Guide Psychotherapy for Borderline Personality Disorder: Mentalization Based Treatment

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This models reflectiveness and allows patients to discover a way of perceiving themselves and others through the therapeutically generated experience of a mind considering a mind Regarding the interpretation of transference, MBT aims to focus the patient's attention on the mind of a therapist, and to assist patients in the task of contrasting their experience of interaction with how that may be perceived by another mind.

The aim is not to offer insights to the patients as to why their perception of therapists may be distorted in specific ways, but rather to model and engender curiosity as to why, given the ambiguity of interpersonal situations, they might have chosen a specific version. Thus, therapists look at the motivation that people have for manifesting a specific kind of transference, but the exploration is focused on encouraging a thinking stance 9.

The following clinical vignette illustrated this aspect of the treatment: Patient: You don't care about me, you think I'm boring. Therapist: I'm not sure what I've done, but I must have done something that makes you convinced of that. Do you have any idea what I might have done?

Mentalization-based therapy (MBT)

Patient: I saw you looking at your watch. Therapist: I do recall that. Perhaps the way you are feeling at the moment it is inconceivable that there could be another explanation for me looking at my watch other than finding you a burden. Patient: It's obvious you were bored. Therapist: Why do you think it is so hard to think of any other possibility?

Patient: I'm so boring.

Peter Fonagy, Anna Freud Centre Chief Executive: What is Mentalization? interview

I always feel that you don't want to be with me and that you would rather be somewhere else. Therapist: I see. So when you saw me look at my watch you might have thought that I would rather be doing something else than be here with you? Patient: I thought I had lost you. I felt that you had gone 9. The final phase of the treatment starts at the month point. The emphasis is on the interpersonal and social aspects of functioning, along with consolidating earlier work and considering the separation responses associated with loss.

A follow-up treatment plan is developed collaboratively 9. Forty-four patients were randomized, and 19 were evaluated in each group. Treatment for the PH group consisted of once-weekly individual and thrice-weekly group MBT, once-a-week expressive therapy oriented toward psychodrama techniques, and a weekly community meeting. The control group care consisted of regular psychiatric review, inpatient admission as appropriate, and outpatient follow-up as standard aftercare.

Treatment with MBT showed significant gains compared to the control on measures of suicidality, self-harm and inpatient stay. Five years after discharge, the group treated with MBT continued to show clinical superiority compared to the control group on measures of suicidality, diagnostic status, service use, use of medication, and vocational status 7.

The IOP aimed to explore the effectiveness of outpatient intervention, with separate individual and group psychotherapeutic components, implemented by generically trained mental health professionals relative to structured clinical management with a supportive psychotherapy component. MBT treatment was implemented according to the same manual, together with an initial group treatment for 3 months targeting suicidal behaviour. Patients in the comparison group were treated with individual and group supportive psychotherapy, received a similar amount of professional attention, but without the manualised interventions offered to the MBT group.

Initial results showed a more marked decrease in suicide attempts in the MBT group, with a reduction in relative risk of 0. This was also true for the reduction of self-harm reduction in relative risk of 1. Taken as a whole, these studies show that MBT is effective at short- and long-term basis, when delivered in a day-care programme and also in an outpatient programme, which enhances the external validity of the technique. Deficits in the mentalization capacity, which are characteristic of several disorders 22 , are a key feature of BPD. RCTs have demonstrated the long-term effectiveness of MBT for the treatment of patients with BPD, and mental-health professionals should be adequately trained to deliver effective interventions, such as MBT, to their patients.

The development of psychodynamic interventions that aim to identify and repair the specific deficits involved in the psychopathology of a disorder is central to the task of increasing the effectiveness of psychoanalytically oriented treatments Detecting personality disorders in a nonclinical population. Application of a 2-stage procedure for case identification. Arch Gen Psychiatry. The prevalence of personality disorders in a community sample. Borderline personality disorder in primary care. Arch Intern Med. Borderline personality disorder.

Bateman A, Fonagy P. Effectiveness of partial hospitalization in the treatment of borderline personality disorder: a randomized controlled trial. Am J Psychiatry.

Treatment of borderline personality disorder with psychoanalytically oriented partial hospitalization: an month follow-up. Psychotherapy for borderline personality disorder: a mentalization-based treatment. Oxford: Oxford University Press; Mentalization-based treatment for borderline personality disorder: a practical guide. New York: Oxford University Press; Affect regulation, mentalization, and the development of the self. New York: Other Press; Allen JG, Fonagy P. Handbook of mentalization based treatments. Fonagy P, Target M. Attachment and reflective function: their role in self-organization.

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Dev Psychopathol. Parenting behaviors associated with risk for offspring personality disorder during adulthood. Fonagy P, Bateman A. Mentalizing and borderline personality disorder. J Ment Health. Gergely G, Watson JS. The social biofeedback theory of parental affect-mirroring: the development of emotional self-awareness and self-control in infancy. Int J Psychoanal. Early intervention and the development of self-regulation. Psychoanal Inq.

Bartels A, Zeki S. The neural correlates of maternal and romantic love. Fonagy P, Bateman AW. Mechanisms of change in mentalization-based treatment of BPD.

References

J Clin Psychol. Progress in the treatment of borderline personality disorder. Br J Psychiatry. Bateman AW, Fonagy P. Mentalization-based treatment of BPD. J Pers Disord. Outpatient mentalization based therapy for borderline personality disorder: Preliminary results of a randomized controlled trial. The American Psychiatric Association APA has concluded that borderline personality disorder is best treated with psychotherapy supplemented as necessary with drugs to alleviate specific symptoms.

Several types of psychotherapies involving cognitive or behavioral interventions may be helpful. Now a small but well-designed, long-term study indicates that a relatively new therapy known as mentalization-based treatment is effective for patients with borderline personality disorder. This therapy is based on the premise that patients with borderline personality disorder suffer from difficulties in their ability to "mentalize," or make sense of themselves and others, on the basis of emotions or subjective mental processes such as feelings, beliefs, and desires.

Patients may be least able to mentalize while interacting with other people — especially those closest to them.


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As a result, they may misunderstand and overreact to other people's words or actions. It is based on their theory about how children gain the ability to mentalize. According to their theory, mentalization develops when a parent or primary caregiver helps a young child convert a physical experience such as crying into a conscious thought or feeling such as sadness through "marked, contingent mirroring" of the emotion.

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A response that is both marked exaggerated or slightly distorted and contingent accurate and responsive enables the infant to better understand an experience. Three mechanisms can derail healthy growth in the capacity to mentalize. Developmental deficits. These may occur because child and caregiver don't develop a strong emotional bond, or because the caregiver does not adequately mirror the child's emotions to help the child contain or soothe the distress.

Defensive measure. Some patients who were abused or traumatized in childhood might avoid mentalization as a self-protective measure, so that they do not have to acknowledge the malicious thoughts of an abusive figure. Biological factors. Genetic changes or developmental strains that alter brain function may affect the stress response system, cause volatile moods, and in other ways disrupt the neural circuitry that links emotion and thought.

Patients who are unable to mentalize, or who lose the ability in certain contexts, devise other ways to make sense of their experience. In "psychic equivalence mode," the patient assumes that what exists in his or her mind reflects what exists in the world.


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In "pretend mode," the patient's internal musings predominate regardless of external reality, so that he or she may obsess in self-critical ways. And in "teleological stance mode," the patient is able to communicate an emotion or thought only in terms of action — such as expressing pain through self-mutilation.