reading notes

Mentalization-Based Treatment for Personality Disorders: A Practical Guide

Anthony Bateman & Peter Fonagy, 2016

tldr: This was the first book I read that was written for practicing clinicians, and it gave me an opportunity to imagine myself in the role of clinician more concretely. It also gave me a more structured understanding of mentalization, though I have to admit I still find the boundries between “mentalization” and other concepts like “self-awareness” and “theory of mind” a bit blurry. One definition from the book: mentalization is “perceiving and interpreting behavior as explained by intentional mental states”.

new terms: Epistemic Trust

This book is written for clinicians - it’s a mix of conceptual frameworks and details of clinical application.

Mentalization: “perceiving and interpreting behavior as explained by intentional mental states”

The target population for the therapy described in the book is primarily adults with borderline personality disorder. It also includes sections about understanding and treating antisocial personality disorder with a modified mentalization-based approach.

The fundamental claims here are:

personality disorders are characterized by failures of mentalization
mentalization can be improved through therapeutic relationships where mentalization is modeled and practiced
improvements in mentalization reduce the severity of personality disorders

The books consists of 4 sections - I: The mentalizing framework, II: Mentalizing Practice, III: Mentalizing groups, IV: Mentalizing the system.

I: The mentalizing framework

A dimensional understanding of mentalization:

automatic vs controlled: healthy, secure relationships mostly function automatically. controlled is activated when we hit an error. it’s analogous to learning a physical skill - when you’re in the groove, you’re operating automatically, but when you’re learning or need to correct an error, your concious attention is engaged.
self vs other: a good model of the self, a good model of the other, an awarness of their interdependence but also a sense of separateness.
internal vs external: working from the inside out vs the outside in.
cognitive vs affective: naming/recognizing/reasoning about mental states vs feeling them.

Adaptive, healthy mentalization is a context-dependent balance across these dimensions.

Arousal, and particularly arousal related to attachment, inhibits controlled mentalization and can lead to nonmentalizing.

The authors describe nonmentalizing as a failure of mentalization and a re-emergence of more primitive, pre-mentalizing processes.

psychic equivalence mode: concreteness of thought, no doubt about the accuracy of perceptions
teleological mode: states of mind are recognized and believed only if their outcomes are physically observable.
pretend mode: hypermentalizing / pseudomentalizing - no connection between narrative and reality.

These failures in mentalization can be understood as extreme cases of inbalance in one or more of the 4 dimensions listed previously.

“externalized alien-self” and “epistemic trust”

I’m not so sure about the alien-self thing - I need to think more about it. They talk about it as a form of projective identification, which to me is a little more clear and something I think I’ve observed in real life. Guilt or shame is in someone, subconciously, and by some mechanism it is expressed as a perception about the other. The authors seem to be claiming mentalization protects against / smoothes over this tendency. Like I said, I need to think more about it. They cite Winnicott Playing and Reality (1956) in their explanation of how we end up with these unintegrated, subconcious “alien selves”.

The authors seem to think restoring epistemic trust is an important common factor therapies that work. I think this is almost certainly true - you need to be open to new information to change your mind. I’m not sure about the connection between epistemic trust and mentalization. Again, I’ll need to think some more.

mentalization and bpd

dsm-5 borderline criteria:

a pattern of unstable intense relationships
inappropriate, intense anger
frantic efforts to avoid abandonment
affective instability
impulsive actions
recurrent self-harm and suicidality
chronic feelings of emptiness or boredom
transient, stress-related paranoid thoughts
identity disturbance and severe dissociative symptoms

The authors boil it down to 3 core features:

emotional dysregulation
impulsivity
social dysfunction

TODO: pg 42 - connect 3 above to BPD

TODO: assessing mentalization

Some unfiltered thoughts on mentalization as I understand it:

Mentalizing depends on having a working model of your own mind (your sense of self) and others (theory of mind). These models are (or ought to be) highly interconnected. You need good models that work well at verifying levels of automaticity, you need them to be stable and accessible, you need to be able to update them as you learn. For these models to be good (adaptive, healthy), they need to be congruent with reality across time.

Good models also include meta-properties about the models themselves. They are flexible, knowing they can and should be updated. They know they are models - the underlying internal states (thoughts, feelings, desires) are opaque… the models can only make inferences about them.

(In writing and thinking about this, I had a strange shift in my own self-awareness, a stronger sense of my own self)

It seems strange that we don’t have full awareness of our own thoughts, at the very least, but considered accross time this is obviously true. My model of my self can only make a guess at what I thought about yesterday, and how those thoughts connected to my actions.

II: Mentalizing Practice

TODO

III: Mentalizing groups

TODO

IV: Mentalizing the system

TODO

Psychoanalytic Diagnosis: Understanding Personality Structure in the Clinical Process

Nancy McWilliams, 2011