(p. 182) Clinician stance
Mentalizing in psychotherapy is a process of joint attention in which the patient’s mental states are the object of scrutiny. The mentalizing clinician continually constructs and reconstructs an image of the patient in his/her mind to help the patient apprehend what he feels and why he experiences what he does. The patient has to find himself in the mind of the clinician and, equally, the clinician has to understand him/herself in the mind of the patient if the two together are to develop a mentalizing process. Both have to experience a mind being changed by a mind.
While this process sounds rarefied, in practice it is not. The clinician must ensure that his/her primary concern is the patient’s state of mind and not his behavior. The clinician’s principal interest is in what is happening in the patient’s mind now, even if it is focusing on a past event; his/her curiosity is about what the patient is experiencing while talking about the events. In effect, the clinician moves from an interest in the events themselves, to the patient’s experience of the events at the time, to his/her reflection about the events, to his/her current feelings about talking about the events (see Figure 6.1).
If the dialogue is about an experience in therapy itself, the clinician needs to recognize that neither he/she nor the patient experiences interactions other than impressionistically. This requires the clinician to monitor his/her own mind as much as that of the patient’s and to keep an eye on any occasional enactments, however small. Despite our contention that individuals with borderline personality disorder (BPD) have a reduced capacity to monitor the mind states of others accurately, their abilities to use an external mentalizing focus to inform themselves about others’ motives and affects are well honed. They may pick up, with remarkable and sometimes uncomfortable accuracy, your errors, your personal weaknesses, and your underlying feelings. So, as we will see, appropriate humility and capacity on the clinician’s part to learn about him/herself from the patient is an important part of treatment. (p. 183)
Some general considerations
The clinician’s mentalizing therapeutic stance (Box 6.1) includes:
◆ Humility deriving from a sense of “not-knowing”
◆ Patience in taking time to identify differences in perspectives
◆ Legitimizing and accepting different perspectives
◆ Actively questioning the patient about his/her experience—asking for detailed descriptions of experience (“what” questions) rather than explanations (“why” questions)
◆ Careful eschewing of the need to understand what makes no sense (i.e., saying explicitly that something is unclear).
(p. 184) An important component of this stance is monitoring and acknowledging one’s own errors as a clinician—getting things wrong and owning up to these mistakes. This not only models honesty and courage, and tends to lower the patient’s arousal through the clinician taking responsibility for interactional difficulties, but also offers invaluable opportunities to explore how interpersonal problems can arise out of mistaken assumptions about opaque mental states and how misunderstanding is a significant aversive experience. In this context, it is important to be aware that the clinician is constantly at risk of losing his/her capacity to mentalize when faced with a nonmentalizing patient. The primary task of the clinician at this moment is to regain his/her own mentalizing. Consequently, we consider clinicians’ occasional nonmentalizing errors as an acceptable concomitant of the therapeutic alliance, something that simply has to be owned up to. As with other instances of breaks in mentalizing, such incidents require that the process is “rewound” and the incident “explored.” Hence, in a collaborative, mentalizing relationship, the patient and clinician have a joint responsibility to understand what goes on between them.
We have often said that clinicians do not need to be overly worried about the primary task of MBT, that is, stimulating mentalizing when it is lost, since they are probably already doing it without being aware of it. Any technique that promotes mentalizing is valid. Rather than beginning afresh, our model requires the clinician to re-examine his/her current practice from the perspective of whether his/her interventions stimulate mentalizing or actually inhibit it. To this extent, the clinician should differentiate between a stance that primarily focuses on descriptive narrative and one that requires attention to mental states. MBT clinicians need the facts, and should not avoid eliciting the facts about important events. Indeed, these are necessary before mentalizing work is done about such events.
clinician: Tell me what happened? [This is a question eliciting facts.]
patient: I walked into the house and found my boyfriend with another woman. They were in the living room and had obviously been fondling each other. I shouted at them and she told me to get out.
clinician: What did you do then? [A further question likely to elicit a story.]
This is a dialogue that elicits facts about events. Once enough detail has been obtained, the clinician returns to the events and begins exploration around the mental states associated with the events.
clinician: What sort of frame of mind were you in on your way home?
patient: I felt quite good. I was looking forward to seeing my boyfriend. We had had a nice evening the day before.
clinician: So what was your general feeling about your relationship with him before this?
(p. 185) This is the beginning of a mentalizing dialogue moving slowly toward understanding the internal states the patient was experiencing in reaction to the events. In principle, MBT clinicians elicit the facts of the events and then rewind to establish the internal experience of the events.
In addition, the clinician needs to be aware of his/her own state of mentalizing. As we have put it before, “Ironically, when you become aware of your nonmentalizing interventions (or excrementalizing!), you are mentalizing. A further irony: when you start obsessing about mentalizing in the middle of a session, you have lost mentalizing, because you are no longer paying attention to your patient” (Allen, Fonagy, & Bateman, 2008, p. 163). Paying attention to your patient’s mind is at the heart of mentalizing. Paradoxically, it is the clever or highly trained clinician who is more likely to turn off a patient’s mentalizing by taking an expert role. Once he finds himself knowing why something is wrong with the patient and how it can be corrected, that is, he takes over the patient’s mentalizing, he is not mentalizing. A general reluctance to admit to himself that he does not know what is happening in therapy sessions compounds the problem!
Knowing takes many forms: we profess a deep understanding of unconscious process, we are sure about good and bad thought processes, we empathically tell patients what they are feeling—all of which are nonmentalizing stances. The MBT clinician needs to stimulate a joint consideration of underlying processes rather than claiming to understand them, to explore different components of thought processes rather than Socratically demonstrating their inaccuracy, and to help the patient attend to his feelings rather than methodically naming them for him. The clinician focuses on the process rather than the content of the patient’s thoughts and feelings, and in doing so he/she asks the patient to attend consciously to the processes within both his own and others’ minds and to maintain this attention as his feelings fluctuate. To develop this process the clinician uses a range of interventions, which share the primary aims of maintaining mentalizing and reinstating it when lost.
The attitude of the clinician is crucial. The clinician will stimulate in the patient a recognition of mentalizing as a core process of successful interaction with others, in part through a process of modeling and identification. The clinician’s ability to use his/her own mind and to demonstrate delight in changing his/her mind when presented with alternative views will be internalized by the patient, who will gradually become more curious about his own and others’ minds and better able to reappraise himself and his understanding of others. This continual re-working of (p. 186) perspectives exemplified by the curious attitude of the clinician, along with consideration of alternatives within the therapeutic relationship, is key to a change process, as is the focus of the work on current rather than past experience.
In an attempt to capture this clinician stance, which gives the best chance of achieving mentalizing goals, we have defined a mentalizing or “not-knowing” stance.
Mentalizing or not-knowing stance
The mentalizing or not-knowing stance is not synonymous with having no knowledge. The term is an attempt to capture a sense that mental states are opaque, and that the clinician can have no more idea of what is in the patient’s mind than the patient himself and, in fact, probably will have a lot less. Your position is one in which you attempt to demonstrate a willingness to find out about your patient’s mind, what makes him “tick,” how he feels, and the reasons for his underlying problems. Your initial task is to see things the way your patient sees them, taking the patient’s perspective. To do this you need to become an active questioning clinician (see Box 6.2), discouraging excessive free association by the patient in favor of detailed monitoring and understanding of interpersonal processes and how they relate to the patient’s mental states.
Your aim is to get the patient to monitor his own mind states in real time. If you take a different perspective from the patient this should be verbalized and explored in relation to the patient’s alternative perspective, with no assumption being made about whose viewpoint has greater validity (see Box 6.3).
The task is to determine the mental processes that have led to alternative viewpoints and to consider each perspective in relation to the other, accepting that divergent outlooks may be acceptable. Where differences are clear and cannot initially be resolved they should be identified, stated, and accepted until resolution seems possible. (p. 187)
The activity of the questioning clinician is illustrated in the following vignette.
The disappointed patient
patient [Talking about her follow-up meeting with her former psychologist]: I don’t think he bothered about what I was saying at all.
clinician: What makes you say that?
patient: I had to repeat myself and he still didn’t say anything except to ask me the same question that I had just answered [possible nonmentalized statement].
clinician: I can see how you get to that [validation without agreement that the psychologist was or was not bothered]. What effect did it have on you? [A question eliciting mental state rather than narrative.]
patient: It made me upset that I had been seeing someone all that time who always seemed to want to listen to me but was actually a fake.
clinician: It is difficult, isn’t it, when someone seems to have changed so quickly, but what about this sense that he didn’t listen?
patient: He was seeing me and so was supposed to be listening to me whatever else he was doing. He just didn’t say much [explains how she has come to her conclusion]. I was not wanted there.
clinician: That’s right, and I can see that it made you feel not wanted, but how did that compare with your feelings for him before? [Affectively based intervention and suggests contrast of her different experiences of him.]
patient: I used to think that he always listened to me and was interested in what was going on in my life, but this . . . I won’t be going again.
clinician: It is really upsetting, isn’t it, when someone doesn’t seem to be how they usually are? Maybe you were influenced by that awful feeling of disappointment that you were not going to see him again [links finality of decision to stop seeing her psychologist (p. 188) with the problematic feeling that was evoked. This goes further than the not-knowing stance, as the clinician suggests that another mental state might be important, but it is a mental state that he has suggested. Technically, this is not fully on the model. It would be better for the clinician to ask if there were other feelings about seeing her psychologist for follow-up].
patient: Maybe, but when I was there it felt like hard work. But you are right, that was not how he usually was. But it was hurtful. He didn’t seem to mind that he was not going to see me again.
clinician: Hmm. Let’s consider how that left you feeling and how you are managing it [now moving the therapy on to consider what effect it will have that she will not see the psychologist again].
The doing clinician
Early in therapy, patients may experience clinicians as understanding their needs only if they provide them with explicit and concrete evidence that this is the case. Pressure for the clinician to do something is high because the teleological psychological function often apparent in people with BPD (see Chapter 1) means that their understanding of the world is dependent on what happens in the physical world—outcomes in the “real” world define meaning. Clinicians will, at times, demonstrate their understanding through appropriate action within the boundaries of therapy—a supportive letter for housing may be necessary, a telephone call to the patient to help him explore the precipitants of an interpersonal crisis and to monitor what is happening in his mind, or even a home visit with a colleague between sessions in an emergency. Many of these acts can become integral to therapy.
Any letter or report written on the patient’s behalf should be shared with him before it is sent off, and rewritten if necessary, as part of the joint attention given to the patient’s needs. The first draft by the clinician gives his/her perspective, while modification in discussion with the patient demonstrates a process of change and the influence of a mind on a mind. If joint agreement cannot be reached about an aspect of the letter, the clinician must decide whether to remove or retain the opinion. Whichever course of action is taken, the reasons for the decision should be explained to the patient. Of course, some reports are supportive of the patient while other reports, for example, those to probation, courts, or child protection teams, might raise complex issues for therapy.
A clinician wrote a report about a patient for the child protection team. He gave the initial draft of the report to the patient to read. She corrected a number of minor factual errors but was most concerned about his view that her emotional volatility meant that her ability to focus on the needs of her baby was compromised. The clinician discussed (p. 189) how he had come to that opinion. She disagreed. Some work was done defining the “elephant in the room” (affect focus; see Chapters 7 and 9) and repairing the therapeutic alliance by accepting the difference in opinion—for her part, the patient was concerned that the clinician would never change his mind and she would not be able to demonstrate her stability; for his part, the clinician was concerned that the patient would cover up her problems and so ensure that treatment was a sham, appearing to be effective while in reality being ineffective. Both agreed that they would openly talk about this when either of them thought it was interfering with therapy.
The aim of this openness about reports or other actions taken on behalf of the patient is to maintain mentalizing around the content of the report or action, which, after all, is about the patient. It is not to take over responsibility from the patient, and work may need to be done in helping them be more effective, for example, in dealing with housing or other organizations. Any major actions taken on behalf of the patient should be carefully considered—preferably with another team member—before they are undertaken, and certainly discussed with the team if they have already taken place within a session. This protects against inappropriate enactments.
The monitoring clinician
Being human, you will inevitably make errors in therapy, some more serious than others. Here we are not talking about structural blunders, for example, forgetting sessions or failing to organize appointments with due care. Gross structural errors require apology, acceptance on your part for your failure, and later demonstration within the therapy process that you are aware of the effects of the event on your patient. We are talking about a requirement to own up to your own mentalizing errors, that is, those that undermine mentalizing rather than promote it; for example, telling the patient how she feels, insisting that your perspective is right, arguing with psychic equivalence. You must not to attempt to cover up your errors or to deny them when confronted. Mistakes are treated as opportunities to revisit what happened and to learn more about contexts, feelings, and experiences—“How was it that I did that at that time?” (see Box 6.4). It is not enough to recognize silently within yourself that you have made an error and change your interventions accordingly. You need to articulate what has happened, not only to model honesty and courage, but above all to demonstrate that you are continually reflecting on what goes on in your mind and on what you do in relation to the patient. This is a central component of mentalizing itself.
This brings us to a controversial aspect of MBT—the clinician’s mental processes must be available to the patient. Mental processes are opaque. This opacity, combined with the person with BPD’s characteristic vulnerability to loss of (p. 190) mentalizing within relationships, sensitivity to external cues such as facial expressions (Lynch et al., 2006), and assumptions about internal mind states, means that the mentalizing clinician needs to make his/her mental processes transparent to the patient; as he/she tries to understand the patient, he/she openly deliberates while “marking” his/her statements carefully. This requires a directness, honesty, authenticity, and personal ownership of what the clinician feels and thinks, which is problematic partly because of the dangers of boundary violations in the treatment of people with BPD. Our emphasis on the need for authenticity is not a license to overstep the boundaries of therapy or to develop a “real” relationship; we are merely stressing that the clinician needs to make him/herself mentally available to the patient and must demonstrate an ability to balance uncertainty and doubt with opinion and professional perspective. This becomes particularly important when patients correctly identify feelings and thoughts experienced by the clinician. The clinician needs to be prepared for questions and assertions that put him/her on the defensive—“You’re bored with me,” “You are fed up with me,” “You don’t like me much either, do you?” and so on. Such challenges to the clinician can arise suddenly and without warning, and the clinician needs to be able to answer with authenticity. If he/she does not do so, the patient will become more insistent and even evoke the very experience in the clinician he/she is pointing out (if, indeed, the clinician was not already feeling it at the time!). Worse still, the clinician invalidates the patient’s correct perception because he/she is embarrassed and uncomfortable. Commonly this is done by the clinician reflecting the question, which is a frequent mentalizing error.
A patient’s accurate perception of what is in the clinician’s mind needs validation:
You are bored with seeing me, aren’t you?
(p. 191) This is likely to be asked from a position of psychic equivalence, in which the patient’s internal thoughts and experience are assumed to be the same as outside experience. Within psychic equivalence, the patient cannot distinguish self and other easily, and so he operates from a perspective that others have the same experience as him.
If the clinician is indeed feeling bored, it is important that he/she says so in a way that stimulates exploration of what within the patient–clinician interaction is boring. An MBT clinician will take equal responsibility for creating boring therapy and move to making this a focus of therapy for that moment:
Now you mention it, I was feeling a bit bored and I am unsure where that is coming from. Is it related to what you are talking about or how you are talking about it, or is it more me at the moment? You know, I am really not sure.
Alternatively, if the clinician is in fact not bored, then he/she needs to find a way to express this that opens up the possibility of exploring what stimulated the patient’s question. To do this the clinician first needs to be open about his/her current feeling, rather than attempting to stimulate the patient’s fantasies about what he/she, the clinician, is feeling. This follows a basic MBT principle—DO NOT make interventions that assume mentalizing when a patient is not mentalizing. To ask a patient to imagine what the clinician’s experience is, and for that image to be given meaning, it has to be represented in the patient’s mind and contrasted with his own experience. This process requires a reasonable mentalizing capacity. Asking a question like “What makes you think I am bored?” to the nonmentalizing patient, without clarifying first whether or not his perception is accurate, is likely to induce pretend mode or, alternatively, simply lead to the development of psychic equivalent fantasy. It is better for the clinician to tell the patient what he/she is experiencing within the therapy at that moment:
As far as I am aware, I was not bored. In fact, I was trying to grasp what you were saying. I felt muddled. But now I am intrigued that you and I were having such a different experience of this at the moment [marked alternative perspective].
The aim here is for the clinician to stimulate exploration of alternative perspectives. If this is to occur, the different perspectives have to be clear. Here, the patient has a specific perspective. Now the clinician has placed an alternative viewpoint but emphasized that it is his/her own state of mind that he/she is reflecting on (marking) and not that of the patient. In doing so he/she is not stating that the patient’s state of mind is wrong, but setting up a platform from which to explore alternatives.
(p. 192) Counter-relationship or feelings engendered in the clinician and marking mental states
In the past, we have blithely used the term “countertransference” to describe the feelings of the clinician occurring in treatment sessions. Correctly, concerns have been expressed about our use of the term. Indeed, our use of the term has been somewhat loose and lacked psychological precision in relation to the complex definitions found in the psychoanalytic literature. The meaning of the word has a long and illustrious history and its sense has changed over time. Yet, whatever definition is used, a core persists, namely, that “countertransference” refers to feelings in the clinician and links to his/her self-awareness, which in turn relies on his/her affective pole of mentalizing. This is the focus in MBT, and so we often talk about the “feelings in the clinician in relation to the patient” rather than using the term “countertransference” because this has implications for the source of the feelings, which are usually considered to be arising from the patient. Some clinicians tend to default to a state of self-reference in which they consider most of what they experience in therapy as being projected by the patient and technically part of countertransference. This default mode needs to be resisted. As clinicians, we need to be mindful of the fact that our mental states might unduly color our understanding of the patient’s mental states and that we tend to equate our own mental states with those of the patient without adequate foundation. The clinician has to “quarantine” his/her feelings. These feelings are defined as those experiences, both affective and cognitive, that the clinician has in sessions and which he/she thinks might help to further develop an understanding of mental processes relevant to the problems of the patient or those in treatment itself. How the clinician “quarantines” his/her counter-relationship feelings informs his/her technical approach to feelings engendered in him/her during treatment.
We frame our technical work with feelings within the clinician (broadly, countertransference) with an exhortation for the clinician to be “ordinary.” Inexperienced clinicians frequently have ideas about how a clinician should behave and act in therapy that lead them to become wooden, unresponsive, and dedicated to technical application. We suggest that being ordinarily human is a better way forward when working with counter-relationship feelings. We do not license clinicians to behave in any way they please or to say whatever they like—any more than they would do in a respectful relationship with a friend. Rather, we recommend that the clinician openly works on his/her state of mind in therapy in a way that moves the joint purpose of the patient–clinician relationship forward, keeping mentalizing on-line. To do this the clinician will often need to speak openly from his/her own perspective (this is termed “marking”) rather than from his/her understanding of the patient’s experience. The (p. 193) key word here is “openly.” Counter-relationship experience expressed verbally by the clinician is an important aspect of therapy, but when it is being expressed it must be marked as an aspect of the clinician’s state of mind. It should not be attributed to the patient, even though it may be a reaction to the patient. In essence, marking implicitly or explicitly speaks to the question about whose mind we are talking about: is it mine, is it my representation of your mind state, or is it a combination of both?
Counter-relationship experience can be powerful in the treatment of BPD, with clinicians struggling with feelings of rage, hatred, hurt, rejection, care, and anxiety. Patients seem able to hit our sensitive spots and sometimes will even focus on them as they try to control the emotional processes in a session. The task of the clinician is to help the patient recognize that what he/she does and says evokes a state of mind in the clinician, just as what the clinician does and says stimulates mental processes in the patient. The patient needs to consider the effects he/she has on others within his/her own mind, rather than to ignore them or maintain that they are of no consequence.
A patient with antisocial personality disorder (ASPD) had a threatening and menacing demeanor. He sat forward in sessions glowering at the clinician. Unsurprisingly, the clinician was fearful. So the clinician decided to try to talk about the problem he was having with offering treatment while feeling scared.
clinician: I think I need to bring up one aspect of our sessions, which I don’t want you to take as a criticism [anticipating patient reaction prior to expressing the clinician’s feelings]. But as you sit forward in the way you are now and raise your voice as you talk to me it makes me feel nervous. I can’t think properly when I am nervous, so it prevents me listening carefully to what you are saying. Could you sit back and lower your voice a little?
patient: You don’t need to be. I am not threatening you [common ASPD dismissal of others’ mental state].
clinician: I appreciate that, but nevertheless it is the effect that it has on me.
In this example, the clinician has managed to maintain his own mentalizing by expressing his own state of mind, namely, the emotion that is reducing his capacity to mentalize in the current session. This is in line with one of the primary principles of MBT—the clinician ensures that he maintains his own mentalizing. The response from the patient suggests that he has no concern about the effect that he is having on the clinician. This is a characteristic mentalizing problem found in people with ASPD and has to be addressed in MBT-ASPD (see Chapter 13).
(p. 194) In summary, the mentalizing clinician is not neutral but engaged in a process of reflective engagement (see Box 6.5), making it essential for him/her to monitor his/her responses more openly than in many other therapies; his/her role is potentially iatrogenic in terms of the interpersonal process. The question for the clinician is what aspect of him/her contributed to what happened and what element of the patient stimulated that involvement, or what aspect of him/her provoked it and what did it stimulate in the patient. His/her reflection about these processes needs to be open and genuinely thoughtful rather than closed and introspective.
This sort of exploration of shared experience requires an open-minded clinician, safe in his/her own failings and appropriately doubtful about his/her viewpoints, so that the patient can manage to open his own mind and begin to question his own rigidly operating schemas about himself and others in the same way that the clinician does. A detached, aloof, refined, defended clinician is unlikely to form a relationship with a patient that helps the patient find himself in the mind of the clinician in an accessible and meaningful way. Patients with BPD have a reduced capacity for understanding the subjective mental states of others; they cannot fathom the inscrutability of a remote mind, and such a clinician stance is most likely to stimulate uncontrolled paranoid reactions. But, equally, they cannot tolerate a clinician who bubbles with emotion, fails to differentiate different perspectives, and exposes them to excessive feelings in others, which might take them over. The clinician needs to become what the patient needs them to be, to feel what the patient wants them to feel, but at the same time to be themselves, while able to preserve a part of their mind that accurately mirrors the patient’s internal state. (p. 195)
It is important to emphasize that this “mentalizing the counter-relationship or feelings in the clinician” is not a process of reversal in which the patient is giving the clinician some therapy or the clinician is exploring his/her own pathology in front of the patient or engaging in self-disclosure—all of which are likely to burden the patient rather than help him understand himself. Reflection on interactions is by necessity focused on the patient–clinician relationship, with both parties being considered responsible for looking at all the elements that potentially contributed to the exchange. This might include the patient’s provocative goading and projective processes on the one hand or the clinician’s sensitivities and unresolved conflicts on the other. This can be discovered only by understanding the mental processes contributing to the problem. So, a “Stop, Rewind, Explore” (described later in this chapter) is necessary, taking the session back before moving it forward again “frame by frame” or “mental state by mental state.” Just as the patient’s behaviors cannot be understood in isolation from the mental processes that have led to them, so interventions by the clinician cannot become meaningful unless their contributing determinants are identified.
Emotional closeness in therapy sessions
Once the clinician has adopted the mentalizing stance and stimulated a mentalizing process, his/her task is to maintain mentalizing within him/herself and the patient while at the same time recognizing that therapy will potentially destabilize mentalizing by stimulating the attachment system (see Chapter 1 for a discussion of this phenomenon). Mentalizing will be threatened simply because the clinician probes, stimulates feelings, and asks questions, all of which are likely to make the patient anxious. Alert to this, the clinician moves emotionally closer to the patient during a session only to the point at which he/she judges the patient is on the verge of losing mentalizing. At this moment he/she moves back, distancing him/herself from the patient, to reduce the level of emotional arousal. Here we encounter a clinically significant paradox—just when the clinician would naturally move emotionally closer to the patient, we ask that he/she moves away. Any person talking with someone who is becoming increasingly disturbed or upset will naturally become more sympathetic and caring. At such times the clinician is likely to become gentler in his/her demeanor, speak more quietly, and try to demonstrate an ever more profound understanding of the patient’s emotional state. Yet this will stimulate the patient’s attachment system, leading to further impairment of his/her mentalizing capacity; this is particularly the case in patients with BPD because of the hypersensitivity of their attachment system.
(p. 196) For this reason, we ask the clinician to curb his/her natural tendency to become increasingly sympathetic when the patient becomes emotional, and to distance him/herself emotionally by becoming less expressive and perhaps more cognitive, even if only momentarily. Once mentalizing is regained, he/she can recapture emotional involvement and begin again to probe, empathize, and focus on the patient–clinician relationship. However, he/she should not be surprised to find that this rekindles the patient’s attachment system. He/she needs to monitor sensitively for further losses of mentalizing and to step back rapidly when necessary. This recommendation of becoming more cognitive does not amount to a recommendation that a caring clinician becomes uncaring. However, caring that manifests itself as sweetness, concern, and sympathy at this moment will only add fuel to the fire, inflaming attachment needs and stimulating further mental deterioration in the patient just at the moment when it is crucial to find a way of stimulating more robust mental processes.
A patient became distressed when talking about her boyfriend being sexually unfaithful. She talked about leaving him, but said that she loved him and so she could not do so. The clinician made many sympathetic noises during this story, and made increasingly supportive statements about the problem for the patient in coping with her conflicting experience. The patient became more and more distressed, becoming inconsolable for most of the rest of the session. This evoked a feeling in the clinician that she should offer an additional session. This immediately intensified the patient’s needs; she then asked if the current session could go on for longer, saying that she thought she could not leave the room.
Inadvertently, the clinician had aroused the patient’s dependency and made her even more vulnerable by becoming more sympathetic and offering additional sessions to the patient at a time when she needed to step back from the patient.
Stepping back in the face of distress requires conscious effort on the clinician’s part if it is to be done sensitively. It is counterintuitive. Not only does it go against instincts and natural tendencies, but it also defies all that was learned in training. Clinicians tend to lower their voices, speak softly, and express apprehension in their facial expressions as they become increasingly concerned and sympathetic. In order to reduce the power of the emotional interaction, the clinician needs initially to respond in a somewhat matter-of-fact manner or move the patient away from his/her current focus, rather than continuing to focus on either affect or the interaction between patient and clinician, both of which will continue to stimulate the patient’s attachment needs. In the earlier example, the clinician would have done better to move the patient away from an internal focus on her affect and to de-emphasize the patient–clinician relationship (a counterbalance). One way of doing this might have been to focus the session more on practical aspects of how she might manage living on her own, for example. Thus, the clinician moves to a more cognitively dominated discussion. (p. 197) This is an example of a contrary move: the more the patient is dominated by affect, the more the clinician becomes focused on cognitions. The clinician should aim to help the patient maintain some elements of mentalizing, in this case cognitive processing, when other aspects are overwhelmed, in this case the capacity for affective reflection about the self. Insistence on further exploration of internal states at times of emotional arousal will only overburden the patient; we suggest the use of contrary moves at these times.
This movement of stepping back from excess emotional stimulation is part of a general technique to rebalance mentalizing that becomes fixed at one end of one of the four dimensions of mentalizing (see Chapter 1, where we discuss the dimensions of mentalizing in detail). In clinical practice, we recommend that you consider moving patients along or rebalancing the dimensions when they become fixed at one end, for example, excessive cognitive rationalization without affect, or persistent focus on self rather than consideration of the experience of others (see Table 6.1).
Table 6.1 Contrary moves
The clinician technically attempts to refocus the patient outwards when he/she is self-focused, or toward him/herself when he/she is excessively externalizing or is other-focused. This is also represented in the clinician–patient interaction, with the clinician moving him/herself toward the patient—that is, making the dialogue more emotionally personal—when the patient moves away, and moving away when the patient becomes emotionally fixed on the clinician.
We envision a “balancing act,” maintaining flexibility of mentalizing around the four dimensions. This advances the scope for reflection and dialogue. In terms of the interpersonal interaction, we anticipate that you and the patient will oscillate back and forth as you titrate the intensity of the attachment relationship. In addition, within him/herself, the person with BPD may at some (p. 198) moments be self-focused, and this is often to be commended; however, this self-reflection may begin to take on a ruminative quality, or the patient may get stuck in a rigidly negative, shameful, self-condemning mode. At such times, taking into account his/her current mentalizing capacity (see later for a caution), you will try to move the patient out of his/her mind and into another person’s mind: “How do you think that affects her?”; “What was going on for him that led him to do that?” You should not be deflected from this task once you have decided that it is an appropriate move in treatment. Many patients respond by saying they don’t know, and quickly return to their ruminative concern with their own state of mind. You may therefore need to be more insistent: “Bear with me a bit—I was wondering what you made of what was happening for him that made him respond like that?”
There will also be times when you will need to make the converse move. Patients who are preoccupied with understanding others and what they are like may need pushing to reflect on their own state of mind: “What did you feel about that?”; “How do you understand your reaction?” This is feasible even when the patient is in psychic equivalence.
There is one caution for the clinician when working with contrary moves, particularly when exploring events about problems in a relationship. In this context the clinician may be tempted to ask the patient about the motives of the other while at the same time exploring the motives and experience of the patient. If the patient is currently in psychic equivalence mode, asking him/her to consider the mind states of an “other” is to suggest an impossible task. At this point the patient’s experience of the other’s mind state is dictated by his/her own psychic equivalence experience.
patient: My probation officer is trying to trick me so that she can send me back to prison [unelaborated statement stating other’s motive, suggesting that it is held in nonmentalizing mode].
clinician: What makes you say that? [Attempt to stimulate the patient to think about the other person’s motive.]
patient: She asked me why I did not attend the police station yesterday and she already knew where I was.
patient: She does not like me. She knew that I was at the anger management meeting and that is why she arranged for me to be at the police station at that time.
clinician: Do you think there is any other reason that she could have done that?
patient: [Thinks for a moment.] She is a cow?
(p. 199) clinician: Oh! Any other reasons? I was thinking more that she might not have known about the conflict of appointments [asking to explore other possible motives of the probation officer].
patient: [Thinks again.] Well if it is not because she is a cow. Maybe she is just a shit.
In this verbatim transcript the clinician has not appreciated that the patient is holding her experience of the meeting with the probation officer in psychic equivalence mode. Asking her about possible alternative motives of the probation officer merely stimulates different ways of saying the same thing. The patient is not in a position mentally to be reflective because of psychic equivalence, in which the patient’s mental reality is experienced as being external reality. The clinician will have to stimulate the patient’s mentalizing in the session before returning to this interaction with the probation officer to explore whether the patient can work on how she manages her relationship with the probation officer.
Contrary moves along the dimensions of mentalizing aim to embed increasing flexibility in mentalizing. The patient who is affectively overwhelmed needs to have some cognitive processes brought to bear on the problem—so the clinician tries to stimulate this in the patient by becoming more rational in his/her responses. The patient who is overly intellectual and rational needs to harness some affective experience related to the problem—and so the clinician tries to trigger some affective response to the problem. To this extent there is a constant reciprocal flow of dialogue between patient and clinician along the dimensions of mentalizing and an attempt to instill flexibility in the internal mentalizing process of the patient irrespective of the context.
Labeling with qualification (“I wonder if . . .” statements)
Labeling with qualification, or “wondering” statements, can sound woolly and be received as irritatingly uncertain (“How should I know? You are supposed to be the therapist”), but when used appropriately can propel a session forward and achieve further discussion and revelation. The mentalizing stance of “not-knowing” implies that the clinician will “wonder” more often than he/she “knows,” but it is important that if he/she “knows” he/she does not “wonder.” Hence, the not-knowing stance is not a continuous “wondering” stance. In our experience, a clinician who “wonders” too much is in danger of not sharing his/her perspective with a patient; for example, he/she wonders when in fact he/she has a viewpoint. This creates a false interaction—the patient may well understand the clinician’s underlying subjective state of mind even if it is not openly expressed and reacts to it unconsciously, constructing a “pretend” interaction in which both patient and clinician are tentative while both are certain. (p. 200) “I wonder if . . .” statements may be useful to ensure that the patient discovers what he/she is feeling. The patient should not be told what he/she is feeling because this takes over his/her mentalizing. The manifest feeling may be labeled without qualification, but the clinician’s task is to identify the consequential experience related to that feeling. This is where labeling with qualification is important: “Although you are obviously dismissive of them, I wonder if that leaves you feeling a bit left out?”
The process clinician
Finally, it is important that the clinician concentrates on developing a mentalizing therapeutic process (see Box 6.6). More attention needs to be devoted to this than to detailed understanding of content. An implicit mentalizing process is a major goal of treatment, and this will develop only if the patient can be freed from rigid views held firmly within a schematic belief system. To achieve this shift, the clinician should focus on the relationship between patient and clinician, as it exemplifies different perspectives and offers opportunities for alternative understanding.
Overt schematic delineation of beliefs will generate explicit mentalizing, and this forms the basis of many cognitive interventions for BPD. This in itself may be helpful, but your goal is the development of an implicit mentalizing process within the therapeutic relationship. Explication of affective states embedded within the current relationship is therefore emphasized more than cognitive exposition in order to generate an experience of “feeling felt” in which the patient feels affirmed, validated, and not alone, and remains in the feeling while being aware of the feeling. Our emphasis on process is in line with other dynamic therapies for BPD, and clinicians who have been trained in the conversational model or cognitive analytic therapy will have little difficulty in recognizing the importance of “listening” to the process rather than paying too much attention to the exact content (see, for example, Meares, 2000; Meares & Hobson, 1977; Ryle, 2004).
(p. 201) Aspects of process that need special attention are the negotiation of a negative therapeutic reaction, a sudden rupture in the alliance, or rapid emotional dysregulation in the patient; all may leave the clinician perplexed and uncertain about how to react. Ruptures frequently result from the conjunction of relationship patterns in the patient and clinician (Aveline, 2005), thereby being the product of both rather than one alone; clinicians must be skilled in repairing them (Meares, 2000). In our experience, the explicitly reflective clinician, who retrieves his/her own mentalizing ability quickly following a collapse in the relationship, is the most likely to negotiate severe ruptures in the alliance successfully, and this capacity may be a key factor in maintaining people with BPD in treatment. Here again is the principle underpinning MBT—the clinician needs to maintain his/her own mentalizing and to work to recover it before he/she can help the patient further.
Ruptures represent a failure of mentalizing. The clinician’s initial response should be open consideration of their part in the rupture—“What have I said or what is it you feel I have done to bring about this sudden change?”—as a demonstration of a continuing process of self-reflection. This allows the clinician to tease out the different contributions to events in therapy without apportioning blame and firmly embeds the dialogue within the immediacy of the patient–clinician relationship. The gravest danger at these times is increasing your use of the techniques that you believe are crucial to patient change, for example, transference interpretation, behavioral challenge, or delineation of cognitive distortions. First, the therapeutic alliance must be repaired by staying in the rupture and seeking a vantage point from which to view it. You and the patient need to move to a position betwixt and between the “heat” of the rupture. You both become detectives seeking clues about what has happened; this is best done by “stopping” and “rewinding” and then moving forward to the point of rupture. This brings us to the final topic of this chapter, which is to emphasize the importance of the clinician managing the process of each session.
The mentalizing focus—managing process
A number of basic mentalizing techniques are used to manage the mentalizing process in each session. We have previously emphasized that MBT is organized around various trajectories. First, there is the trajectory of treatment over 12–18 months, with different aims and processes at the beginning of treatment compared to the middle and end of treatment. Second, there is the trajectory through each group and individual session. There is the opening component of a session in which a focus is developed. This is followed by exploration of the focus from a range of perspectives, for example, the perspective apparent at the (p. 202) time when the problem occurred, the current perspective in the session, and the perspective on similar events in the future. Finally, there is the trajectory of intervention—often synchronized with the session trajectory—which moves from empathic validation at the beginning of a session, to affect exploration and focus, to mentalizing the relationship, and back to empathic validation and summary toward the end of the session. These trajectories need careful management by the clinician, and we have defined some techniques that can be used to manage the process. These are grouped together as “Stop, Listen, Look” and “Stop, Rewind, Explore.” These aide-memoire “catchphrases” refer to the actions of the clinician as he/she tries to reinstate a mentalizing process in the session.
Technically, the clinician may Stop, Rewind, Explore the process in the session itself or Stop, Rewind, Explore the content of the narrative, asking for more detail. The minds of both patient and clinician need to stop and/or rewind together to understand the process in the session better or, alternatively, to identify important elements of the events at hand. The purpose of both strategies is to reinstate mentalizing when it has been lost or to promote its continuation in the furtherance of the overall goal of therapy, which is (to re-reiterate) to encourage the formation of a robust and flexible mentalizing capacity that is not prone to sudden collapse in the face of emotional stress. As a session moves forward it is sometimes necessary either to pause, to consider, and to explore the moment, or to move back to retrace the process or re-examine the content.
Exploration: Stop, Listen, Look
As an individual or group session unfolds, the clinician needs to listen constantly for nonmentalizing processes and interactions. Indicators of poor mentalizing such as failure to respond to feelings expressed by others, dismissive attitudes, trite explanations, or lack of continuity of dialogue suggest that the clinician needs to Stop, Listen, Look (see Box 6.7). To do so, he/she holds the group or individual session in a suspended state while investigating the detail of what is happening by highlighting who feels what about whom, and what each member of the group understands about what is happening from their own perspective (see Box 6.8).
On the one hand, the clinician has to be active about this exploration of the current state of the group or individual session, but on the other hand, he/she must also listen to the responses carefully to piece together the complexity of the interactions and make sense of the affective process that is interfering with each person’s capacity to think about themselves in relation to the others. Once the group has worked around the “stop” point it can move on.
It is only when mentalizing is seriously disrupted that a “Stop, Rewind, Explore” takes place. (p. 203)
Stop, Rewind, Explore
Stop, Rewind, Explore is indicated when either the patient, the clinician, or the group has lost mentalizing. The clinician has to stop the group or individual session and insist that the session rewinds back to a point at which constructive interaction was taking place or he/she was able to think clearly and was maintaining his/her mentalizing stance. The clinician has to take control, rewind, and, with a steady resolve, explore while moving forward “frame by frame,” diverting the path that led to the loss of mentalizing. To do this he/she must retrace the steps that led to the point of loss of mentalizing by reverting to the point at which the patient or patients were able to think about themselves and others constructively, albeit with some difficulty (see Box 6.9).
Stop, Rewind, Explore should be implemented as soon as the clinician thinks the group or individual session has become uncontrolled and/or is in danger of (p. 204) rapid self-destruction, for example, patients walking out or engaging in inappropriately aggressive discourse.
The suicidal patient
A patient talked in a group about how suicidal she felt and about her plans to take an overdose. The group, with the help of the clinician, worked hard with her to understand what had precipitated her negative and destructive state of mind in which she felt no one cared if she lived or died and she did not feel that she had anyone or anything to live for. Many attempts to help from other members of the group were rebuffed, and it was apparent that the frustration of the group was building up. Before the clinician could control this and highlight the underlying frustration, the following interaction took place:
patient [to the suicidal patient]: I am fed up with all this. Whatever we say it is no good. Why don’t you put everyone out of your misery and just do it?
[Immediate silence in the group.]
clinician: That is a serious thing to say [stop] and I suspect that while you mean it at this moment it has come out of somewhere which we will all regret and so we had better go back [rewind] to see how we have reached this point in which one of us doesn’t care if someone else lives or dies [explore].
patient: So it will all be my fault I suppose now when she takes an overdose.
clinician: No [stand]. We are going to go back to see what has happened that has led you to be so frustrated that you don’t care if she takes one or (p. 205) not [stop]. Actually, I don’t think that it is like you, and so perhaps we can start with going back to the point at which you began to feel frustrated [rewind]. When did you first feel like that? [Explore.]
When implementing a “stop” the clinician may initially use exploratory probes in an attempt to help the patient reflect—“What happened there? We seem to have gone off topic.”
In conclusion, the clinician stance is inquisitive, active, empathic, and at times challenging, but most importantly the clinician should refrain from becoming an expert who “knows.” His/her mind is focused on the mind of the patient and he/she is intrigued, curious, questioning, and not-knowing. The clinician’s primary aim is to stimulate a robust mentalizing process and to do so he/she needs to manage the process of sessions carefully. Sessions need to be focused and well paced, and this is the responsibility of the clinician. At times it is useful to effect closure of a session through a summary of the session, working with the patient to ensure that the summary reflects both the patient’s and the clinician’s perspectives. Many patients request a copy of each note made in their electronic record. The summary is a good way to ensure that this is accurate and meaningful.
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