiation perhaps, and yet at another moment in the meeting to be sensitive to the emotional states of oneself and others if the negotiation is to be completed successfully. A patient who is overwhelmed by emotion may not be able to represent his/her states of mind to him/herself or to others and so loses the chance of someone else helping him/her with how he/she feels. Maintaining some cognitive sense of the bewilderment of the other might allow enough expression of the content of the emotion to enable another person to offer appropriate comfort. So the immediate task of the clinician is to help the patient maintain balance between the different poles of each dimension of mentalizing; move the patient towards an internal focus if they are excessively externally focussed or vice versa, heighten the affective component if the cognitive state of mind is to the fore, or vice versa, and so on.

Affect and Significant Events

A focus on affect in the context of significant events, especially in those involving relationships and personal interactions, is often considered to be a process of focussing on the patient’s current affective state, identifying the what he/she is feeling, and labelling the emotion. This is only part of the focus on affect that is central to the practice of MBT. While important, this process is not sufficient to characterise the affect focus within a session. The patient must begin to identify the specific aspects of an interaction to which they are sensitive, develop ways of managing the affect they experience, and eventually become aware of them before they overwhelm their capacities to manage. To this end the clinician and patient identify affects as they arise during events and then label them as emotions to be monitored over time in treatment itself. So the process is the identification of these important affects and sensitivities and their recognition as and when they are triggered in a session. It is often the clinician’s task to try to identify such affects so that they become available as part of the joint work. Identifying the affect is an important step in MBT because it links general exploratory work of affect to relational sensitivity. So it is within the patient–clinician interaction that detailed work is done to understand how relational processes interfere with mentalizing.

Mentalizing the Relationship

It has been suggested that the patient–clinician relationship in terms of transference is not used in MBT [32]. Perhaps it is the vigilant attitude to the use of the interpersonal relationship to promote mentalizing that has led to this view. Practitioners are cautioned firstly about the commonly stated aim of transference interpretation, namely to provide insight, and secondly about genetic aspects such as linking current experience to the past because of their potential iatrogenic effects. But equally ‘mentalizing the relationship’ is a key component of mentalizing intervention and so we have set out a series of steps to be followed to minimise the risk of harm.

The issue is the mentalizing capacity of the patient and its relationship to arousal. Complex interventions such as those related to detail of patient–clinician interaction or the genesis from the past of current states require a thoughtful and reflective patient if they are to be effective. A non-mentalizing patient who holds rigid mental perspectives and who has limited access to the richness of past experience is unlikely to be able to hold other perspectives in mind while he/she compares them to his/her own, particularly if they are complex and subtle. He is likely to feel overwhelmed; far from stimulating a mentalizing process the intervention compounds non-mentalizing by increasing anxiety. The patient panics, feeling incapable of considering the clinician’s fully mentalized and coherent intervention. Structuring of mental processes occurs and the patient becomes more rigid and insistent about his own point of view.

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   1. The first step is the full validation of the experience the patient is having about the relationship with the clinician. The clinician seeks to see the perspective of the patient without implying the experience is a distortion. The danger of the genetic approach to working with transference is that it might implicitly invalidate the patient’s experience

   
   
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   2. The second step is to identify and explore some of the detail of the patient experience – when did they first notice it, what are their thoughts about it. As the events which generated the feelings in the relationship are identified and the behaviours that the thoughts or feelings are tied to are made explicit, sometimes in painful detail, the contribution of the clinician to these feelings and thoughts will become apparent

   
   
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   3. The third step is for the clinician to accept his contribution towards the patient’s experience. The patient’s experience of his interaction with the clinician is likely to be based on a partially accurate perception of the interaction, even if they are based on a small component of it. It is often the case that the clinician has been drawn into the relationship and acted in some way that is consistent with the patient’s perception of him/her. It may be easy to attribute this to the patient, but this would be completely unhelpful

   
   
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   4. The fourth step is collaboration in arriving at an alternative perspective. Mentalizing alternative perspectives about the patient–clinician relationship must be arrived at in the same spirit of collaboration as any other form of mentalizing. The metaphor used for training is that the clinician must imagine sitting side by side with the patient rather than opposite him. They sit side by side looking at the patient’s thoughts and feelings, where possible both adopting an inquisitive stance about them. The fifth step is for the clinician to present an alternative perspective, and the final step is to monitor carefully the patient’s reaction as well as one’s own

Some of this process can be considered as mentalizing the ‘counterrelationship’ which is broadly the clinician presenting his own perspective. It is best to think of it as ‘being ordinary’ in the sense of considering what would you say or do if your friend told you this or behaved in this way towards you. This is not a licence for you to behave in any way you please or to say whatever you like – any more than you would do in a respectful relationship with a friend. Rather, it is advocating openly working on your state of mind in therapy in a way that moves the joint purpose of the relationship forward, keeping your and your patient’s mentalizing on-line. To do this you often will have to speak from your own perspective rather than from your understanding of your patient’s experience.