by Kevin Redmayne (Medium)

Mentalization-Based Treatment is changing how we view mental health — it is in fact revolutionizing therapy for BPD.

In 1967, a teenage Hungarian refugee named Peter Fonagy was checked in to a mental health clinic in Hampstead, London. Fifty-two years later that same clinic is now the Anna Freud Centre. Peter Fonagy still resides there — not as a patient, but a doctor. Since the late 1980s he’s been on an incredible journey to understand the root cause of mental illness. A world-renowned expert in Borderline Personality Disorder his Mentalization-Based Treatment (MBT) could be the new gold standard in therapy. It all begins with that word — mentalization.

On the outside looking in

Mentalizing is the process by which we understand ourselves and each other by mental states. If we are able infer, and imagine the thoughts, emotions and motives of our own, and other people’s behavior, then we can build a strong sense of self, and regulate our emotions.

Individuals with BPD have problems with mentalizing: ‘Hyper-mentalization’ refers to the desperate almost obsessive attempt to understand the mind of others which verges on paranoia. ‘Hypo-mentalization’, refers the inability or unwillingness to understand the mind of others, and is more like dissociation. According to Fonagy those of us with BPD, have three bad habits:

1. We tend to equate our own internal state with the external world. This means we expect our experience to match reality. We assume others know how we’re feeling, and that our thoughts are as real as the environment. This is called psychic equivalence.
2. While we can intellectually comprehend the idea of mental states, we do so by detaching them from physical reality. Theory doesn’t coincide with practice, and so there’s no real understanding when a crisis hit. This is called pretend-mode.
3. Finally, we assume we know the intention of others solely by what we can see in the physical world around us. Not recognizing thoughts and feelings as predictors of behavior, we believe what is observable must be cause of it. This is called the teleological stance.

Fonagy found that individuals with BPD mentalize on the same level as children. That’s not to say we’re oversized toddlers lacking empathy — rather mentalization is a developmental achievement (not a milestone). If adults or adolescents with BPD haven’t learnt it, it’s because it hasn’t been taught.

What’s Love got to do with it?

Individuals with BPD have insecure attachment styles: Veering from relationship hyperactivity to complete deactivation, we seek intense stormy interactions, or lean toward isolation. Trading one stance for the other in accordance with our mood, we swing back and forth between approach and avoidance creating interpersonal chaos. The hallmark symptom of BPD, is mediated by mentalization, which begins in attachment.

Fonagy argues that infants aren’t just hardwired to attach to caregivers for survival, but because attachment creates a sense of security. A parent who can soothe a crying baby, provides a stable base for learning about emotional regulation. Insecure attachment on the other hand, is a strong risk factor for emotional instability and an unstable sense of self. Insecurely attached mothers, usually have trouble mentalizing the thoughts and feelings of their infants and so have insecurely attached children who also struggle mentalizing the thoughts and feelings of their mothers, and by extension their own thoughts and feelings too. The intergenerational scarring of mental illness in this case, is in not caused by genetic transmission but learnt behavior — and a little bit of biology

fMRI scans, have shown the feel good chemicals, such as the neuropeptides oxytocin and vasopressin, and the brain’s dopamine reward system, are all activated during mother-infant bonding. Securely attached mother’s feel rewarded by their interactions with their babies, insecurely attached mothers don’t. In fact, when insecurely attached mother interact with their crying babies, the part of the brain associated with feelings of unfairness, the anterior insula, lights up. Mentalization has a biological signature, and if an insecure attachment develops in infancy, it will sustain itself even into adulthood.

The Broken Mirror

The self is born in the eyes of others. In the first few months of life a baby begins to discern emotional states by watching their caregivers facial expressions, and correlating them with their own physiological state. For example if a baby cries and mother responds with sympathetic cooing, the baby learns what sadness feels like. If a baby smiles and a mother smiles back, the baby learns what joy is. When a mother and baby’s facial expression match it’s called Mirroring.

Mirroring must be congruent, meaning mothers must accurately discern their baby’s emotion and align their expression to it. However it must also marked, a mother’s facial expression, should match their baby’s facial expression, but shouldn’t necessarily depict her true emotion. If a baby smiles, but the mother grimaces, or a baby cries and the mother sheds real tears, problems emerge: The self is broken into fragments.

Most of the time this mismatch isn’t intentional and parental stress and infant temperament play a part. Other times, non-responsiveness is deliberate, and a precursor of childhood maltreatment. If trauma’s involved in BPD it’s like the bits of glass which form the shattered self, are razor sharp and pointing inwardly.

Traumatization

Up to 70% of individuals with BPD have a history of childhood trauma. However, clinicians don’t know whether BPD is a disguised form of PTSD or a condition in its own right in which adversity plays a part. Most likely, chronic interpersonal trauma is an aggravating factor in the development of personality disorder. It distorts attachment and impedes mentalization even further. Children who are abused, ‘hyper-mentalize’ as a way to predict erratic adult behavior, or inhibit mentalization as a way to avoid thinking about their parents wish to harm them. If abuse is further met with invalidation on the part of caregivers, accurately linking mental states to behaviors becomes impossible. If a victim of sexual abuse is told they ‘want’, ‘deserve’ or ‘like’ what’s happening, they may become phobic of looking into another person’s mind. On the other hand, a person subjected to physical violence, may want to invade the mind of another in order to foresee danger. Trauma severs the link between mental states and behavior, and meaning is obliterated.

A further complication occurs when children internalize images of their caregivers. If a child is subjected to ambivalent displays of love and rejection, they will create ‘good’ and ‘bad’ images of that person. This leads to the future emergence of the BPD symptom of splitting; a defense mechanism marked by idealization and devaluation of the self and other. If the caregiver’s abusive, the person on the receiving end, will inevitably take on such qualities too: The image will be that of an ‘inner critic’ or ‘bully’ who may insist the individual hurts themselves leading to BPD symptoms of self-harm.

Alternatively, if an individual is overwhelmed by this bully or inner critic, they will push it onto another person, forcing them to take the role of persecutor. This leads to the BPD symptoms of excessive anger, paranoia, and also further abusive relationships. Traumatized individuals may be drawn to malevolent people who can take on the role of persecutor willingly, or they will self-sabotage and scare decent people away. Good and bad internal representations need sorting out, but this is impossible without mentalization.

If the mirror is shattered it can still be repaired. If mentalization is lost it can still be recovered. If you have Borderline Personality Disorder, whether it was caused by insecure attachment, or abuse, you can still get better. First of all we need to look at how the environment stops us mentalizing.

The Glass Castle

Some home’s are like glass castles: Fragile and opaque, if they are breaking no one can see the cracks. In dysfunctional families marked by ignorance and avoidance, family members are often too stressed to listen and too afraid to talk. Comments like ‘go away’ or ‘I’m busy right now’ abandon a child to their own thoughts. On the other hand in a disordered family marked by interpersonal conflict, communication is used as a form of attack. Comments like ‘you hate me,’ ‘I hate you,’ or ‘you are doing this to hurt me’ throw a dark veil over a child’s understanding of motivation. Finally, in perfect families honest conversation is distorted. Comments like ‘you don’t feel angry,’ or ‘you’re misinterpreting it’ threaten a child’s viewpoint, and teach them to distrust their own emotions. The facade of a loving family, under the weight of non-responsiveness soon crumbles. The home becomes a battleground with families left in ruins.

Borderline Personality Disorder, occurs because the mind of the individual, having been abandoned childhood, perceives itself to be alone. It is like looking at people as if through a dirty window, seeing only vague shapes and shadows. Meanwhile, over the sphinx-like self, lies a riddle: Who am I, what do I want, how do I feel?

Teachers, doctors, and clinicians, can all play a part in recovery, however all too often, they let their own assumptions determine the outcome, meaning they can also hinder it. A non-mentalizing clinician is especially dangerous. The psychiatrist who stigmatizes, the psychologist who obfuscates, the educator who starts blaming, cause further iatrogenic injury to a person who has already lived their life feeling misunderstood. The family dynamic of non-responsiveness repeats itself in the wider environment, only this time, it’s backed up with the seal of authority. The forgotten child, becomes the persecuted adult.

Those in glass castles shouldn’t throw stones. Those accusing individuals with BPD of lacking empathy should look in the mirror. If it’s crystal clear, they should recognize the prerogative to judge is a privilege not a right. It was gifted to them by good parents and wide support network. Therefore when encountering individuals with mental health problems they should adopt a stance of not-knowing. Be humble, listen and learn from those who suffer, because most of the time they know more than you think: The knowledge is not gleaned from a books, but real life. The experiences are legitimate, so to the broken mirror stared into each day.

In the end it’s elementary: Mentalization just means acknowledging someone else’s existence, seeing them as a complete human being, with thoughts, feelings, and motives, rather than an empty idol. Show us a broken mirror we’ll spit the shards of a broken self back at you, show us one that’s crystal clear, we’ll see the best versions of ourselves, and share it with the world.

Seeing Clearly

We return now to Dr Peter Fonagy — what exactly happened in 1967? As a young adolescent, alone in a foreign country, and not speaking a word of English, Fonagy was planning to commit suicide. A chance encounter with a neighbor near Kew Gardens, meant a fast-track referral to Hampstead clinic. It was here he underwent intensive psychoanalysis and the mind shrouded in mystery revealed itself.

It was a seemingly innocuous event which changed Fonagy’s life. While reclined on the couch gushing about his new car — an old Ford Anglia — his therapist broke the script. She got up walked to the window said ‘Peter that is a wonderful car’. For the first time, Fonagy realised he wasn’t alone. He could share his thoughts and feelings with others and be understood, and vice-versa, he could understand others. This is the basis of Mentalization-Based Treatment and the foundation for recovery.

When we collaboratively talk about thoughts and feelings in a sincere way, the broken mirror becomes a crystal ball, as we begin to accurately infer intention. Soon the glass castle becomes a stable home as we find the security we never knew existed. It’s at this point, the forgotten self and exiled world are invited back in.

** If you want to find out how to mentalize more effectively, or how to recover mentalization capabilities visit www.rightresilience.com

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