(p. 147) Structure of mentalization-based treatment
The overall aim of MBT is to develop a therapeutic process in which the mind of the patient becomes the focus of treatment. The objective is for the patient to find out more about how he/she thinks and feels about him/herself and others, how that dictates his/her responses to others, and how “errors” in understanding him/herself and others may lead to actions in an attempt to retain mental stability and to attenuate incomprehensible feelings. The clinician has to ensure that the patient is constantly reminded of this goal, that the therapy process itself is not mysterious, and that the patient understands the underlying focus of treatment. This cannot be assumed even if the patient has undertaken the MBT-Introductory (MBT-I) course (see Chapter 11).
The mentalizing process can only be developed if the structure of treatment is carefully defined. The overarching structure in MBT consists of the assessment process followed by MBT-I, and then MBT-Individual plus MBT-Group (see Figure 5.1).
It is important to remember that the assessment process itself is an intrinsic part of the trajectory of treatment and not something dislocated from the whole treatment process. It forms part of the initial sessions and is a significant aspect of engaging the patient in treatment itself. Because of its importance, assessment is dealt with separately, in Chapter 4.
Trajectory of treatment
The trajectory of treatment has a number of main phases, with a beginning, a middle, and an end. The overall aim of the initial phase is assessment of the patient’s mentalizing capacities and personality function, contracting and engaging the patient in treatment, and identifying problems that might interfere with treatment. Specific processes include giving a diagnosis, providing psychoeducation, establishing a hierarchy of therapeutic aims, stabilizing social and behavioral problems, reviewing medication, defining a crisis pathway, and agreeing outcome monitoring (see Figure 5.2). (p. 148)
During the middle sessions, the aim of all the active therapeutic work is to stimulate a more robust mentalizing ability within the context of emotional arousal and attachment relationships. The more specific technical aspects of this phase of treatment are discussed in later chapters.
In the final stage, preparation is made for ending treatment. This requires the clinician to focus on the feelings of loss associated with ending treatment and how to maintain gains that have been made, as well as developing, in conjunction with the patient, an appropriate follow-up program tailored to his/her (p. 149) particular needs. The view often expounded by protagonists of particular models of therapy that patients with severe personality disorder improve adequately following 12–18 months of treatment to the extent that they require no further support is fanciful, and remains part of research mythology rather than realistic clinical practice.
Assessment of mentalizing
The assessment of patients’ mentalizing capacity is discussed in Chapter 4.
Giving the diagnosis and introducing the approach
Mental health professionals have expressed a great deal of anxiety about giving a patient a diagnosis of personality disorder. Fears are rightly expressed about pejorative overtones, judgmental attitudes, blaming the patient, attacking the very “soul” of the individual, and stigmatizing the patient for life.
One of our patients complained that even after treatment, when she no longer met criteria for a personality disorder, medical staff treated her with suspicion and uncertainty as soon as they saw her notes, despite her obvious ability to interact with services appropriately.
Despite these potential drawbacks, we firmly believe that it is both necessary and constructive to give the patient an appropriate diagnosis. But how does one give the diagnosis in such a way that it is beneficial and helpful? This is less of a problem with patients who show characteristics of non-comorbid borderline personality disorder (BPD), although even then it may be difficult. But it becomes more problematic if the patient meets criteria for borderline, narcissistic, paranoid, or antisocial personality disorder and also has a major psychiatric disorder such as depression. We cannot hide behind the failings of nosology, pass responsibility and blame on to inadequate diagnostic systems, or simply say that we do not believe in diagnosis. Even if we do not believe in categorical diagnostic systems, someone else in the mental health service is likely to have given the patient a diagnosis or simply to have told the patient that their needs cannot be met within the normal service “because they have a personality disorder which is untreatable.” Uncertainty and doubt about the value of diagnosis may be appropriate, but avoidance and lack of clarity are likely to induce the patient to distrust the competence of the practitioner, making the development of a therapeutic alliance more difficult.
Let us assume that you are taking a categorical approach to personality and have concluded that a patient has BPD. In our experience, the best approach is to be direct and explanatory, bearing in mind that you want to stimulate the (p. 150) patient’s capacity to reflect on him/herself and on your perspective about him/her. There are many ways to go about this and we do not presume to have the correct answer. You, the reader, may have a better way of explaining the diagnosis and, if so, you should keep to what you do. However, from the perspective of MBT, the primary purpose of giving the diagnosis is to stimulate the patient to consider all aspects of him/herself and to reflect on your thoughts about him/her, while you demonstrate your capacity to consider his/her problems.
When giving the diagnosis it is necessary to check out the patient’s understanding of what you are saying frequently. It is anti-mentalizing on the part of the clinician to make assumptions about how much or how little the patient knows. If you assume too much you will induce defensiveness, but if you assume too little you may well be challenged as patronizing. It is equally anti-mentalizing—that is, undermining to the patient’s mentalizing—to “make sure that the patient has understood what you are saying.” The point is not to “tell” the patient what you know and to demonstrate the extent of your knowledge, but to stimulate reflection. The mentalizing clinician finds out what the patient has understood about what the clinician is saying. In principle, you are trying to find out whether what you have in your mind about the patient actually corresponds to a state of mind that he/she recognizes. You are not trying to persuade the patient of your viewpoint.
Opening a “dialogue about diagnosis”
You may wish to begin with a clear statement of your diagnosis, but in general it is best to move toward the diagnosis sensitively, asking the patient about what sort of person he/she feels that he/she is. Some questions that can be used as part of this process are summarized in Box 5.1.
Eventually, the diagnosis should be broached:
Trying to put together everything that you have told me, I think that you have borderline personality disorder. Have you ever heard this term?
(p. 151) If the patient has some prior knowledge of the disorder, then ask what he/she understands about BPD from what he/she has learned about it previously. More specifically, try to access his/her underlying feelings about talking and thinking about him/herself as “having a diagnosis.” For some patients the process may stimulate anxiety; for others, it is a relief to be told that what has been happening to them over a period of years is well recognized by mental health professionals and part of a known psychological problem. Yet others may find it dehumanizing and demeaning. So, the clinician must ensure that his/her attitude is thoughtful and sensitive, and at times reassuring. In particular, the discussions should be illustrated by relevant examples from the patient’s story to exemplify what is actually meant. Equally, the judicious use of clinical examples from the clinician’s previous experience may alleviate tension by temporarily taking the focus away from the patient him/herself.
In our experience, once the diagnosis has been broached in a sensitive manner the subject becomes less of a philosophical conundrum and more of a stimulus to understand what the patient’s underlying problems actually are. This requires a dialogue about our understanding of the development of BPD, giving an explanation—and at this point a conflict arises for the mentalizing clinician. On the one hand, it goes against the spirit of mentalizing to promote our understanding of the disorder as a vulnerability to loss of mentalizing within the context of attachment relationships (because in doing so we are in danger of taking over the patient’s own understanding), but on the other hand, it is important that the patient understands the mentalizing focus of treatment and our reasons for taking this particular approach. It is therefore important for the clinician to present this as an understanding, rather than a “fact.”
Giving an explanation
Psychoeducation is perfectly in keeping with our model. Hence, an introductory program, which normally lasts 12 weeks but can sometimes be shorter, is part of the treatment pathway (see Chapter 11). In the assessment, the clinician starts off this process by explaining the possible causes of BPD, the psychological problems and difficulties in maintaining a mentalizing mind that are a consequence of BPD, the goals of treatment, and how group and individual therapy are used in MBT to stabilize mentalizing in the context of attachment relationships. Nevertheless, the primary method used to help a patient appreciate the process of therapy is not through “education” but by engaging him/her in the work itself during the initial sessions. The clinician listens carefully to the way in which the patient talks about him/herself and others, identifies features (p. 152) that suggest mentalizing strengths, highlights emotional competencies, and, when these positive aspects of mentalizing occur, uses them to explain the therapy process.
You sound like you really understood what happened then. Increasing your ability to do that even when you are upset, hurt, or having other feelings is the focus of treatment. In treatment we will come across a lot of experiences that you have, both here and outside, which we won’t understand. One of the main tasks of therapy is for us to explore those times so that we can make sense of what might have been going on in your mind at the time.
An attachment understanding of borderline personality disorder
Our understanding of BPD, outlined in Chapter 2, is discussed with the patient at the end of the assessment process. To this extent, the patient is prepared for the introductory group sessions, that is, MBT-I (see Chapter 11).
In discussing the origins of BPD there is a danger of oversimplifying the causes on the one hand, and on the other of becoming excessively complicated. Some patients feel patronized if clinicians give explanations that appear trite and might react by becoming angry. Others feel overwhelmed by the information, often becoming perplexed. It is therefore important that the clinician gauges the patient’s knowledge and capacity to focus on new concepts carefully before embarking on explanations. In our experience it is becoming increasingly common to find that higher-functioning patients have sought information on the Internet before coming for treatment, and so the clinician should first explore what the patient knows about the disorder—“Maybe you have already read something about BPD yourself?” It is essential that “giving the model” does not mimic a classroom in which the clinician, as a “teacher,” imparts information that needs to be “learned” by the patient. Some individuals will want to treat the exercise like a school lesson, but this commonly indicates that their mentalizing has been switched off and teleological functions are in the ascendant. Patients with BPD often feel cared about according to concrete outcomes, so imparting information in the manner of a teacher can be converted into a signal that to these patients indicates “real” care. For the most part it is best to allow the patient to consider each aspect of the developmental model in terms of his/her own life and to consider its relevance to him/her. Rather than giving a long and complicated explanation, the clinician should give simple and short accounts of each aspect of the model, preferably in terms of the patient’s own history and current problems. The explanation must be tailored to the individual him/herself to stimulate a reappraisal of the patient’s own understanding of his/her problems and, in the furtherance of mentalizing, each problem area should be linked to the treatment program.
(p. 153) clinician: It sounds like you and your Mum just did not see eye to eye and that you felt that she didn’t really understand things. But you didn’t give up trying to let her know that you were unhappy. Even when you were a teenager, it sounds like you wanted her to recognize that you were in trouble, for example, asking her to come to the school when you were expelled and to the hospital when you took an overdose. What is your understanding of why she didn’t seem to respond?
patient: She was just a horrible woman. [A nonmentalizing explanation, because it is a descriptor, an absolute, and lacks elaboration and reflection on mental content.]
clinician: I suspect that it might have been more complicated than that, and in the treatment we will help you explore that a bit more. One feature of treatment is that we ask patients to reconsider some of their personal explanations of events and especially how they understand things now. In the group therapy you will have a chance to hear other people’s understanding of your problems, which will help you reappraise your own understanding. One possibility is that you will begin to feel that people here don’t understand, and you must let us know if that is the case. We all bring our past experiences to present situations, and you have told me that you have never really trusted anyone so you may be constantly on the lookout to see if we understand. So, talk to your individual clinician about this and perhaps let the group know if you feel that they are misunderstanding what you are trying to tell them.
Historically, there have been two variants of MBT. The first studies of MBT were undertaken in the context of a day (partial) hospital program in which patients attended initially 5 days per week. The maximum length of time in this program was 18–24 months. For entrance to the day (partial) hospital program, patients were required to show a number of clinical and descriptive features, including high risk to self or others, repeated hospital admissions interfering with adaptations to everyday living, severe daily substance misuse, fragmented mentalizing, inadequate social support, and unstable housing. Patients who showed some capacity for everyday living and who had stable social support and adequate accommodation were more likely to be treated within an intensive outpatient program (see following paragraphs), particularly if their vulnerability to loss of mentalizing processes was confined mostly to close emotional relationships.
(p. 154) The day (partial) hospital program (Bateman, 2005; Bateman & Fonagy, 1999) is no longer offered in the United Kingdom, although some services in Europe continue to offer this more intensive treatment. All patients in the United Kingdom are treated in outpatient programs (MBT-OPD), of which the best researched is an 18-month intensive outpatient treatment consisting of a weekly individual session of 50 minutes and a weekly group session of 75 minutes (MBT-IOP) (Bateman & Fonagy, 2009).
There were a number of reasons for the change from the day hospital to the outpatient program. First, our research suggested that those patients whom we thought required more intensive treatment, for example, those with more than one personality disorder, who were at risk to themselves or others, and had serious drug misuse engrained in their daily function, did equally well in the outpatient program. Second, the clinicians found that managing this group of individuals as outpatients did not elevate their own anxiety to unacceptable levels. Finally, the lower level of interaction between patients and clinicians increased the pressure on the patients to maintain a higher level of self-efficacy. The outpatient program was also more cost-efficient.
Further programs aiming to help people with BPD have been developed over the past few years. In some of these, patients are offered less intensive treatment than MBT-IOP, for example, group MBT or individual MBT alone. On the other hand, a slightly higher-intensity treatment, MBT-HIOP, also now exists. MBT-HIOP is MBT-IOP plus an additional element if warranted, such as an expressive therapy. Currently, there are no data to support these variants of the original mentalizing approach, but many services for people with personality disorder attempt to allocate patients to treatment according to the severity of their symptoms. However, at present, there is no agreed measure of severity of personality disorder, so it is impossible to assign patients to one program or another according to a universally agreed severity score. This may change with the current proposal for the 11th revision of the International Classification of Diseases (ICD-11), which suggests that personality disorders be organized according to severity, ranging from mild to moderate to severe (Tyrer et al., 2011; Tyrer, Reed, & Crawford, 2015). So far, there is no clarity about how severity will be assessed by clinicians. Our data suggest that allocation of patients to programs of different intensity should be done according to levels of comorbidity for personality disorders as an indicator of severity, risk, and instability of social circumstances (Bateman & Fonagy, 2013).
What is important in all the programs is the interrelationship of the different aspects of the program, the working relationship between the different (p. 155) clinicians, the continuity of themes between the groups, and the consistency with which the treatment is applied over a period of time. Such nonspecific aspects probably form the key to effective treatment, and the specificity of the therapeutic activities remains to be determined.
It will come as no surprise to the reader that integration within the program is achieved through our focus on mentalizing. All of the constituent parts of the MBT program have an overall aim of increasing mentalizing and within a framework that encourages exploration of minds by minds, even if the route to this goal is via expressive techniques such as artwork and writing.
Intensive outpatient program
In MBT-IOP, patients are offered one individual session (50 minutes) and one group session (75 minutes) per week. This is not an “a la carte” but a “fixed” menu. We clarify at the outset of treatment that the two aspects of the program, that is, the group and individual sessions, are not divisible, and that frequent absence from one will lead to a discussion about continuation in treatment. It is not our policy to simply discharge a patient because of nonattendance. But it is our guiding principle that if someone does not attend one aspect of the program on a regular basis this has to be discussed with him/her in the next session he/she attends, whether it is the individual or group session. It is more common for patients to fail to attend the group than the individual session; nonattendance in the group thus requires the individual clinician to explore the patient’s underlying reasons for absence in the next individual session. Only when it appears to be impossible to help the patient to return to the group is the question of discharge from the program raised. It is not possible to suggest an exact point at which this should be considered for a nonattending patient, but in our clinical experience patients are told at the beginning of treatment that persistent and prolonged absence from the any aspect of the program will lead to discharge to our low-maintenance outpatient clinic for further consideration of treatment. Return to the program remains possible after this, but only following further work on the patient’s underlying anxieties.
This fairly rigorous stance about attendance is taken because many patients find the individual sessions more acceptable than the group sessions and attend the former and not the latter. On occasions, this has understandably stimulated patients and others to ask why we have group sessions at all. “The group is no good”; “I don’t get anything out of it” may become the refrain and eventually the individual clinician is challenged to explain the purpose of the groups. This question should not be avoided by the clinician but understood from a perspective of mentalizing, with some judicious further explanation about the importance of the group work. Of course, the reason for group therapy should have already been explained toward the end of the assessment.
(p. 156) Why group work?
Some patients are reluctant to participate in group therapy and their lack of enthusiasm surfaces as soon as group therapy becomes a reality. The patient may have apparently accepted the inevitability of group work in the assessment interviews but have done so only to access individual therapy. This must be addressed as soon as treatment starts. People with BPD have a reduced capacity to keep themselves in mind or to recognize that others have them in mind when listening to the problems of others, which accounts, to some degree, for their anxiety about groups and their oscillations between over- and under-involvement with others. As they become involved with someone else’s problems they lose themselves in their own mind and in the mind of the other and, when they do so, they begin to feel alone and “self-less,” which in turn leads to rapid distancing from the other person to save themselves.
The clinician needs to have a convincing reason for group therapy and a way of discussing it with the patient that does not become patronizing or frightening but is encouraging and explanatory. It is best if a team of clinicians providing MBT can develop their own understanding about the reason for group therapy within a mentalizing framework, so that a consistent explanation is given that is in keeping with the overall approach (see later in this chapter for some discussion of the mentalizing team).
Many clinicians explain group therapy by talking about the ability of people to function within groups in society and how group therapy can be used to practice this exceptionally complex skill, which requires a high level of mentalizing. In many ways, the capacity to function well within constantly changing social situations and within social groups is a peculiarly human attribute, and many people with BPD decompensate when “the going gets tough.” For these individuals, social interactions create anxiety, misunderstandings abound, and mental collapse is inevitable, often leading to “flight or fight.” So, to explain group therapy, we first discuss the conscious anxieties the patient has about groups and link them to the patient’s own experiences when mixing with friends or others in social situations. We try to understand the feelings the patient has about groups, for example, anxieties about having to share with others when feeling that they have always been deprived of attention, or being concerned that others will not be interested in their problems. But primarily we discuss the power of group therapy to stimulate the capacity of the patient to manage anxiety within highly charged circumstances while maintaining mentalizing. It is in the group that patients can truly practice balancing emotional states evoked in a complex situation and their ability to continue mentalizing. The group requires patients to hold themselves in mind while trying to understand the minds of a number of others at the same time.
(p. 157) Here is an explanation (condensed from a whole session) about the reason for group therapy given to a patient. We make no claims that it is a perfect explanation, but it does contain the essential components: suggesting that the purpose is to consider one’s own mind and the minds of others within a dynamic process.
Groups can be very difficult for all of us, but they remain the context in which we lead our lives. All of us meet with other people and have to function in relation to others, sometimes suppressing our feelings and ideas because we know that they may cause offence or lead to reactions that we don’t want. Negotiating all this is part of our everyday life. We also have to learn how to say things while remaining true to ourselves. The purpose of our groups is to work all this out and to learn that we can discuss things, even personal things about ourselves or our feelings toward others, without causing disturbing reactions in others and while feeling that we have expressed what we mean. We need to be able to say how much we feel for someone or how we value their support and friendship. Doing all this requires us to understand not only our own motives and needs but also the reactions of others to what we are saying. We also need to be able to think about others’ responses and to change our own way of thinking accordingly, otherwise we simply insist that others take on our views. One problem we all have is respecting different views. We try to focus on this process in the groups. We hope that if you have a problem discussing things in the group you will be able to talk to your individual clinician about it, which will help you feel stronger to talk about it in the group.
The initial formulation is made by the individual clinician after the first few sessions and after discussion with the treatment team. It is then given in written form to the patient for further consideration. The aims and important aspects of the formulation are outlined in Box 5.2.
If formulations are to be openly discussed, developed, and redeveloped, the team members must be able to work together with honesty and consideration of each other, and refrain from excessive competition within the group and rivalry between individuals. Each team member must develop the skill of discussing the formulation with patients without overstimulating their emotional states. For all patients, reading a frank account of how someone else thinks they may have become who they are evokes considerable turmoil, and its significance to the patient should not be underestimated.
A patient who read her formulation along with the complete medical notes was overwhelmed by the information. On reading the transfer letter from her former psychiatrist and psychotherapist she became upset because former feelings of rejection, which she had experienced when they had talked to her about referring her for specialist treatment, were reawakened. She felt abandoned and tricked by the transfer of care and that they had not told her the real reasons for referral, which were that they could not (p. 158) cope with her and were concerned about her level of risk. In short, she believed that the information in the letters suggested that they were frightened of her. There was some merit in this, but it was clearly not the complete story. Balancing her feelings of rejection was an appreciation that they had taken great care to document everything that had happened and put in a considerable amount of thought about her. Nevertheless, the experience of reading her medical notes followed by the formulation led her to feel overwhelmed, and she cut herself despite seeing a member of the team shortly after reading the notes to discuss her reactions.
In the formulation, the initial goals should be clearly stated and linked to the aspects of treatment that will enable the patient to attain them. There should be a brief summary of the joint understanding that has developed between the patient and clinician, with a focus on the underlying causes of the patient’s problems in terms of loss of mentalizing. The formulation (p. 159) should also include longer-term goals in terms of the patient’s social and interpersonal adjustment, which are likely to be important indicators of improved mentalizing. Finally, it is necessary to identify the attachment strategies of the patient (Choi-Kain, Fitzmaurice, Zanarini, Laverdiere, & Gunderson, 2009) and explicitly work jointly to establish them as important for treatment.
Example of a formulation
Ms. A is 22 years old and has difficulties relating constructively to others and persistent doubts about herself. She has tried to harm herself on a number of occasions and was referred following an overdose of her antidepressant medication that resulted in admission to the intensive care unit. She has not been able to work over the past year, but prior to this was working part-time as a secretary. She is the oldest of four children and experienced her mother as strict, rigid, and controlling. She was closer to her father, who often agreed with her that her mother was a “difficult woman.” She was sent away to school, in part because of uncontrollable behavior, where she was bullied and at the age of 8–11 regularly sexually abused by an older boy. She informed the school, who did not believe her, but never told her parents.
She now sees herself as being dependent on others’ approval. Without it she rapidly becomes insecure. This applies to many of the relationships she has had in the past, which have been characterized by seeking approval, to the extent of trying to do what the other person wants even if she herself does not want to do it. This has extended to her sexual relationships, in which she has been abused by two men whose wishes to inflict pain have been gratified by her passive compliance.
Despite these areas of developmental and interpersonal difficulty she managed to complete school and gain a number of higher examination passes. However, when she went to university she found that after a term she could not go back, much to her mother’s scorn. She obtained employment as a secretary but this broke down over a year ago, for reasons that are unclear. Ms. A just woke up one morning and felt that she could not go to work.
Engagement in therapy
Ms. A is likely to engage in therapy initially, partly because she recognizes that she has problems but also because she will be eager to please and to seek our approval.
It is possible that if she feels she is not getting adequate recognition or feels that others have not given her enough attention (e.g., not being given enough time in the group) she may suffer in silence initially but then stop coming. The group clinicians will try to be alert to this.
Her anxieties in relationships and tendency to engage with others within a passive role may make her vulnerable to exploitation by others. This includes other members of her group, and the individual clinician should be aware that this might become an important dynamic within the individual sessions.
Relationship difficulties (Individual plus Group)
Ms. A finds it difficult to make her wishes and desires clear to others and sometimes does not actually know what they are.
She tends to accept that her wishes are those of the other person and she cannot separate the two. Alternatively, in an attempt to establish her own wishes she withdraws.
(p. 160) She recognizes a tendency to devalue others, especially when she feels she has failed them in some way. This was explored in the assessment as being a way to manage feelings of rejection.
These solutions are unsatisfactory and she feels angry, misunderstood, and neglected, although her behavior becomes passive and accepting of the other person.
Other problem areas (Group)
Ms. A tries to listen so carefully to others that she tires easily. This may be more apparent in the group sessions when she tries to listen to everybody.
She feels that she has to do something useful for other people and to provide a solution to their problems, and this may be represented by her becoming the helper in the groups.
Her inability to show anger and anxieties in relation to others costs her a lot of energy and adds to her feeling of being tired and listless.
She recognizes that she becomes quiet and withdrawn when feeling excluded and that this has been a long-term characteristic. She tends to blame others for this, seeing them as “jerks,” “snobs,” etc.
Self-destructive behavior (Individual)
Alcohol and cannabis are used on an intermittent basis but on average 2–3 evenings per week. She tends to wake late after cannabis use or alcohol binges, and this might interfere with therapy and so will need to be a focus of early sessions of Individual Therapy
Self-laceration of wrists and thighs occurs on an almost daily basis. Ms. A recognizes that this occurs in relation to bewildering feelings with high levels of tension and often when she experiences difficult interactions with others—focus of early sessions of Individual Therapy. Consider any links with alcohol and cannabis use.
Ms. A tends to judge people based on what they do and makes assumptions without checking them out. She has not spoken to her current closest friend for 2 weeks because the friend failed to ring her at a prearranged time. She feels that it indicated that her friend did not care about her.
If people do not agree with her suggestions about what they should do to solve their problems she believes that they don’t like her.
Ms. A avoids disagreement and she acquiesces to other people’s opinions. She withdraws when difference arises and avoids any conflict.
In the assessment she was aware that she actively avoided certain areas—she often reacted to things by saying “Maybe” or “So whatever,” and when this was pointed out she agreed that it usually meant that she did not want to talk about something.
Ms. A has spent a lot of time thinking about her problems and feels ashamed that she was unable to go back to university after the first term and that she was no longer able to work. She recognizes that this shame is in keeping with her mother’s opinion of her as a failure, and this causes her tremendous distress.
She is able to understand what is in the mind of others a lot of the time, but when she becomes anxious she finds that she loses her clarity of mind and becomes uncertain. Her only way of managing this is to withdraw. She is also aware that she is oversensitive to the opinions of others but doesn’t know what to do about it.
(p. 161) She wants to be able to develop relationships in which she feels there is a mutual sharing. She has found that when she has been able to explain her underlying feelings this has made a difference to her relationships. Although she has not spoken to her closest friend since her failure to phone at the agreed time, she realizes that she is being unforgiving and has left her friend a message.
The written formulation is given to the patient for discussion during the individual session on the basis that the clinician’s understanding of the patient is a jointly developed hypothesis about the patient’s problems and that this understanding can be influenced by the patient him/herself, leading to a reformulation as additional evidence accumulates. If the patient disagrees with aspects of the formulation it is incumbent on the clinician to consider the reasons for the underlying disagreement and to modify his/her own opinion accordingly, if appropriate, and to demonstrate that he/she has done so. A briefer formulation than the example given here is preferable for many patients. Indeed, the example here could be summarized before it is given to the patient and even given an “executive summary” as an aide-memoire for both clinician and patient (see Box 5.3).
Review and reformulation
All patients in MBT programs have a review with the whole treatment team every 3 months. The group clinician, the individual clinician, the psychiatrist, and other relevant mental health professionals meet with the patient to discuss progress, problems, and other aspects of treatment. Practitioners meeting together jointly with the patient does not just ensure that everyone’s views are (p. 162) taken into account and integrated into a coherent set of ideas; it also ensures that mentalizing, as manifested through the discussion of the different viewpoints that may be expressed in the meeting, is modeled as a constructive activity that furthers understanding. These regular reviews lead to a reformulation, which can then form the basis of ongoing treatment. If required, they can also become more than a review about progress or lack of it and be used to address significant impairments to treatment.
Review of medication
As part of good medical practice, all patients should have their medication reviewed on a regular basis. This review can take place in the “review and reformulation” meeting. Many patients are now referred after prolonged treatment with medications, and over 50% are taking various combinations of antipsychotics, antidepressants, mood stabilizers, anxiolytics, and hypnotics (Zanarini, 2004). Medication is reviewed at the beginning of treatment by the team psychiatrist, but rarely is the prescription changed immediately unless it is obviously dangerous or inappropriate. Medication is reviewed regularly and altered only by agreement when the team and the psychiatrist know the patient better. As a general protocol we follow the guidance on use of medication in BPD outlined in the UK National Institute for Health and Clinical Excellence guidance for the treatment of BPD (2009) and provide the patient with information about the recommendations made in this guidance.
Developing a crisis plan with a patient is possibly one of the most effective general therapeutic strategies for people with BPD, although a recent study has thrown this clinical opinion into doubt (Borschmann, Henderson, Hogg, Phillips, & Moran, 2012). Nevertheless, all patients with BPD will experience crises during treatment, and so it is necessary for the clinician and patient to outline what to do in the event of a crisis. Here we will discuss only the practical aspects of developing a plan. From a mentalizing perspective, it is not appropriate to “give” the patient a plan but more fitting to stimulate identification of a pathway that will help the patient to access help when he/she needs it, in the hope that this will prevent serious self-destructive acts. The format described here is used both in MBT and in structured clinical management for people with BPD (Bateman & Krawitz, 2013). At its core is a responsibility shared between the patient and clinician to manage crises.
(p. 163) What signals does the patient have that a crisis is emerging?
Ask the patient to describe at least three examples of crises that have led to self-destructive behavior and/or contact with services. Taking each in turn, spend time attempting to work out early warning signs:
◆ Was there a particular feeling?
◆ Was there a behavioral change?
◆ Were thought patterns different?
Even if a patient cannot answer these questions, the task of attending to what was happening is in itself therapeutic. Empathize with the patient who does not know what happens and finds that his/her feelings go “from zero to a hundred” in milliseconds—“It just happens and there is nothing that I can do.” Even if this is the case, the clinician needs to work with the patient to find some early warning signs, as this aspect of the crisis plan is one of the basic strategies for focusing mentalizing on the precursors of self-harm.
Patients are asked to rate their crises on an “escalator,” with 0 at the bottom of the escalator = in control; 1 and 2 = defined by patient and clinician; and 3 at the top of the escalator = crisis point or out of control. The clinician uses clarification techniques, frequently coaxing the patient to rewind their mental processes to points before their loss of control, thereby helping them to identify triggers and the effect they have on their internal states. In other words, the patient is asked to work methodically on answering the question “What makes me vulnerable?” Jointly, the points on the escalator are defined in increasing detail.
What can the patient do and not do?
The patient identifies when they could have re-established self-control and what could prevent them from moving on to the next stage toward a crisis. How do you stop the escalator? How do you get off or walk back down against the direction of movement? Strategies that have been helpful in managing emotional crises in the past are identified, for example, leaving a provocative situation, telephoning someone if trapped in a feeling of loneliness, or distracting the mind by engaging in an action task such as cooking. The clinician also tries to stimulate the patient to reflect on how others might observe each stage (i.e., signals for others) and what others could or should not do that might be helpful (see next section). Significant others are invited to sessions to work out this part of the crisis plan jointly.
What can other people do and not do?
How do others know that a crisis is emerging? What might they do to help? Taking in turn the examples of crises that the patient has provided, the clinician asks (p. 164) him/her to consider what practical and emotional responses of others would have been helpful and to identify those that are unhelpful. Someone else being aware of what not to do might have more traction in a crisis than attempting actively to do something useful. For example, partners may be advised to avoid confrontation, side-step disagreement, and to minimize defensiveness when the patient with BPD is emotional and anxious. This is not the same as simply asking others to accept unwarranted personal attacks. Partners need to choose the time for discussion; an emerging crisis in people with BPD is not one of them. After the patient has carefully defined what his/her partner or others can do when he/she feels vulnerable and in danger of reaching the top of the escalator, discuss how he/she can pass on this information to them.
What can services do and not do?
In general terms, it is important to minimize the usefulness and effectiveness of services in a crisis. Certainly, medical emergency health services are not well organized to manage patients with BPD, and personnel are poorly trained to understand the severity of the condition. Sadly, the same can be said for many mental health emergency services, and the patient is well advised to keep away from poor-quality mental health emergency services if at all possible. Again, the crisis plan may not so much be about what the services can do, but what they should try not to do. For example, crisis presentation is a time when clinicians commonly change medication, when it is, in fact, the least sensible time to alter a prescription. A statement in the crisis plan such as “Even if I demand it, please be careful about changing my medication in a crisis. I can consider this later when I am calmer” will help professionals act responsibly rather than out of their own ill-considered panic and need to do something.
The crisis plan is a work in progress, and each time certain points become clearer they are added to the plan. The clinician is required to revisit the crisis plan whenever a crisis occurs. When agreed actions or psychological techniques fail to stop movement “up the escalator,” they are re-evaluated. In this way the clinician continuously maintains the patient’s own responsibility for dealing with painful and possibly overwhelming emotions while at the same time strengthening his/her ability to do so, with clinician support.
Having identified possible self-help interventions and the role of the MBT treatment team during office hours, the feasibility of implementation of the plan 24 hours, 7 days a week needs to be considered. Many crises will occur in the evenings, at night, or at weekends, when only emergency services are available. The clinician outlines the emergency system that is available to the patient, emphasizing that emergency teams will have access to the crisis plan and will attempt to help the patient manage an acute situation until he/she is able to (p. 165) discuss the problem with the MBT treatment team on the next working day. The patient and the team may organize an emergency appointment the following working day, which lasts no more than 20 minutes and is focused entirely on the crisis, how to stabilize the situation if it recurs, and reinstating psychological and behavioral safety for the patient and others. Further work on the crisis should be done within the group and individual sessions.
The lack of availability of MBT clinicians outside office hours requires the person with BPD to develop his/her own strategies in advance and implement them without the immediate involvement of an “expert” in the emotional turmoil. Having an agreement within the treatment contract of an emergency session the next day with a member of the team if the crisis has been contained without serious consequence helps to bolster the patient’s resolve, maintains responsibility with the patient, and gradually increases the patient’s confidence to manage increasingly complex situations. Each crisis is discussed in detail at the emergency meeting that follows and, if necessary, the crisis plan is reworked.
Clarification of some basic “rules” and giving guidance
We follow the common “principles of engagement” that are applied when treating patients in any health service. We have a commitment to implement the treatment program professionally and with interpersonal respect, just as patients have an obligation to attend to their difficulties within the boundary of the treatment outline. There are particular “principles” we follow about violence and the use of drugs and alcohol, and we offer guidelines about sexual relationships between patients—that is, that they interfere with the treatment of both people involved. These principles are discussed in more detail in our description of the program in our original book on MBT and BPD (Bateman & Fonagy, 2004). The question here is how the clinician explains the “principles” to the patient.
It is wise to be straightforward about general “principles” and guidelines of treatment, to have a leaflet or information sheet about them, and to make them as clear as possible so that both patient and clinician understand them fully. It is inadequate simply to state “rules” or to give guidance without giving reasons. A discussion about why the principles are necessary must take place and be explored with the patient. Some patients will accept the principles without question, but others will apparently agree with them while privately ignoring them or at least feeling that “the rules don’t apply to them.” Still others, perhaps more commonly those with antisocial personality disorder, will actively challenge “rules,” seeing them as authoritarian, unenforceable, and excessively restrictive. Whatever the patient’s reaction, the clinician must discuss the (p. 166) underlying reasons for the principles and explore the patient’s response. So, what are the underlying reasons?
First, there is a general point that anything that reduces mentalizing is antithetical to the treatment program. Drugs and alcohol alter mental states and interfere with the exploration of mental states, and as such, negate the overall aim of treatment. Sexual relationships involve the “pairing” of minds, which will alienate others within the group. Violence controls minds through fear, closing them down rather than opening them up. So, we suggest to the patient that anything that is likely to reduce their interest in the whole group, alienate them from the group, prevent them reflecting on themselves, or close down the minds of others is not recommended. Second, we explain that there is some overlap between the areas of the brain responsible for mentalizing and those that are affected by drugs and alcohol and even sexual relationships. This surprises many patients. We have found that the best way to explain this is to point out that when anyone is excited, in love, or smoking cannabis there is often no space in their mind for other people. The person in love does not reflect but becomes preoccupied with their loved one, the person “high” on cannabis becomes self-centered and may even be, in an altered state of consciousness, unaware of others around, and the person who is violent or threatening has his/her mind taken over altogether and attempts to close down the minds of others. Our view about the overlap between the neurobiological systems responsible for addiction and those driving attachment relationships is discussed in more detail elsewhere (Bateman & Fonagy, 2006; Insel, 2003).
Finally, we also know from empirical data that BPD symptoms can improve over time, but this natural progression can be influenced by factors such as substance misuse, which prevents patients taking advantage of positive social and interpersonal circumstances and decreases the likelihood of a natural remission (Zanarini, Frankenburg, Reich, & Fitzmaurice, 2012). The patient should be made aware of this.
Principles apply to a whole group, protect the integrity of an overall treatment program, and define boundaries of professional involvement. Contracts tend to be individualized and specific, often targeting particular areas likely to cause problems in treatment. We are not great proponents of draconian contracts likely to lead to discharge when their conditions are not fulfilled. Fluctuating mentalizing capacity means that a patient who agrees to a contract at one point may not actually have the same competence in a different context, or have access later on to the state of mind he/she was in when he/she agreed the contract. It is important to remember that effective mentalizing requires a patient to understand his/her (p. 167) state of mind at any given time, to be able to project him/herself into the future and recognize his/her likely emotional state at that time, to reflect on his/her state of mind in the past, and to consider his/her possible state of mind in many different contexts. Agreeing a contract relevant to future time requires all these capacities. Patients whose BPD is severe do not retain these abilities over time, and so can do only one of two things when faced with a contract—they can either agree the contract without hesitation, attributing little meaning to it and giving it only cursory importance, or challenge it as being a further way to test them that is likely to lead to humiliating failure. The hesitant patient who is wary of agreeing a contract because he/she realizes that he/she may not be able to fulfill his/her obligations may well have a higher capacity to mentalize than someone who simply signs the contract straight away. Doubt at entry to treatment may be a good prognostic feature rather than an indication of a lack of motivation. It is important for the clinician to engage with this uncertainty and ensure that the contract does not induce a sense of failure in the patient if it is broken.
There are a number of dangers associated with issuing contracts. Too often they become punitive and unachievable, and place the clinician in a “therapeutic corner” where there is limited flexibility. Clinicians often introduce contracts to put pressure on an individual to control behaviors that interfere with treatment. We have some sympathy with this view, but have found that in patients with severe personality disorder this use of contracts is of limited effectiveness—particularly in improving attendance and reducing self-harm and suicide attempts, which are the most common reasons given for issuing contracts. Under these circumstances the patient is being asked to control the very behavior for which he/she is seeking treatment, and he/she is likely to fail. Disorganized behavior outside treatment is mirrored within treatment, so discharge of patients who fail to attend consecutive sessions due to chaotic lifestyles, and preventing an early return to treatment, will simply perpetuate their poor engagement in services. Some patients, particularly those with antisocial and narcissistic features, may even be triumphant about defeating contractual strictures and relish their “untreatability” as they challenge treatment boundaries. Finally, contracts with negative consequences are unenforceable within statutory health services, although, of course, it is important not to keep offering a treatment that is manifestly failing. Under these circumstances it is necessary to suggest alternative help.
MBT now incorporates routine outcome monitoring of treatment, and this has become an integral part of the model. Evidence suggests that individual clinicians can have a substantial impact on patient outcomes independent of the (p. 168) treatment method, and this may be of particular importance in routine clinical practice. In any psychotherapy treatment, around 5–10% of patients will have a negative outcome; between-clinician differences may account for this (Hansen, Lambert, & Forman, 2002). In one study of psychotherapy (Luborsky, McLellan, Woody, O’Brien, & Auerbach, 1985), the outcome effect size across clinicians for patients with drug addiction (many of whom were likely to have had personality disorder) ranged between 0.13 and 0.79. In the US National Institute of Mental Health trial of treatment for depression, no differences were found between treatments when differences between clinicians were accounted for (Elkin, Falconnier, Martinovich, & Mahoney, 2006). Furthermore, some clinicians are able to retain patients in treatment more effectively than others, suggesting the existence of distinct differences in clinicians’ ability to repair therapeutic ruptures.
A classic analysis by Luborsky, Chandler, Auerbach, Cohen, and Bachrach (1971) identified a number of clinician characteristics that influenced the prognosis of therapy across 161 studies of different groups of patients. These included (1) experience, (2) attitude and interest patterns, (3) empathy, and (4) similarity between the clinician and patient. These parameters have stood the test of time (Ackerman & Hilsenroth, 2003), and there is no reason to believe that they are any less important in the treatment of patients with BPD. Indeed, there are indications that clinician effects may be of particular importance in the treatment of people with BPD, who may be especially sensitive to therapeutic interventions and, when treated by less skilled clinicians, may be left worse off at the end of treatment than when they began (Fonagy & Bateman, 2006). However, such descriptions of clinicians are of little value in the context of quality improvement initiatives in clinical services as they fail to offer tangible goals—either to clinicians and managers, or to patients—that are likely to improve services. Clearly, individual clinicians who are more likely to have negative outcomes need support and practical assistance to enhance their outcomes, rather than to be stigmatized.
Fortunately, in the area of generic psychotherapeutic work, a method based on intensive outcome monitoring of ongoing treatments has been developed and applied, which apparently serves to create an “early warning” of negative outcomes and provide a means of supporting modifications of ongoing interventions (Okiishi, Lambert, Nielsen, & Ogles, 2003; Okiishi et al., 2006). Randomized controlled trials have demonstrated the value of such an approach in reducing negative outcomes by over 50% and leading to improvements in patient satisfaction and treatment alliance (Shimokawa, Lambert, & Smart, 2010). It is possible that a combination of improved therapeutic alliance and moderation of the wish to disengage from therapy accounts for the (p. 169) improvements observed. This patient-focused research aims to evaluate patients’ response to treatment throughout the course of therapy. Feedback is provided to clinicians on patients’ progress. This allows clinicians to make treatment decisions based on patients’ distress rather than simply trusting in the treatment itself. Providing feedback to clinicians on a regular basis has been shown to improve patient retention in treatment and to improve outcomes if clinical support is given to clinicians whose patient(s) are deviating from the expected course (Okiishi et al., 2006). Clinicians need feedback to be able to identify which patients are not on track. Research shows that they are notoriously poor at predicting which of their patients will do badly. Hannan and colleagues (2005) interviewed 40 clinicians and asked them early in treatment to predict which of their 550 patients would deteriorate. They identified only 1 of the 40 patients who eventually deteriorated. In addition, they were even poor at recognizing that a patient was currently showing deterioration and consistently rated them as doing better when they were not.
There is no reason why such benefits of clinician feedback should not accrue in the treatment of BPD, although previous work on outcome monitoring has focused on short- rather than medium- or long-term psychotherapy, and has avoided patient groups with a primary diagnosis of personality disorder. Identifying the trajectory of patient change during treatment and the impact of clinician feedback and provision of clinical support when a patient is deviating from the expected course of change has not been investigated with patients with BPD. If clinicians could monitor the trajectory of patient progress and have rapid access to information suggesting that change is not taking place at the expected rate, clinical services offering complex psychotherapeutic treatments for BPD may also be improved. The variability of outcomes observed in the treatment of BPD suggests that clinician effects may be particularly important for this group. In a trial of dialectical behavior therapy for BPD (Feigenbaum et al., 2012), all of the patients of one clinician dropped out despite significant attempts by the team to retain them in treatment. Gunderson and colleagues (1997) found that ratings of the patient–clinician alliance by clinicians treating patients with BPD was predictive of subsequent dropout. Lingiardi, Filippucci, and Baiocco (2005) also showed that early evaluations of the therapeutic alliance are good predictors of dropout in patients with personality disorders and that clinicians evaluate their alliances with patients with BPD significantly more negatively than their alliances with patients with other personality disorders. A trial of MBT (Bateman & Fonagy, 2009), using general linear modeling to map the progress of individual patients over time, also suggested that there was a statistically significant variability in the rate of clinical improvement, some of which could be accounted for by clinician identity. The longer length of treatment provided for (p. 170) patients with BPD makes research into these sources of variance mandatory. Treatment lengths of 12–18 months make it imperative to identify such patients early in treatment, even if only on the basis of personal cost for the patient and clinician, let alone the financial cost to services, to see if problems can be addressed at an early stage.
In conclusion, variability in outcomes is a significant factor in service provision. Using actual treatment outcomes based on the effects of individual clinicians to improve patient outcome would dramatically influence the delivery of effective care and give an opportunity to manage and improve outcomes in specific clinics. So, all patients engaged in MBT are now asked to complete brief weekly monitoring questionnaires, and they and their clinicians have full access to the scores over time. The patient has to be inducted into this process at the beginning of treatment so that it becomes an area of interest for both patient and clinician. In effect, both “mentalize” about the change, good or bad, in the scores. Improvement is of equal interest to deterioration—what might be the explanation for this change, how has the change come about, is there something happening in therapy that is useful or harmful? Current measures in use include symptoms, quality of life, social adjustment, interpersonal function, service use, suicidality and self-harm, reflective function, and therapeutic alliance (scored independently by the patient and the clinician). In addition, a goals-based outcome measure is completed every 3 months to ensure that the formulation and goals are revisited methodically and the treatment focuses on areas of importance to the patient.
It is in the middle phase that the hard work for the patient takes place. For the clinician, this phase may appear easier because by the time the initial phase has been negotiated many of the crises will have subsided, the patient’s level of engagement in treatment will be clear, the patient’s motivation may have increased, and his/her capacity to work within individual and group therapy may be more apparent. This allows an increasing focus on process rather than management. In addition, the clinician may have a better understanding of the patient’s overall difficulties and so have a more robust image of him/her in mind, while the patient will have also become aware of the clinician’s foibles and way of working.
While this somewhat rosy picture may be the case for some patients and clinicians, for others the treatment trajectory may continue to be disrupted. A primary task of clinicians is to repair ruptures in the therapeutic alliance and to sustain their own and patients’ motivation while maintaining a focus on (p. 171) mentalizing. The mentalizing techniques associated with the middle phase form the core of this book. Here we will mention the need to develop and to sustain good team morale for the MBT treatment team by building in supervision and paying heed to feelings engendered in the clinicians.
The mentalizing team
This section borrows heavily on the summary of team work included in the manual of structured clinical management for BPD (Bateman & Krawitz, 2013) and on the team working recommended in adolescent mentalization-based integrative treatment (AMBIT—see http://www.annafreud.org/services-schools/services-for-professionals/ambit/).
The characteristics of a mentalizing team are summarized in Box 5.4.
A commonality of purpose in a team and coherent responses to a wide variety of clinical situations can come about if a team functions with one mind while its members retain their own individuality. To do this, a team needs to follow some basic principles. First, respect for each other has to be apparent and worked on rather than assumed. Second, the team needs constantly to define and redefine its aims with each patient; these aims have to be consistent with the overall aims of the treatment process. Third, the team must emphasize communication between its members. All members hold equal responsibility for ensuring that information, ideas, and plans are shared appropriately. Finally, leadership and support structures need to be agreed upon. All members have to be committed to working within these structures—mavericks are welcome but loose cannons will destroy a team, and it may never recover. The identified team leader does not have to be the permanent leader of team discussions. Well-functioning teams show flexible processes rather than strict hierarchical structures, and the leader of (p. 172) a discussion may be someone identified at the beginning of a team meeting or, for example, be chosen on a rotational basis.
Respect means that each team member gives appropriate regard to other team members’ feelings, opinions, and experience. All clinicians are aware that people with BPD can evoke contradictory feelings, and this inevitably becomes apparent between team members. One team member may be enraged with a patient while another feels highly protective; patients may engage one member of the team by outlining—perhaps exaggerating—the shortcomings of another clinician in the team. For the unwary, this can have a seductive quality, as criticism of a “rival” promises the potential of clinical “riches” in becoming special to a patient. Sometimes the criticisms of a colleague reported in a clinical session by a patient are highly accurate and may even hit sensitive differences between members of the team. Of course, this cuts both ways, and the same patient may be reversing the criticisms when seeing another team member. An explicit and collective refusal by team members to be drawn into these subtly subversive conversations improves the chances of effective team functioning. Integrating the views of the patient and the reciprocal reactions of the clinicians to the patient’s perspective is a key function of the team. Valuing another view, however different from your own, maintains the respect required to facilitate an integrated view of a patient’s psychological function.
Maintaining good team morale is essential to prevent “burnout” and to minimize inappropriate emotional responses to patients and other clinicians. It is remarkable how apparent the underlying atmosphere can be in a treatment facility, even if entering it for only a short time. The atmosphere of a unit is likely to be instrumental in the effectiveness of interventions and the outcome for patients. Bearing in mind that MBT treatment programs involve multiple clinicians providing individual and group psychotherapy and crisis support, it is easy to see that problems can arise between clinicians and that, if unresolved, they are likely to interfere with the implementation of treatment.
Team morale refers to the overall sense of safety and the prevailing attitude in the team. Positive, hopeful, and enthusiastic attitudes in the team are likely to instill similar feelings in patients and stimulate involvement in a therapeutic process. Negative, anxious, and hopeless attitudes will fuel despair and mirror many of the inner feelings of patients, who may begin to feel that what is inside is now outside; their psychic equivalence is confirmed.
(p. 173) Team morale is maintained by ensuring that the focus of treatment for the patient—namely mentalizing—also becomes the heart of the interaction between clinicians. The clinicians have to be able to practice what they preach and stick to a mentalizing stance when discussing their own viewpoints with each other. Splitting is more frequently described in the treatment of patients with BPD than most other psychiatric disorders, but it is less often recognized as a problem of the team rather than the patient. Clinicians who disagree have to work together toward integration and synthesis. But the interaction of the clinicians cannot be left to chance, and so case discussion between clinicians is built into the timetable to maintain morale and to ensure that clinicians adhere to the mentalizing model.
In the day (partial) hospital program that is now practiced in the Netherlands, brief team meetings are arranged on a daily basis to discuss clinical issues as they arise within the groups and individual sessions. The leaders of the discussion about the groups are, of course, the group clinicians; responsibility for integration of the team perspective in the overall treatment of each patient lies with the individual clinician.
In MBT-IOP, the individual and group clinician must meet, or at least talk, between sessions so that prior to each session, whether an individual or a group session, the clinician knows what has happened in the other treatment session. These discussions take place in a meeting held shortly after each group or individual session in which the clinician reports the session. Differences in opinion should be aired and resolved if possible, and each clinician should try to understand the perspective of his/her co-clinician. Inevitably, some differences arise, and these are discussed in a larger consultation/supervision meeting, which occurs weekly. It is here that views are discussed and integrated and strategies are agreed for use in the group and individual sessions. This ensures that clinicians keep to the mentalizing model, because in our experience it is easy to be diverted from the model and for clinicians to revert to their base technique, whether dynamic or cognitive in orientation.
Successful planning needs organizational support for team meetings and an explicit statement to all team members about the emphasis in practice on taking into account different clinical perspectives. The team members organize themselves around the problems of the patient and begin a process of integrating different ideas and clinical suggestions. Often this can be done with the patient, who, detached from the emotional intensity of team interactions, may be able to benefit from observing others discuss alternative ideas about help, which gradually coalesce into a practical and meaningful plan to which everyone can commit.
(p. 174) One patient informed a member of the team that she brought a knife to sessions as she felt unsafe on the streets and felt more secure in therapy sessions with the knife in her bag. The clinician was concerned—not only because carrying an offensive weapon is illegal but also for her own safety in the session. It was a concern to the team for exactly the same reasons, and team members expressed worries that the clinician would not be able to focus on the patient’s treatment while she was so concerned that the patient was carrying a knife. The team was uncertain what to do, so they organized a meeting of the whole team with the patient to discuss the matter. An array of opinions were expressed, ranging from discharging the patient unless she promised not to carry knives to sessions to more protective comments about the patient’s anxieties. The process of discussion enabled the patient to realize that the states of mind she was evoking in the team were untenable for continuing treatment, and she agreed never to bring weapons to sessions. The process of discussion allowed all participants to believe that her statement was an accurate reflection of change rather than a mere glib and superficial statement with no basis in future reality.
Many teams follow an agreed protocol in clinical meetings (see Box 5.5), and we outline here some suggestions for this protocol based on work with young people with emerging personality disorder. First, it is important that the clinicians who want to discuss a clinical problem make this known at the beginning of the meeting. It is surprising how often people bring up some complex clinical problem just before a meeting finishes! Second, the clinician who wants to discuss a problem identifies or “marks” the task. Third, the clinician states his/her case. Fourth, there is a general discussion, which enables all team members involved in the treatment of the patient to offer their perspective. Team members who are not involved “mentalize the discussion” by ensuring that all views are respected and that the emotional support the clinician needs is addressed. Finally, the team “returns to task” to answer the initial questions posed by the clinician.
(p. 175) Identifying and marking the task
Once team members have expressed a wish to discuss a clinical problem and the order of discussion has been agreed, the team must help the clinician to explicitly identify the problem and what he/she wants out of the discussion. Too often, clinicians and teams revert to story-telling. While this has merits, particularly in helping clinicians ventilate their feelings and feel validated, it is unlikely to lead to practical and effective ongoing treatment planning. This is why marking the task is necessary. This is the responsibility of the presenting clinician. In the earlier example, the clinician identified her concerns about the patient carrying a knife and marked the task as being how to manage this practically and how she processed her fearfulness in the session. Additional examples of marking a task are:
I would like to discuss the level of risk of this patient and decide on how to address it.
I would value discussing how to increase this patient’s level of motivation for treatment and what I can do—or even do less of—to improve his attendance.
I am anxious before seeing this patient. During the session I am very careful about what I say. I feel reticent about challenging her and I would like to think more about that.
Stating the case
The clinician then briefly presents the clinical problem without interruption. The veto on interruption is important because too many diversions from the task will prevent effective presentation of the problem as the clinician experiences it. Equally, the clinician has to ensure that the presentation of the problem does not drift into story-telling but focuses on the identified task.
Discussing and mentalizing the process
Once the clinician has completed his/her presentation, the meeting is open to the team for comments and perspectives. Importantly, any team member who is not involved in the care of the patient acts as the guardian of the mentalizing process of the discussion, listening carefully for “absolutes” and extreme views (e.g., “She is just . . .,” “Clearly he is . . .”) and quickly identifying them explicitly. Teams can easily and yet imperceptibly fall into a group process that demonizes patients with BPD, seeing the problem as the fault of the patient when in fact it is a problem within the team or the treatment plan. Organizing a team discussion so that dispassionate members of the team act as “sentinels” of the process is necessary to prevent this.
Return to task
The chair of the meeting takes charge of returning the team to task. Often this is best done by summarizing much of the discussion and linking it to the problem identified initially. An effort is required at this point to define clear practical (p. 176) actions. It is helpful to remember the START criteria around any planned task. The five aspects of START are Space (where?), Time (when?), Authority (who has authority?), Responsibility (who has responsibility?), and Task (what actions need to be done?).
It is now known that people with BPD naturally improve over time, and that they do so to a greater extent than was formerly believed (Zanarini, Frankenburg, Hennen, Reich, & Silk, 2005; Zanarini, Frankenburg, Hennen, & Silk, 2003). However, the improvement is primarily in impulsive behavior and symptoms of affective instability. While this seems to be good news on the surface, the same data also suggest that interpersonal and social/vocational functioning remains impaired. Complex interpersonal interaction, intricate negotiation of difficult social situations, vocational functioning, and interaction with systems may improve less even with treatment. The patient with BPD who no longer self-harms may still lead a life severely curtailed by his/her inability to form constructive relationships with others. Patients remain incapacitated in how they live their lives unless they develop constructive ways of interacting with others. The focus of the final phase of MBT is on the interpersonal and social aspects of functioning, provided the symptomatic and behavioral problems are well controlled, and on integrating and consolidating earlier work. The goals of the final phase are summarized in Box 5.6.
The final phase starts at the 12-month point when the patient still has a further 6 months of treatment. In keeping with the principles of dynamic therapy, we consider the ending of treatment and associated separation responses to be highly significant in consolidation of gains made during therapy. Inadequate (p. 177) negotiation by the clinician of the experience of leaving and/or inadequate processing of the ending on the part of the patient may provoke in the patient a re-emergence of earlier ways of managing feelings and a concomitant decrease in mentalizing capacities. The consequence is a reduction in social and interpersonal function.
It is important that the clinician maintains an awareness of time throughout the trajectory of treatment. The unconscious is timeless, making it easy for both patient and clinician to “forget” about time when working closely together. It may fall to another member of the team to point out to the clinician that time is passing faster than anticipated and that it is time to raise the issue of ending.
When a clinician mentioned to a patient that he had been in treatment for a year and that there were 6 months left, the patient fell silent and eventually responded by saying that he might as well leave now—“I can’t see my feelings changing during that time and so I might as well get it over and done with. What is the point of the next 6 months if finishing is going to be hanging over my head?” The clinician recognized this as a collapse in mentalizing in the face of anxiety, demonstrated by the difficulty the patient had in seeing himself as different in the future. “It is a bit of a shock, isn’t it, but I am intrigued that you can’t see yourself or your feelings about our relationship as being any different at that time.” The clinician then explored the patient’s immediate shock about having only a further 6 months in treatment and the fears associated with the loss of the clinician and treatment support.
Entrenchment of negative reactions can be avoided by allowing the patient to take the lead in leaving—setting the date, putting forward his/her own plans for what he/she is to do after discharge, negotiating contingency plans—with the clinician judiciously supporting him/her in reasonable endeavors such as returning to education, obtaining part-time employment, or doing voluntary work.
Responsibility for developing a coherent follow-up program and for negotiating further treatment is given to and shared by the patient and individual clinician. No specific follow-up program is routinely offered in MBT. Most patients ask for further follow-up, which may be a measure of the success of treatment but, equally, can be a way for some patients to avoid finishing treatment and an indicator of our failure to adequately address the anxieties associated with ending. Some patients may have had a “career” over many years of interacting with mental health services; to leave this behind requires a radical change in lifestyle, which may not be fully embedded by the end of 18 months. For patients with severe personality disorder who have a history of many years of failed treatments, multiple hospital admissions, and inadequate social stability, it is unlikely that they will be able to walk away from services, never to return, after (p. 178) the 18 months of MBT, irrespective of the success of the treatment. Most patients require further support as they adapt to a new life. To refuse appropriate help to them would “spoil the ship for a hap’orth of tar.”
Various follow-up programs are available: group therapy, couple therapy, outpatient maintenance treatment, college/educational counseling associated with return to education, and, rarely, further individual therapy. These treatment programs are not fully integrated into the specialist treatment programs because all patients are considered in their own right for follow-up and have to apply for further treatment alongside other patients referred to the unit. We attempt to minimize the waiting time for further treatment once the form of further help has been discussed, but there may be a gap between ending the specialist program and entering the follow-up phase. This is the reality of the statutory provision of treatment in the United Kingdom and patients have to adapt to the vagaries of the National Health Service, like all other citizens, if they are to access treatment from this source, whether psychological or physical, in a constructive manner. The ability to use services appropriately offers obvious benefit to a patient who may either have been refused treatment in the past or failed to have his/her physical health taken seriously. In addition, the constructive use of services leads to considerable cost-offset to health systems.
Outpatient maintenance of mentalizing
Many patients choose intermittent follow-up appointments rather than further formal psychotherapy. This is organized within the treatment team. Senior clinicians who have known the patient and who are known to the patient offer individual appointments on a 4–6-weekly basis for 30 minutes per appointment. The purpose of these meetings is clearly specified, as summarized in Box 5.7.
During follow-up appointments, the clinician continues to use mentalizing techniques exploring the underlying mental states of the patient and discussing how understanding themselves and others is leading to resolution of problems, (p. 179) enabling them to reconcile differences, and helping them to manage problematic interpersonal areas and intimate relationships. The follow-up contract is flexible and the patient can request an additional appointment if there is an emotional problem that cannot easily be managed. In general, however, the trajectory over follow-up is to increase the time between appointments over a 6-month period to encourage greater patient self-determination. How long a patient is seen in this manner is dependent on the clinician and patient and should be agreed between them. Some patients elect to be discharged relatively early during follow-up on the basis that they can call and request an appointment at any time in the future. We offer this option in our own clinical service. Other patients prefer to make an appointment many months ahead, which provides adequate assurance within their own mind that we continue to have them in mind, giving them greater confidence and self-reliance to negotiate the stresses and strains of everyday life.
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