Treating Borderline Personality Disorder With MBT

2024 Author: Harry Day | [email protected]. Last modified: 2023-12-17 15:43

MBT (Mentalization-Based Treatment) is a mentalization-based therapy. It is a specific type of psychodynamically oriented psychotherapy designed to help people with BPD [5].

Mentalization implies focusing on mental states, ours and others, especially when explaining behavior. In a mentalization mindset, the very fact of thinking about alternative possibilities can lead to a change in beliefs. Mentalization is an imaginary mental process, because we have to imagine what the other person is thinking or feeling [1].

The treatment is based on mentalization developed by Anthony Bateman and Peter Fonagi.

The term “mentalization” was originally introduced in École de Paris's work on psychosomatics (Leslie, 1987). It was first used in 1989 by P. Fonagi. Since then, an understanding of a number of mental disorders has been developed in terms of mentalization [6].

MBT is rooted in attachment theory.

MBT is the treatment most clearly defined as therapy for BPD (Bateman, Fonagy, 2004). There are reasons for this - clear empirical support, a number of randomized controlled trials (Bateman, Fonagy, 1999; 2001) [6].

Treatment based on mentalization promotes understanding of human behavior and improves interpersonal communication in patients with BPD, since this category of patients very often has a misunderstanding of various aspects of another person's behavior due to various cognitive distortions, increased feelings of anxiety and fear, PTSD, special sensitivity and receptivity of the psyche.

In general, it is worth noting that clients with borderline disorder exhibit the following behavioral characteristics: hypersensitivity, their psyche is similar to "body parts without skin." In addition, they keenly feel the falsity of another person's behavior, his pretense. They are especially sensitive to their surroundings. People with BPD may pay attention to things that seem natural and ordinary to others. They do not tolerate when an emotionally significant person leaves them, breaking up with someone close to people with BPD is a huge stress. The life of people with BPD is accompanied by feelings of loneliness. Their feelings change quickly, in the evening they can love, and in the morning they can already hate. They often idealize and devalue others. It is common for them to experience feelings of anger and rage, but this is an indicator that they trust the other person. They tend to change their place of work frequently. A deep sense of shame is characteristic, especially after they commit impulsive, rash acts. For example, they may offend someone, and then they very much regret it. People with BPD have great difficulty regulating and controlling their behavior. Self-esteem problems: People with BPD have very low self-esteem and self-destructive behaviors. They do not know who they are, they do not differentiate themselves well from another person. They tend to project their qualities onto another. They can "dig their own grave", perform auto-aggressive actions (self-cut, self-harm). Experiencing emotional pain, which is difficult for them to cope with, they often say: "the soul hurts." It is during periods of intense emotional pain that they tend to self-destructive behavior. People with BPD do not tolerate stressful situations well; against the background of a stressful situation, there are dissociation and suicidal attempts that can be fatal. After getting out of a stressful situation, the psyche can stabilize for a while. Interaction with the world and others occurs at the “poles”, in extremes. Others seem to them to be either very good or very cruel people. They perceive others unambiguously, for example, either bad or good, often in black and white. Difficulty with empathy. Life for people with BPD is like an uncontrolled roller coaster ride. This is especially true in situations of stress. They are literally thrown from side to side from bright anger to complacency. Frequent mood swings and acute sensitivity psychologically exhaust such people. They can immerse themselves in traumatic experiences and "get stuck" in them for a long time, experiencing pain, loneliness and discomfort. Characterized by "inflexible, bony thinking processes, excessive confidence in one's own righteousness, extravagant claims to know what someone is thinking, or why some actions were performed" [1, 39]. The appearance of paranoid ideas, which indicate the loss of mentalization, is characteristic [1, 40].

Difficulties in therapy with BPD clients arise also because they are very difficult to keep in therapy, their usual way of life is associated with throwing and chaotic interpersonal relationships. Relationships with others can be disturbed due to their impulsiveness, the affects of rage and anger. “BPD is characterized by a mentalization deficit that is partial, temporary and dependent on relationships, but this is what is considered the central problem” (Bateman, Fonagy, 2006) [1, 37].

In the treatment of BPD, schema therapy (D. Young), dialectical-behavioral psychotherapy (M. Linehan), psychonalytic therapy (Otto Kernberg) and therapy based on mentalization (P. Fonagy) are used. In our opinion, BPD therapy is not recommended using Skype technology.

“Treatment (MBT) of patients begins with individual sessions. This is followed by the first group session, which allows the patient to reflect on what the therapist has told him and discuss it with other patients in the group. The advantage of further discussion is that misunderstandings or questions that arise during the individual session can be corrected by the group therapist and investigated with the participation of other patients”[1, 67]. In some cases, supervision by a psychiatrist is also necessary. Sometimes, in a crisis situation, patients need to be given clear instructions for treatment, including monitoring the actions of an unstable condition. The prognosis and quality of life of people with BPD largely depends on the competent actions of specialists. First of all, a dialogue must be competently built and a trusting relationship formed, since it can be very difficult for them to trust others.

According to a number of researchers (Bateman, Fonagy, 2006), dialectic therapy has a powerful effect on behavioral problems associated with impulsivity, its effect on mood and interpersonal functioning is more limited [1, 54].

In directive approaches, clients with BPD may be intimidated by the “framework” and authoritarianism of the group leaders, and may run away from therapy. Therefore, the focus should be on caring interpersonal relationships.

Effective approaches to treating BPD have a number of things in common. These include: 1. A theoretically consistent approach to treatment 2. Establishing an attachment relationship with the patient 3. A focus on mental states 4. Consistent use over a significant period of time (rather than subclinical doses). 5. Maintaining psychological closeness with the patient, despite his frank attacks on the therapist and a pronounced desire to push him away 6. Full recognition of the degree of functional deficits in the patient 7. A well-structured and relatively easy to use set of therapeutic measures that can withstand the patient's resistance and be applied with in a continuous and assured manner 8. Although this is a sustainable set of interventions, it must be flexible and tailored to the specific needs of individual patients 9. Treatment must focus on relationships (Bateman, Fonagy, 2006) [1, 56].

Mentalization-based therapy (MBT) is characterized by interaction in a safe and supportive environment. MBT helps people to differentiate and distinguish their own thoughts and feelings from those of others [6].

The initial challenge in MBT is to stabilize a person's emotional state, because without improved affect control, there can be no serious consideration of internal representations. Uncontrolled behavior leads to impulsivity. In turn, the restoration of mentalization helps patients to regulate their thoughts and feelings, which then make relationships and self-regulation realistically possible [6].

Therapy focuses treatment on strengthening the mentalization itself [1], because “mentalization in BPD is weakened, but primarily when there is stimulation of attachment relationships and when the complexity of interpersonal interactions increases” [1, 226].

With the help of treatment based on mentalization, it is possible to understand how the process of violation of understanding of the behavior of other people occurs at the moment of stimulation of interpersonal relationships, which in itself allows to improve mentalization in specific relationships and in relationships with others in general.

In MBT, there are some winning techniques that can keep the patient in therapy and help make contact in a way that is as easy as with other therapies.

MBT techniques can be divided into several blocks: 1. Mentalizing motivation. 2. Support attitude 3. Forbidden statements 4. Identification and study of positive mentalization 5. Explanation 6. Development of affect 7. Stop and stop 8. Stop, listen, watch 9. Stop, listen, watch - questions 10. Stop, rewind, study.

For more information on MBT techniques, see Bateman, E. W., P. Fonaga, Mentalization-Based Treatment for Borderline Personality Disorder (2006).

Another important aspect that I would like to touch on in this article is an example of a therapist using the MBT approach:

Throughout the session, the patient complained that no one understood his problems.

Therapist: So I suppose that since I don't understand anything, it will be difficult for you to come to me, especially if it means that I am not going to take your problems seriously (basic mentalization, linking the topic with the therapist / patient relationship and with subsequent alarm?)

Patient: (In a challenging tone) You cannot understand, because you have never experienced what I experienced. You weren't mistreated when you were a child, did you? I think I need to go to a group where the members had this experience. At least they can know how I feel.

Therapist: How do you know? (In a defiant tone)

Patient: How do I know?

Therapist: That I never experienced emotional abandonment as a child?

Patient: You are not.

Therapist: But why did you decide that?

Silence.

Therapist: You are very worried that when all these mental health professionals start making the assumption that you are fine and you don't need help. But when you yourself begin to make assumptions about me and base your attitude on these assumptions, it seems to you quite normal. I can be neglected as another person who is unable to understand you, because you decided that I have never experienced abandonment.

Patient: This is different.

Therapist: Why different?

Patient: Other.

Therapist: Really? Did you write a formal complaint about other people making assumptions about you and then acting on them? It looks like you are doing the same to me.

This section of the session used the Stop and Stand technique. The therapist restored some ability to reflect in the patient. His mostly preconscious assumptions about the therapist have now been brought into consciousness, 'laid out' on the table for discussion as something that might trigger feelings in him, inevitably followed by interruption of treatment and repetition of his past interactions with therapists and possibly writing new complaints. Further, the therapist revealed in the patient a fear that he would never be understood, and a feeling that the therapist would never be able to understand that he wants to be seen as a person with his desires and needs, in need of support, emotional care and help. The stop and stop technique is only effective for a long time if used with care.

There are many factors negatively affecting the implementation of the MBT model program in our country and other countries [4]. But the advantages of such treatment of patients with BPD are obvious, and this is evidenced by a number of studies (Fonagy, Bateman, 2006) [1].

The goal of mentalization-focused therapy is not to take the initiative to substitute for the patient, but to be close to him, helping him explore zones of uncertainty and generate meaning. The therapist must keep in mind the image of two people looking at a map to decide where to go, although they may have agreed on a destination, neither side knows the road and in reality there may be many ways to get there [1]. Obviously, this is a rather serious burden for the therapist, but with a well-planned psychotherapy process, there is an opportunity to help this most difficult and difficult group of patients.

The peculiarities of using MBT in the practical work of a psychologist consists in compulsory training in the techniques and skills of the MBT model, as well as in the presence of the necessary qualities for work, such as empathy, stress resistance, the ability to resolve conflict situations and work with aggressive clients, ethical values, etc.

Thus, MBT offers some hope for patients with BPD, as this approach is based on the support, empathy and training of interpersonal communication of patients. People with BPD need not only certain skills of self-regulation, coping with stress, but also an awareness of the causes of destructive behavior and the ability to adequately perceive interpersonal interactions. Mentalization-based treatment provides an understanding of the destructive behavior of individuals with BPD in terms of attachment theory, which will further facilitate the competent interaction of psychotherapists with patients with borderline personality disorder.

Literature

1. Bateman, E. W. Treatment of Borderline Personality Disorder Based on Mentalization / E. W. Bateman, P. Fonagy. - M.: "Institute of General Humanitarian Research", 2014. - 248 p.
2. About MBT
3. Introduction to Mentalization: [Electronic resource].
4. MBT Implementation and Quality Assurance: [Electronic resource].
5. Mentalization Based Therapy (MBT): [Electronic resource].
6. Mentalization based treatment for borderline personality disorder: [Electronic resource].
7. Mentalization: [Electronic resource].
8. Mentalization-Based Treatment: [Electronic resource].