After Anthony Bateman and Peter Fonagy

Dr Andrew LeggettMBBS, MPhilCW (UQ), FRANZCP, Full Member QPPA

Consultant Psychiatrist and PsychotherapistAssociate Professor Griffith University School of Medicine

Senior Lecturer University of Queensland School of Medicine

Therapist stance: MentalizingProcess of joint attention in which the patient’s

mental states are the object of attentionThe therapist continually constructs and

reconstructs an image of the patient, to help the patient to apprehend what he feels

Neither therapist nor patient experiences interactions other than impressionistically

Differences are identifiedAcceptance of different perspectivesActive questioning

Active Questioning

Why do you think that he said that?I wonder if that was related to the group

yesterday?Perhaps you felt I was judging you?What do you make of her suicidal feeling in

the group?Why do you think that he behaved towards

you as he did?What do you make of what has happened?

Highlighting Alternative Perspectives

I saw it as a way to control yourself rather than to attack me (patient explanation); can you think about that for a moment

You seem to think that I don’t like you and yet I am not sure what makes you think that

Just as you distrusted everyone around you because you couldn’t predict how they would respond, you are now suspicious of me

You have to see me as critical so that you can feel vindicated in your dismissal of what I say

Reflective Enactment

Therapist’s occasional enactment is acceptable concomitant of therapeutic alliance

Own up to enactment to rewind and exploreCheck out understandingJoint responsibility to understand over-

determined enactmentsMonitor your own mistakesModel honesty and courage via acknowledgement

of your own mistakes -- past, current, and futureSuggest that mistakes offer opportunities to re-

visit and learn more about contexts, experiences, and feelings

Questions Suggesting Reflection

Is there something I have said or done that might have made you feel like that?

I am not sure what made me say that. I will have to think about it.

I believe that I was wrong. What I can’t understand is how I cam to say it. Can you help me go back to what was happening here before things went wrong?

Have I missed something that is obvious?

Mentalizing processNot directly concerned with content but with

helping the patient:To generate multiple perspectivesTo free themselves up from being stuck in the

‘reality’ of one view (primary representations and psychic equivalence)

To experience an array of mental states (secondary representations) and

To recognize them as such (meta-representations)

Affective focus and its representation in patient/therapist relationshipFocus the patient’s attention on therapist experience

when it offers an opportunity to clarify misunderstandings and to develop prototypical representations:

Highlight patient’s experience of therapistUse transference to emphasize the different experience

and perspectiveNegotiate negative reactions and ruptures in therapeutic

alliance by identifying patient and therapist roles in the problem

Explication of feelings draws attention back to implicit representations:

Use language to bolster engagement on the implicit level of mentalization

Highlight the experience of ‘feeling felt’ (mentalized affectivity)

InterventionsGeneral characteristics:Simple and shortAffect focussed (love, desire, hurt,

catastrophe, excitement)Focus on patient’s mind (not on behaviour)Relate to current event or activity -- mental

reality (evidence based or in working memory)

De-emphasize unconscious concerns in favour of near-conscious content

Clinical pathway for interventionsHierarchy of increasing emotional intensity:Identify the affect, not simply the behaviourExplore the emotional contextDefine the current interpersonal context

outsideExamine the broad interpersonal theme in

treatmentExplore the specific (transference) content

Spectrum of interventionsReassurance, support and empathyClarification, challenge, and elaborationBasic mentalizingInterpretative mentalizingMentalizing the transferenceNon-mentalizing interpretations -- use with

care

Which intervention to use when?If in doubt start at the surface -- support and empathyMove to ‘deeper’ levels only after you have performed the

earlier stepsIf emotions are in danger of becoming overwhelming take

a step towards the surfaceType of intervention is inversely related to emotional

intensity -- support and empathy being given when the patient is overwhelmed with emotion; mentalizing transference when the patient can continue mentalizing whilst ‘holding’ the emotion

Intervention must be in keeping with the patient’s mentalizing capacity at the time which it is given. The danger is in assuming that borderline patients have a greater capacity than they actually have when they are struggling with feelings

Function of self-injuryTo maintain the self-structure:Explore reasons for destabilization of self-structuree.g. ‘Tell me when you first began to feel anxious that

you might do something?’

Make a systematic attempt to place responsibility for actions back with the patient to re-establish self-control

e.g. ‘I can’t stop you harming yourself or even killing yourself but I might be able to help you understand what makes you do it and to find other ways of managing things.’

Motivation for self-injuryRe-stablize:Predictable, mentalizable schematic relationshipRigid understantable motivations -- ‘He didn’t turn up

because he wanted me to suffer’.Formulaic explanations -- ‘He deserves to suffer

because he is bad’. ‘I won’t come because they don’t want me there’.

Reduce panic:Establish existence:Support for bodily existence through seeing bloodWhen mental existence is in doubt reinforce existence

through your bodyEmptiness becomes partially filledRarely to control/attack other:

Pathway and interventions for self-injuryEmpathy and supportDefine interpersonal context:Detailed account of days or hours leading up to

self-injury with emphasis on feeling statesMoment to moment exploration of actual episodeExplore communication problemsIdentify misunderstandings or over-sensitivityIdentify affect:Explore the affective changes since the previous

individual session linking them with events within treatment

Review any acts thoroughly in a number of contexts including individual and group therapy

Interventions for self-harmDOExplore conscious motive:How do you understand what happened?Who was there at the time or who were you thinking about?What did you make of what they said?Challenge the perspective that the patient presents:

DO NOTMentalize the transference in the immediacy of a sucide

attempt or self-injury Interpret the patient’s actions in terms of their personal

history, the putative unconscious motivations or their current possible manipulative intent in the ‘heat’ of the moment. It will alientate the patient.

Basic InterventionsMaintaining motivation:

Demonstrate support, reassurance and empathy as you explore the patient’s mind

Model and reflectivityIdentify the discrepancy between the experience of the

self and the ideal self -- ‘how you are, compared with how you would like to be’

‘Go with the flow’ or ‘roll with the resistance’ for a short time

Re-appraise gains and identify continuing problem areasHighlight competencies in mentalization and listen for

mentalizing strengths

Supportive attitudeRepectful of patient narrative and expressionPositive/hopeful attitude but questioningUnknowing stance -- you cannot know their

positionDemonstrate a desire to know and to understandConstantly check back your understandingSpell out emotional impact of narrative based on

common sense psychology and personal experience

For the patient but not acting for them -- retains patient responsibility

Proscribed statementsWhat you really feel is …I think what you are really telling me is ..It strikes me that what you are really saying

…I think your expectations of this situation are

distortedWhat you mean is …

Identifying and exploring positive mentalizingJudicious praiseExamine how it fells to others when such

mentalizing occursExplore how it fells to self when an emotional

situation is mentalizedIndentify non-mentalizing fillers, for example,

trite explanationsHighlight fillers and explore lack of practical

success associated with them

Provoking curiosity about motivationsHighlight won interest in ‘why’Qualify own understanding and inferences Guide patient’s focus towards experience and

away from ‘fillers’Demonstrate how such information could

help to make sense of things

ClarificationTidying up of behaviour which has resulted

from a failure of mentalizationEstablish important ‘facts’ from patient

perspectiveReconstruct the eventsMake behaviour explicit -- extensive detail of

actions and associated feelingsAvoid mentalizing the behaviours at this pointTrace action to feelingSeek indicators of lack of reading of minds

Affect elaborationDuring non-mentalizing interaction therapist

firmly tries to elicit feeling statesTherapist recognizes mixed emotions -- probe for

other feelings than first, particularly if first emotion is unlikey to provoke sympathy in others or lead to rejection (e.g. frustration, or anger)

Reflect on what it must be like to feel like that in that situation

Try to learn from individual what would need to happen to allow them to feel differently

How would you need others to think about you, to feel differently?

Stop and standPersist and decline to be deflected from

explorationSteady resolveConvert deceit into frank truthIdentify affect attached to actionEnsure ‘here and now’ aspects are included

in the challenge

Dealing with an impasseClarify your boundary whilst giving your

understanding of patient’s position in relation to it

When all avenues are explored, state the impasseRecruit group members to recognize impasses

and shift from ‘dialogue of the deaf’ to a mentalizing discussion

State own position (If we can’t get around this I may have to say that the treatment has failed and should finish).

Monitor countertransference to ensure no acting out by therapist

Stop, listen, lookDuring a typical non-mentalizing interaction

in a group or individual session:Stop and investigateLet the interaction slowly unfold -- control itHighlight who feels whatIdentify how each aspect is understood from

multiple perspectivesChallenge reactive ‘fillers’‘Identify how messages feel and are

understood, what reactions occur

Stop, rewind, exploreLet’s go back and see what happened just

then.At first you seemed to understand what was

going on but then …Let’s try to trace exactly how that came

about.Hang on, before we move off, let’s just

rewind and see if we can understand something in all this

Labeling with qualification (‘I wonder if …’ statements)Explore manifest feeling but identify

consequential experience

Transference tracers -- always currentLinking statements and generalizationIdentifying patternsMaking transference hintsIndicating relevance to therapy (e.g. that

might interfere with us working together)

Steps in MBT transference interpretationsValidation of transference feeling:Feeling is not crazy, it is real and legitimateExploration of transference:Use techniques of exploration and elaboration

aboveAccept enactment (if any):Being drawn into transference is normal, admit it,

draw attention to itCollaboration in arriving at interpretation:Use inquisitive stance to engage patient in inquiryAlternative perspective from therapistFollow patient reaction with next interpretationJourney more important than the destination

Therapist stance: MentalizingProcess of joint attention in which the patient’s

mental states are the object of attentionThe therapist continually constructs and

reconstructs an image of the patient, to help the patient to apprehend what he feels

Neither therapist nor patient experiences interactions other than impressionistically

Differences are identifiedAcceptance of different perspectivesActive questioning

Active Questioning

Why do you think that he said that?I wonder if that was related to the group

yesterday?Perhaps you felt I was judging you?What do you make of her suicidal feeling in

the group?Why do you think that he behaved towards

you as he did?What do you make of what has happened?

Highlighting Alternative Perspectives

I saw it as a way to control yourself rather than to attack me (patient explanation); can you think about that for a moment

You seem to think that I don’t like you and yet I am not sure what makes you think that

Just as you distrusted everyone around you because you couldn’t predict how they would respond, you are now suspicious of me

You have to see me as critical so that you can feel vindicatied in your dismissal of what I say

Reflective Enactment

Therapist’s occasional enactment is acceptable concomitant of therapeutic alliance

Own up to enactment to rewind and exploreCheck out understandingJoint responsibility to understand over-

determined enactmentsMonitor your own mistakesModel honesty and courage via acknowledgement

of your own mistakes -- past, current, and futureSuggest that mistakes offer opportunities to re-

visit and learn more about contexts, experiences, and feelings

Questions Suggesting Reflection

Is there something I have said or done that might have made you feel like that?

I am not sure what made me say that. I will have to think about it.

I believe that I was wrong. What I can’t understand is how I cam to say it. Can you help me go back to what was happening here before things went wrong?

Have I missed something that is obvious?

Mentalizing processNot directly concerned with content but with

helping the patient:To generate multiple perspectivesTo free themselves up from being stuck in the

‘reality’ of one view (primary representations and psychic equivalence)

To experience an array of mental states (secondary representations) and

To recognize them as such (meta-representations)

Affective focus and its representation in patient/therapist relationshipFocus the patient’s attention on therapist experience

when it offers an opportunity to clarify misunderstandings and to develop prototypical representations:

Highlight patient’s experience of therapistUse transference to emphasize the different experience

and perspectiveNegotiate negative reactions and ruptures in therapeutic

alliance by identifying patient and therapist roles in the problem

Explication of feelings draws attention back to implicit representations:

Use language to bolster engagement on the implicit level of mentalization

Highlight the experience of ‘feeling felt’ (mentalized affectivity)

InterventionsGeneral characteristics:Simple and shortAffect focussed (love, desire, hurt,

catastrophe, excitement)Focus on patient’s mind (not on behaviour)Relate to current event or activity -- mental

reality (evidence based or in working memory)

De-emphasize unconscious concerns in favour of near-conscious content

Clinical pathway for interventionsHierarchy of increasing emotional intensity:Identify the affect, not simply the behaviourExplore the emotional contextDefine the current interpersonal context

outsideExamine the broad interpersonal theme in

treatmentExplore the specific (transference) content

Spectrum of interventionsReassurance, support and empathyClarification, challenge, and elaborationBasic mentalizingInterpretative mentalizingMentalizing the transferenceNon-mentalizing interpretations -- use with

care

Which intervention to use when?If in doubt start at the surface -- support and empathyMove to ‘deeper’ levels only after you have performed the

earlier stepsIf emotions are in danger of becoming overwhelming take

a step towards the surfaceType of intervention is inversely related to emotional

intensity -- support and empathy being given when the patient is overwhelmed with emotion; mentalizing transference when the patient can continue mentalizing whilst ‘holding’ the emotion

Intervention must be in keeping with the patient’s mentalizing capacity at the time which it is given. The danger is in assuming that borderline patients have a greater capacity than they actually have when they are struggling with feelings

Function of self-injuryTo maintain the self-structure:Explore reasons for destabilization of self-structuree.g. ‘Tell me when you first began to feel anxious that

you might do something?’

Make a systematic attempt to place responsibility for actions back with the patient to re-establish self-control

e.g. ‘I can’t stop you harming yourself or even killing yourself but I might be able to help you understand what makes you do it and to find other ways of managing things.’

Motivation for self-injuryRe-stablize:Predictable, mentalizable schematic relationshipRigid understantable motivations -- ‘He didn’t turn up

because he wanted me to suffer’.Formulaic explanations -- ‘He deserves to suffer

because he is bad’. ‘I won’t come because they don’t want me there’.

Reduce panic:Establish existence:Support for bodily existence through seeing bloodWhen mental existence is in doubt reinforce existence

through your bodyEmptiness becomes partially filledRarely to control/attack other:

Pathway and interventions for self-injuryEmpathy and supportDefine interpersonal context:Detailed account of days or hours leading up to

self-injury with emphasis on feeling statesMoment to moment exploration of actual episodeExplore communication problemsIdentify misunderstandings or over-sensitivityIdentify affect:Explore the affective changes since the previous

individual session linking them with events within treatment

Review any acts thoroughly in a number of contexts including individual and group therapy

Interventions for self-harmDOExplore conscious motive:How do you understand what happened?Who was there at the time or who were you thinking about?What did you make of what they said?Challenge the perspective that the patient presents:

DO NOTMentalize the transference in the immediacy of a sucide

attempt or self-injury Interpret the patient’s actions in terms of their personal

history, the putative unconscious motivations or their current possible manipulative intent in the ‘heat’ of the moment. It will alientate the patient.

Basic InterventionsMaintaining motivation:

Demonstrate support, reassurance and empathy as you explore the patient’s mind

Model and reflectivityIdentify the discrepancy between the experience of the

self and the ideal self -- ‘how you are, compared with how you would like to be’

‘Go with the flow’ or ‘roll with the resistance’ for a short time

Re-appraise gains and identify continuing problem areasHighlight competencies in mentalization and listen for

mentalizing strengths

Supportive attitudeRepectful of patient narrative and expressionPositive/hopeful attitude but questioningUnknowing stance -- you cannot know their

positionDemonstrate a desire to know and to understandConstantly check back your understandingSpell out emotional impact of narrative based on

common sense psychology and personal experience

For the patient but not acting for them -- retains patient responsibility

Proscribed statementsWhat you really feel is …I think what you are really telling me is ..It strikes me that what you are really saying

…I think your expectations of this situation are

distortedWhat you mean is …

Identifying and exploring positive mentalizingJudicious praiseExamine how it fells to others when such

mentalizing occursExplore how it fells to self when an emotional

situation is mentalizedIndentify non-mentalizing fillers, for example,

trite explanationsHighlight fillers and explore lack of practical

success associated with them

Provoking curiosity about motivationsHighlight won interest in ‘why’Qualify own understanding and inferences Guide patient’s focus towards experience and

away from ‘fillers’Demonstrate how such information could

help to make sense of things

ClarificationTidying up of behaviour which has resulted

from a failure of mentalizationEstablish important ‘facts’ from patient

perspectiveReconstruct the eventsMake behaviour explicit -- extensive detail of

actions and associated feelingsAvoid mentalizing the behaviours at this pointTrace action to feelingSeek indicators of lack of reading of minds

Affect elaborationDuring non-mentalizing interaction therapist

firmly tries to elicit feeling statesTherapist recognizes mixed emotions -- probe for

other feelings than first, particularly if first emotion is unlikey to provoke sympathy in others or lead to rejection (e.g. frustration, or anger)

Reflect on what it must be like to feel like that in that situation

Try to learn from individual what would need to happen to allow them to feel differently

How would you need others to think about you, to feel differently?

Stop and standPersist and decline to be deflected from

explorationSteady resolveConvert deceit into frank truthIdentify affect attached to actionEnsure ‘here and now’ aspects are included

in the challenge

Dealing with an impasseClarify your boundary whilst giving your

understanding of patient’s position in relation to it

When all avenues are explored, state the impasseRecruit group members to recognize impasses

and shift from ‘dialogue of the deaf’ to a mentalizing discussion

State own position (If we can’t get around this I may have to say that the treatment has failed and should finish).

Monitor countertransference to ensure no acting out by therapist

Stop, listen, lookDuring a typical non-mentalizing interaction

in a group or individual session:Stop and investigateLet the interaction slowly unfold -- control itHighlight who feels whatIdentify how each aspect is understood from

multiple perspectivesChallenge reactive ‘fillers’‘Identify how messages feel and are

understood, what reactions occur

Stop, rewind, exploreLet’s go back and see what happened just

then.At first you seemed to understand what was

going on but then …Let’s try to trace exactly how that came

about.Hang on, before we move off, let’s just

rewind and see if we can understand something in all this

Labeling with qualification (‘I wonder if …’ statements)Explore manifest feeling but identify

consequential experience

Transference tracers -- always currentLinking statements and generalizationIdentifying patternsMaking transference hintsIndicating relevance to therapy (e.g. that

might interfere with us working together)

Steps in MBT transference interpretationsValidation of transference feeling:Feeling is not crazy, it is real and legitimateExploration of transference:Use techniques of exploration and elaboration

aboveAccept enactment (if any):Being drawn into transference is normal, admit it,

draw attention to itCollaboration in arriving at interpretation:Use inquisitive stance to engage patient in inquiryAlternative perspective from therapistFollow patient reaction with next interpretationJourney more important than the destination