Psychiatry & Psychotherapy Podcast - Mentalization-Based Therapy (MBT) Explained: Practical Techniques to Improve Clinical Outcomes in Borderline Personality Disorder, OCD & Narcissism

Episode Date: July 29, 2026

In this episode, Dr. David Puder speaks with Robert Drozek, clinical director of the Mentalization-Based Treatment (MBT) Clinic at McLean Hospital and teaching associate at Harvard Medical School, about practical Mentalization-Based Therapy techniques to improve clinical outcomes in borderline personality disorder (BPD), OCD, and narcissism. Drozek explains the "What, Why, and How" model of mentalizing, how to address psychic equivalence (rigid certainty), pretend mode, and teleological thinking, and offers concrete strategies clinicians can use in session and assign as between-session work to help patients reconnect with difficult emotions, reduce intellectualization, and develop more flexible, reflective ways of understanding themselves and others. Link to blog Link to YouTube video

Okay, welcome back to the podcast. I am joined by Robert Drozek. He is the clinical director of mentalization-based treatment clinic at McLean Hospital in Massachusetts. He is a teaching associate and the Department of Psychiatry at Harvard Medical School and specializing in borderline personality disorder, narcissistic personality disorder, and PTSD. He is the author of a new book, mentalization utilizing reflection to heal from borderline per sali disorder. This is the first book for the general public about mentalization based treatment. And so where would you like to start out? Well, first of all, David, great, I'm really happy to be back. I think you knew you were the first podcast. I think I was ever on when we were releasing the narcissism book a few years ago. And

I just love that conversation. And so I'm excited to kind of talk with you again. So So really happy to be here and where to start. I'm mentalizing the audience, which means I am imagining what they're feeling, thinking, desiring. They want practical knowledge that helps them be better clinicians. And so, yeah, how are you mentalizing the audience? Maybe we can start there. Well, it's a good question.

I guess my first question is, do you feel like your audience knows, like, kind of like what mentalizing is even in the first place you would say. Yeah, maybe I think it's a good place to start. And there's actually some kind of like code words that I feel like are used in the sort of subgenre mentalization based therapy. So maybe we could start by defining it. Oh, cool. Yeah.

Well, basically, you know, for those, you know, I think this podcast, I think more than any other, you really, you spend a lot of time thinking about mentalizing and reflective function and really have, in my opinion, like leaders in the field to kind of talk about that. So, but those of you who might be newer or need a refresher, like mentalizing is the ability to read, access, and reflect on mental states in ourselves and other people. And really, mental states, it's kind of like all the invisible stuff of the mind. So thoughts, emotions, desires, attitudes, values. So that is the kind of kind of. core aim of MBT, which is to sort of stimulate reflection in the areas where patients tend to

really struggle. So for BPD, we would be kind of a borderline personality disorder, we would be kind of trying to really help folks with their insecure attachment, with their difficulties with self-injury, with maybe their anger issues. If we're kind of helping folks with narcissism, we would want to kind of like aim mentalizing at their conditional sense of self-worth, maybe an elevated sense of self or a dismissiveness of other people's perspective. So depending on what the kind of problem area is, we kind of, the shape the mentalizing takes is different, but the through line is that it's reflecting on what's going on inside of ourselves and other people.

Okay. Yeah. So it's different than empathy. Because how would you define empathy compared to this? Well, I would suggest empathy is like a species of mentalizing because there are different components of it. Actually, one way I like to define it, it's like reflect and connect. You know, we've got to get patients considering their minds and the minds of others,

but not just thinking about them. We've actually have to help our patients connect with their own emotions and connect with the emotions of others. And so empathy is really not just reading others, but caring about others. And that is a part of mentalizing, but it's like a kind of sub, you know, kind of like a subpart of it, basically. Okay. So like let's say you have someone who's newly in a relationship. They're over the moon.

They're having a great time. Okay. They're in this kind of like the honeymoon phase of the relationship. They're just overjoyed, all positive. And then they notice a slight withdrawal of the other person. Yeah. Okay. And this triggers intense abandonment.

Now, they feel this. Maybe there's some truth. Maybe there is some withdrawal. But then how can someone, let's say with more of an insecure attachment style, add into that their own fears, their own stuff, right? because mentalizing would be accurately seeing reality, accurately seeing what's going on in the other person. Yeah.

So it's like they're adding in some extra stuff there. Yeah, the idea that almost their own insecurities are kind of leading to them to interpret the other as potentially, like, and maybe as kind of this person's pulling away from me, where really it could be a range of other different things that could be happening. Is that the idea? Sure. Well, maybe they are pulling. away a little bit. But, but it feels now, like, so awful. It feels so horrible. It feels catastrophic to

them. Yeah. If you're a therapist, how do you show your patients how to mentalize in scenarios like the one you've just described? And essentially, one way to kind of spell it out in like a really like clear, like step-by-step fashion is the what, the why, and the how. Okay. So I'll say it again, because it's so important, the what, the why, and the how. So we got it when we're mentalizing, the first step is we've actually got to put words on what's going on for us and what's going on for others. And for this patient, the hypothetical patient you're describing, you know, we would want to be understanding, what is this bringing up for you, what are you feeling, right? And obviously, we'd ask any patient that. And we would want to really be considering the partner's mental

states. You know, how do you interpret? Like, what's your sense of what could be going on for that person? And then also broaden it, because often with these patients, there are what we call biases in mentalizing. They, they, you know, there's been research on this in BPD. It's that neutral facial expressions will be read as negative, right? So in those moments, we're going to try to do clinically is to try to expand the array of mental states we're considering in the other. That's like base level mentalizing.

The next level is what we call why mentalizing. What could this be about for the partner or the new person? What may, you know, could it be about something going on in their life? could it be something that you actually are doing to potentially push them away? You see, that's like a higher level mentalizing, not just putting words on feelings, but kind of broadening it out a little bit.

Okay. And that's sort of the second tier of mentalizing, and then kind of really where the money is, is looking at disruptions and how the person, really the process that they're engaging in to read others' mental states, and I think right now that really gets at the heart

of what you're saying, which is for a lot of folks with BPD and insecure attachment, there are problems with certainty. You know, I know he's pulling away from me or she's pulling away or they're pulling away. I know that without this relationship, I'm not going to be okay. You know, I need this relationship in order to be okay. Something like that. So then the kind of the highest level mentalizing is process mentalizing. where really what we're trying to do is, you know, help patients see how they can get a little stuck in their perspectives and hopefully helping them to be more flexible in their way of seeing or interpreting relationships in themselves.

Okay. Okay. So this is good. So we're, so think about like the why. Okay. Help me think through the why on this, the specific scenario. Like, why are they pulling away? Is that it? Yeah, yeah. So, Bob, they're pulling away because they don't want to be with me anymore. Okay, they figured out I'm defective. Okay, and I'm sure about that. Okay, yeah, yeah. It feels, that feels 100% true. Okay, okay, yeah, yeah.

So what I'm doing right now, by the way, it's just kind of pull back from this. I'm not thinking, I'm not thinking, I'm not thinking. I'm going to go through a roleplay with you. Okay. I'm thinking what we're going to, what we want to really talk about is that, so we're seeing this in the session. We're seeing this air of mentalizing, okay?

For us as the outsider, we're looking at this, and we say to ourselves, well, there's this certainty that this person has, and it's creating this awful, awful feeling inside of them of abandonment, maybe they're suicidal now, Maybe they're going to act erratic. Maybe they're going to do something in the relationship that is going to create a real conflict. Mm-hmm.

Yep. Okay. And so the why is certain. The why that they perceive is certain. Definitely. Yeah. They know the reason. They know what's going on.

Right. Yeah. Okay. Well, so this is essentially the clinical question here, which is worth thinking about for your listeners is, one is, in the moment that we're encountering that certainty in the mind of the patient, what can we do about it? That's kind of one question. What I'm trying to do in this kind of new model of mentalizing is, let's say outside the heat of the moment, how would we teach patients to target and address their own certainty? So they're kind of different

questions clinically. And a lot of our work in MBT, thus far has been teaching clinicians how to address it when it arises in the session. And essentially, there's this other technical option, right, which is that how, for our patients who struggle with that certainty, outside the heat of the moment, how do we actually teach them to look at their certainty? So it's kind of a choice point, if that makes sense. Right, right. It's like in the moment, it's hot. Yeah. So you don't always strike the iron when it's hot. Totally. Yeah, yeah. MBT's line is, strike when the iron is cold.

Okay. So in the moment of hotness, for a patient, they may have a different set of things that may help them cool down a little bit. Yeah. And to create some ability to then reflect. So in that moment, they've lost their ability to mentalize. Yeah.

And their reflective function would be low. there would be assumptions, there would be this kind of like, they're mind reading, they're like a more CBT model, right, their mind reading, they're all or nothing thinking. Okay, so then what do you do in the moment? What's the tendency of an MBT clinician to do in the moment? Okay. Well, so, yeah, so the first step is to invite the patient to reflect on how they get there. So we don't challenge it in the moment. That's always the first step. Okay, so it's really clear to you that your partner is pulling away from you. Kind of what clues you into that?

Don't challenge it. Ask them to start making their case. Okay. And when the patient may say, well, he hasn't responded to my text in three hours. Okay. Or, you know, or, you know, we haven't been having sex as frequently as we have. when the relationship started or something like that, right? And then you're just as a therapist, you're just kind of like trying to kind of gather.

I see. So for you, and then you empathically summarize the case, right? He hasn't responded to your text. You're not having sexes frequently. He kind of like hasn't yet invited you to kind of, you know, visit his parents or get to meet his parents. So that feels for you, that really shows that he is pulling away from him. Yeah.

And so that's the first step. Second step is, according to MBT, is examine or explore the impact of the certainty. So then you ask the patient, so wow, so for you to have this sense that he is pulling away from you, what does that do to you? And then the patient will share about their feelings and sort of like, you know, basically like all the kind of emotional consequences of feeling quite certain of this thing. Yeah. Okay.

And then once we get there, that's all within the patient's viewpoint. Now we've got to start working towards seeing things more broadly, more from a broader perspective. And the best, this is what Anthony Bateman, who I know has been on this podcast before, will say, you got to find a chink in the armor. You got to find some area of kind of flexibility or nuance within the patient's perspective. You know? And it may be something because actually when I think when you're like laying this out, I just say, I just want to check in. You said earlier that it, quote, seems like he's pulling away from you.

What were you getting at there? Okay. Interesting. You caught that, right? It's the, it's, it's maybe not how it was felt by the patient. But I added that as someone who's mentalizing the, the patient's experience. But for the patient themselves, he is pulling away. It's true, but when patients talk about it, and as you ask them these questions, what's the case, what clues you in, how does this impact you? You will hear, and often if you're listening, you will hear something that will just be slightly more multifaceted or nuanced, slightly more reflexible. Okay, you're noticing the moment of higher reflectiveness. Yeah, you're noticing this chink in the armor, okay, so to speak.

Yeah, go ahead. But then when you do that, when you find it, the job there is open it up. Don't make your case still. Like I'll say, yeah, you said seams. Can you say more about what led you to say seams? And then just have them open it up. So it's a kind of a cool technique. It's not CBT.

It's not like try to kind of argue against your own perspective. or try to revise it, it's that we've got this pathway of certainty. Now let's open up this other pathway right alongside it. So that's step three. So we have examine the case, examine the impact, explore nuance from within the patient's viewpoint, and then the final step of how we treat,

and we're calling a certainty, as you know, in MBT, the technical language is, quote, psychic equivalence mode. like basically like I because I think it it makes it true so the final step in treating psych equivalence or certainty in MBT is to share our own perspective and this is something that I think is really important because for especially for therapists who are a little more exploratory in nature or they are kind of taught to kind of be very client-centered and kind of just kind of like be a little more kind of validating of what patients are bringing, a lot of times therapists will not actually

share their view. And in MBT, because it's about two minds in the room, we have to share our view at the end of the sequence. So in this case, for me, it could be me saying something, like my different view might be, you know, it's not, as you share about this, I hear all your points. And it's not quite clear to me yet how much of this is that he's pulling away versus could this be somewhat of how the relationship is just unfolding? Because in my experience with relationships, there don't tend to be at the same level of intensity like all throughout. What do you think about that?

You share your mind and ask the patient to kind of consider your mind. You know, there might even be a side move you do, though. too. You may end up saying something like, you know, this makes me think a little bit about the last relationship and you had a similar concern, right? That may be the move. We don't actually take issue with it or we just kind of broaden it a little bit and then have the patients consider our mind. So those kind of four steps are the steps that clinicians can engage in or use in the moment to try to kind of like address patients maybe like rigid thinking. Okay.

Yeah. So it's like you're, you are taking your own reflective stance and then asking them to reflect on your reflective stance. Exactly. Yeah, definitely. But do it at the end, not the beginning. Because if you do it too early,

patients will feel like we're invalidating them. Okay. So it's always start within the patient's viewpoint. they need to feel seen by us. They need to feel like we're really getting what it's like to be them. And at the end, they've got to actually get a sense

of what it's like to be us. You know, we're kind of, but we kind of include that at the end of the sequence, but you've got to have both for it to be MBT. So, okay, we've talked a little bit about psychic equivalence. Tell me about how pretend mode

might apply in this scenario. Yeah, definitely. Or, well, in this scenario, This does feel more like psychic equivalence, but yeah, we can talk if you want. Okay, so it's kind of like the person is talking about something detached, not really emotionally congruent.

They're emotionally decoupled from the real experience. So it's like, oh, what's happening is my insecure attachment and my, and they're using these big work. to describe, you know, maybe that they don't really feel resonating. They're not resonating with these big words. Yeah, definitely. So it's like, or how would you just define how this could be taking place? Definitely.

Well, so pretend mode is essentially disconnection from authentic mental states in self and other. And there's really like, I would say, like three types of pretend mode. There's disconnection from self, disconnection from other. others, in other words, like problems and empathy, or disconnection from reality, which is something that we see a lot in narcissism. So there are these three kind of forms of pretend mode. So this is one of the hardest things, in my opinion, to treat in therapy. So that was one of the things I was most excited about in terms of actually kind of like, because essentially the broad technique we use in an MBT for pretend mode is challenge.

It's getting more in reality, asking factual, clarifying questions, and ultimately bringing in our mind in a way that disrupts the patients. But how do we help patients do this themselves? It's a little challenging, right? Or maybe because there's no therapist, if you don't have a therapist to challenge you, how do you then get more connected? So basically, I think this is sort of, how do we teach patients to get connected to themselves is essentially the question. And the first step is helping them identify essentially what is the emotion they need to connect to.

Like you can't access it if you don't know what might be there. It's definitely not anger because I would never feel anger. Okay. This is the thing. I would propose, David, you're playing the patient there? That's certainty. Right? So I wouldn't be treating.

Okay, okay. Yeah, you know what I mean? Like, but if it's, yeah. But I think what I think what I'm kind of hinting at is, for good reason, people may not want to say that they would feel various emotions. Definitely, definitely. And if that's the case, then it's a problem of certainty. you got to treat the certainty first. Okay.

Because there's often self-judgments around what emotions they're feeling and they can't find them because it make them feel bad about themselves. Yeah, self-judgment. Okay, so the self-judgment keeps people from being congruent or seeing what they feel.

Yeah. Okay, so then getting back into pretend mode, so they might pretend in a way to be disconnected. from what they're really feeling. Yeah, it's a good point. That's how that's one of the challenges of the term pretend mode

is that literally the word pretend is in it, but in general the way that it's used is it's more just that often people when they're in pretend mode, they don't know what they're feeling. They really are just, they're really just disconnected or they kind of know, but they're just not feeling it. So an example, like,

Basically, the proposal is this. We can treat it in session, but what I'm proposing now is that in addition to that, we've actually got to help patients access emotions outside of sessions as well and teach them how to do that. So, for example, if you think of a patient who really struggles to feel a certain feeling, can you either hypothetically or a real patient you have,

what's a specific emotion that you think, that you think one of your patient struggles with? To find. Let's, yeah, let's go with the anger. Perfect. So, but let's put it to a clinician. So let's imagine a clinician coming to you that struggles with the thought that they could ever be angry.

Yes, love it. Okay. That's very common. Very, very common. You know, anger can feel very dangerous to people and they can struggle to find it. So there's the one pathway to treat it is the certainty stuff. The other pathway is to just really try to help them connect more with the anger. So basically, just to kind of go through, if you wanted to kind of work with,

if you're going to help a patient with that, it can't just be in the moment. Like, you're going to need to kind of, I would propose, like, there's going to need to be worked on outside a session, like, you need to kind of give some mentalizing assignments, so to speak, where the person starts by putting the anger they're trying to, they're putting the emotion they're trying to find and access. So they would write down anger. The first step is to actually, like, try to essentially imagine what it would look like, what would it look like for me to access this anger, try to really envision the accessing of it,

you know, have them kind of like imagine I could see myself doing this, I could see, so actually kind of like spelling it out. The other is actually what we call invoking an emotional memory. And they've got to kind of do this on their own. You can help them with this, but say, I'm just curious,

is there a time in your life where you can remember actually feeling angry. Tell me about it. And then you kind of invite them into that. The other is, and this is something that Act does a little bit too, acceptance and commitment therapy, but you sort of imagine somebody being with you

where if they were kind of relating to you in a certain way, it would be easier to find the emotion. So is there anybody in your life that you find it easier to access that anger with. Okay. And then you kind of instruct patients, I want you to write about that, write about what it would look like for you to be with that person and to feel or access like that feeling. Additional steps, self-validation.

A lot of times to your point that you were making, like patients who struggle to feel a certain thing, will they have judgments of themselves for feeling it? So if they write out, it's reasonable that I would feel this way because. And then finally, the last step is just having them close their eyes and to really try to inhabit the emotion in question. So this is an example of what it looks like to kind of teach the skill of treating pretend mode. and my experience sort of like as patients are kind of practicing this more and more is over time they get better at feeling the feeling. Yeah.

So, you know, it seems like this is kind of like intellectualization, isolation of affect, rationalization, you know, denying the emotional reality. Sometimes there's some somatization that takes place with this kind of like distancing. from the actual emotion, I like how you're pulling together these different types of lines of reflection, reflecting upon, right? So these are reflecting upon, writing upon both a time where you were angry,

a time where you were able, or a person you're better able to connect with in the midst of anger, or the person you feel the safest with, right? Exactly, yeah. I was thinking about how, So I've been teaching cohorts and we'll do writing assignments. And some people will heavily intellectualize early on.

Oh, yeah. They have maybe the language of a psychotherapist, right? They have big words that they can pull upon. And they'll throw in all those big words together. And it kind of distances themselves from what they're actually feeling. feeling. And in the process of leading these groups, one thing I've realized is that it's almost like you have to start with trying to get to a lower reflective function writing. Nice. Oh, say more. I love that. Yeah, yeah. So the lower, so, so because people think

that they have to articulate in a certain way to be accepted, right? They're imagining me wanting a certain, you know, these more psychodynamic language or more, you know, they, they want to be appearing articulate or all put together. And so they write in a certain way that's distancing themselves from their own internal experience. Okay. Definitely. Yeah. No, it's a huge thing. And to be honest, what I start by saying is that we need to actually, I call this like stop dissociative behaviors for like literally stop doing actions that disconnect you from yourself

because you can't you're then you're working across purposes right for a lot of people especially smart people one of the biggest behaviors you can engage in to disconnect yourself from your emotions is talking like talking people I see this in groups when somebody starts to feel something and then they start talking and they kind of, they choke up, and then they start talking, and they leave the emotion. So there, from an MVP perspective, we'd want to say, I just want you to pause.

Don't say anything. Yeah. What were you just feeling? And you're right. The more words, the less feeling, and you've got to kind of start it more basic, or else the person's going to lose the emotion. Right. More words, especially, you know, like the doctor.

and the higher, you know, professors. It's like words are a way of obfuscating away from, right? So it's like just because the words articulate word doesn't mean that there isn't a heavy degree of intellectualization. Definitely. And the more primitive stuff can seem like a lower reflective function starting point, you know? Yeah, it's a good point. Yeah, that's why I like to say, like to define.

mentalizing is reflect and connect. Sometimes we need more reflection. Other times we need more connection. And so you're right. You're going to turn down the reflection a little bit and kind of like beef up the inhabiting. The inhabiting, right, yeah. The inhabiting, yeah.

So I like how you are kind of like assigning people or sort of getting people to think about, like, okay, what is the time that you did feel angry? Talk about that, right? And you could get someone to do that, and then they could almost distance themselves in the talking about it. So as a clinician, we're looking at that.

Right. And we're being curious about, like, are they, the more they talk, are they distancing themselves from it? Definitely. And then in the midst of, you know, finding that person they're most able to share that emotion with, you know, which it could be you.

could be the therapist, right? Like potentially long term. Oh, that's true. Yeah, yeah. You know, like, oh, this, you know, how many times have you heard from a patient like, I feel safe being angry or feeling something that I don't feel safe with other people? So true. Definitely.

Yeah. So we're talking about how do we kind of overcome the intellectualization, the isolation of affect, how do we get back to the real emotion without hypermentalizing, which is another thing you guys talk about this kind of like distancing yourself with a lot of words over analytical hyperreactive RF definitely and I think that's where it's tricky so where so when I talk about like writing a lower reflective function it's like getting more in touch with the raw feeling I think and then from there it's like okay why am I feeling this raw this the rawness of this Well, this is a good question.

So basically, why questions? In general, in MBT, we don't kind of ask explicit why questions for a couple of reasons. One, this is exactly what you're saying. When we ask why, that pulls more cognitive, right? So in general, we're not going to ask why. We are going to probably, you know, we're going to be curious about where it comes from. But if the person is more disconnected, we would not want to be like, where is this coming from?

We just want to say, I just want you to pause. Try to tell me, what are you feeling right now? We want what questions when the person is more disconnected. And then if they start talking, well, I think what's going on for me is I'm, no, no, no, no. What is the emotion you're feeling? Like, you almost got to get them to stop talking and just focus. on what's happening for them in the moment, or can you just put words on what you're wanting right now?

And then, I think what's important to me is that I really get better, no, no, no, no, I'm saying right now in your interaction with me, what's the wish? So you almost have to kind of stop the intellectualization in its tracks and reorient to present affect. If you're working on it in the session, that's like we would have to be very active,

in MBT. That's what we'd be proposing. Okay. So this is the interesting conundrum because the why questions are the demand reflective questions in the adult attachment interview.

Okay. And so this is always, this has been a puzzle, but I think we can kind of like make sense of what's going on here. Right, right. So in the adult attachment, interview when you're when you're trying to gauge a reflectiveness your demand you're you're you're

asking a why question well why do you think your parents behave the way they did why do you think you felt that way right which um and interestingly when they looked at uh transference focus therapy which is the therapy where they've looked at reflectiveness before and after which is it's kind of um it's kind of a funny research competition between you guys and Transverse-focused therapist. Because they used your own early research to show that their research was superior to not to your research,

but to the other, you know, things like the dialectal behavioral therapy and such. Right, right, yeah, yeah. So they were looking, and there's more why questions in their therapy profile. Oh, in TFP. There's more, yeah, there's more demand questions. And something like twice as much in this one study they did where they were looking at transcripts.

So, but I kind of remember the words of my mentor, Dr. Tar, and he said, be careful with why questions, because it can induce shame. Because a lot of times people don't know why. Exactly. And what I found with clinicians in kind of like asking the why questions is sometimes it can induce shame. because they may not know why, right? Exactly. Yeah, definitely. And also I would propose that sort of one of the challenges here is that often when we're

asking why questions, that presumes that the why matters. Okay, okay. But going back to this initial example of this person that felt abandoned by their partner, okay, if you were to ask them an early, well, why did this happen? Right? They would give a low reflective answer. Well, obviously, with 100% certainty, they're rejecting me. They're tired of me. They've lost interest in me, right? Whereas if you did all these steps that you gave me and you asked that why question again, then they would say, well, at first, I felt like I was 100% sure that they had abandoned me. Yes. Yes. But now after talking with you, I'm really.

that this is kind of this pattern that I've been having throughout my life where I will jump to certainty that this person has rejected me maybe before they fully have, right? And with that certainty, I'll act in a way that maybe pushes them away. Love it.

But what I'm realizing is that it's because I've had this deeper longing for this type of love and I'm just so hungry for it because I didn't get this maybe in a stable way. Yeah. Okay, so, I don't know.

Do you see what I'm talking about? You're making the point that if we target the certainty and essentially what we call process mentalizing, that patients will then be able to kind of reflect on where this is coming from in a more flexible, nuanced way, which that is definitely MBT's argument, like essentially stimulate a process of reflection, and then patients are going to be in a spot where they can see things from a variety of perspectives. I would still propose, though, we need to give patients more resources

to kind of understand where all these things are coming from. And so part of it is that essentially, if people are trying to, let's say they know, okay, so in this case, they feel clear that what's a mental state that they think is going on in their partner. It's like the partner's pulling away from me. I guess. So the question would be,

all right, so let's presume that there's some way in which your partner is not wanting to engage with you as much. Bracket, that's a mental state, right? That's a mental state in the other. Then there are basically, arguably, three things that could be causing that.

Something in the partner's life, some other emotions the partner might be feeling, or behaviors that the partner or the patient are engaging in. So essentially, situations, emotions, behaviors. So that is very, very common for people with BPD to not know why they're feeling what they're feeling or why others are kind of feeling what they're feeling. So, all right, think about it. What other situations are going on in your partners like? that could be affecting, you know, their wish to engage with you. Okay, consider that.

What other emotions could your, could be actually happening in the partner that could be impacting this wish? And then finally, I'm just curious, is there anything you've been doing that has been impacting your partner's level of potentially like interest in connecting with you? Well, I was critical of him last week. Okay, tell me more. So the idea is if we can sort of, there's a whole structure to do this

that patients can do on their own where they can basically try to see things more broadly, and that would be the hope, is that if they are able to consider situations, emotions, and behaviors, that actually that can broaden out the reflection. But we got to kind of give them some education about the ways to do it.

Because a lot of times in therapy, to your point, patients don't know how to do it yet. I think, and we're sort of watching as well for the second portion, right, are they starting to over-intellectualize? Are they isolating away from their affect? But I love those steps. I think that is great.

I think that maybe the pet peeve, of modern therapy is that instead the therapist goes bad on the partner. Okay, wait, sorry, what do you mean? How? Yeah, I mean, this guy is, you know, pulling, he is gaslighting you. He is, he's stonewalling you is what's really going on. He is, he's love bombed you, and now he's withdrawn, right? And that withdraw is part of the game that he's playing. Oh, man. Yeah. Go ahead.

No, I just totally, I totally hear that point. Like, you're right. Like, therapists can almost align with the patient's certainty and then get what we, an MBTB we call teleological, that we're like, the solution is leaving these losers. And sometimes that's absolutely right. Like, obviously, in situations of abuse or really maltreatment, we do need to kind of not be in relationships to those people. and, you know, a more reflective

or kind of like mentalizing therapy would want to be kind of trying to see it from a broader perspective, what more is going on in you, what more is going on in the other, and hopefully not just kind of arrive at a concrete behavioral solution. But I totally agree with you.

This is a thing in the therapy world. Well, it could be like a lens, right? A lens of, of a pop culture lens that could be overly placed on the situation, right? Yeah. And then once you have, yeah, it does increase certainty in a way, right? Oh, yeah. And I think this is what sometimes friends will do it for other friends, right?

They'll go bad on the partner to allow some sort of psychological escape, right? So it can be helpful in the moment to psychologically stabilize someone, by making the other person all bad, right? But it can be harder. The harder work is to increase the uncertainty to allow for accurate understanding of the self and the other. Definitely. No, absolutely.

And that's kind of the good news, in my opinion, is a lot of patients, when, a lot of times when patients are caught in certainty, there, what they go back to is like, well, sure, I'm certain, but I'm right. And that's kind of the case. But I'm right, I'm right to be certain. And then we also kind of have to dodge that a little.

It's like, I'm not denying that you do have a point, and I see the point, but I'm wondering, could we also look at what's leading you to feel so certain as well as other ways to see it too? Like, would you be up for that? And my experience is if we do that, like, things tend to go in the right direction. Like, problems happen in treatment when we just kind of either ignore or align with patient certainty. But if they're up for kind of trying on multiple perspectives and that's what I'm trying to do as a clinician, things tend to move the way that they're supposed to move. What do you think about, you know, OCD is a big disease of uncertainty?

Oh, yeah. You know, so it's a quest for certainty. Yeah. So OCD is like the doubting disease. So I doubt, you know, so that most simplest is like, you know, I think my hands are dirty. I think they're contaminated. And then to create certainty, I'm going to go wash my hands. that they're clean.

Okay. And then 10 minutes later, I think my hands are dirty and so they do it again. Right? So then they're doing this quest for certainty over and over again.

Definitely. So, you know, is that also the case in some of these more anxious attached folk where it's like, I'm feeling anxious about the relationship,

I need a quest for certainty, I need reassurance. So the compulsion is to then seek it through a different, you know, maybe reassurance, right? Reassurance is a form of compulsion. Well, I like what you're doing, because in some ways, just by the nature of your questions,

you kind of begun to cover all of our non-mentalizing modes. So in MBT, we, you know, we essentially say there are three non-mentalizing modes, certainty or psych equivalence, disconnection, or pretend. And then the last one, which I think is implicit in your question is what's called teleological mode

or an excessive focus on what's visible. You know? And behaviors are visible, right? So this idea that if I experience uncertainty, I need to take this action, that's the heart of OCD. Or any other sort of kind of like compulsive, checking,

interpersonal kind of process as well. So in MBT, I mean, I do tons of that work with patients. Like I do exposure-based work using, you know, exposure and response prevention for OCD. But if we want to see it through a mentalizing lens, it's certainty that in order to avoid this feeling, I need to take this action. And Peter Fonagy, I don't think he's written this,

but it's sort of, it's a very simple line, but Peter Fonagy, when I was like first learning MBT, he just said something very simple that I'll never forget. He says, when somebody is not mentalizing, you need to stop it, which is so obvious. But checking, asking those questions, like, that's got to stop.

And so a lot of times in the treatment of BPD, all those behaviors that patients engage in, that kind of kick up more dust or kind of cause more trouble in their life. Any effective treatment needs to organize itself around that, I would propose. So if it's asking constantly how you feel about me if I'm in a relationship with you, that's going to have to be a treatment target. And we would work on helping patients not do that by mentalizing rather than acting. So I would say any treatment is going to have a version of what you're described.

and we need to kind of help patients kind of not engage in those behaviors. So teleological mode, okay, we gotta like, we gotta make this more concretely understood. Yeah. We need to make this like completely observable, right? So that only the action counts.

No, that's a joke. Okay, so the teleological mode, it's like if this patient that I had brought it before, said, you know, I want you to cancel, if you really cared about me, you would cancel your fun adventure with your guy friends and stay with me tonight. Wait, wait, wait, wait, wait, what do you mean? Like, maybe not leave town is the point. Not leave town with your guy friends.

Okay, good. All right, because that's, yeah, all right, good. All right, so basically you caring equals you staying. And then if you, if you go, then that means you don't care. Yeah. Okay, perfect. Is that teleological mode? That's a beautiful description, yes.

And that's another thing is that when patients are in teleological mode, how do we teach them to treat those tendencies in themselves? And essentially, the first step is whenever somebody is in a teleological state, there's an equation. They're linking some outside thing to some inside thing. Okay, so in your case, the teleological equation is either, there are two options. One, you care equals you don't go on the trip with your friends. The other equation is, if you go, that means you don't care.

Right? So basically, like what, you know, sort of I'm doing with patients now is what are your teleological equations, and then work, what would it look like to work on that? And it's, the early part of it follows the similar steps that I mentioned earlier, which is, what's your case for that connection that you going, that therapist David going means he doesn't care, how does it impact, you know, you to see it that way, right? Those are the early two steps. The next step is trying to envision things more broadly. So, let's, let's be. Let's see. I mean, like, does make it very concrete for your listeners.

The first step is, can you imagine, just take a minute and consider this possibility that essentially David cares about you, but still goes on the trip. Can you just picture that possible world? Well, I know that. I said, no, no, no, no. I don't want you to say you know it.

Take a minute and just picture him caring about you while he's on the trip. People will write this out, actually. They'll actually write it out, okay, I can see David on this trip, and I can imagine that, even though I'm not the most important thing to him, that he still does value me as a person.

Okay? That's one way to treat it. And it's really pretty cool. Is it patients start to do that on their own? Things start to get a little more flexible, but we're not done yet. What about now? I'd like you to imagine,

this is going to sound really aggressive what I'm about to say, but try it on for size. I also like you to envision me staying here, not going on the trip with my friends, but not caring about you. Okay. And then I can imagine that,

okay, I'm going to picture it. Like, you stay, but you really don't care about me. It's just about the paycheck. It's just that you, you know, whatever. ever don't want to get into a fight with me. Okay. So then you're basically, what you're doing is you're taking issue with both sides of that

equation, David, and patience themselves. And then you kind of envision it, okay, well, so imagine all the feelings David could have on that trip with his friends. You know, just broaden it out. He could care. He could not care. He could want to spend time with his friends. you can want to maintain professional boundaries.

So there are literally these bubbles, like thought bubbles that you can kind of broaden the range of mental states you envision in the other. So that's something that I'm excited about is that it actually is letting patients, not just therapists doing this for patients, but patients starting to do that for themselves and to start to challenge their own teleology,

if that makes sense. Okay. So it's like you're having them challenge both sides. Exactly. Of this thing. Okay. Try it out. It actually is really, this is, again, this is Anthony's genius. It really works in a cool way.

Okay. So it's because in the certainty, you're challenging both sides of the certainty. Well, yeah, I do think if I imagined him home not caring about me because he's upset at me. Because like secretly he knew, now he's really upset at me. now he's really pulling away because he gave up his his time with his guy friends so he's upset

oh I see I see okay okay yeah so that he's resentful your point is that he could be like resentful of you because he didn't go on this trip

yeah okay but I want to propose another possibility just imagine him not going with these friends okay can you picture him caring about you

just take a minute and really see that yeah okay okay you see i'm thinking like okay so you're trying to get them to imagine that he could he could go with his friends and also care about about me exactly yeah okay and he could stay home and not care about you and we do a same with this this version it's a it's such an elegant set of interventions but it also works with ourselves so for example let's say you have a patient who is feeling like all of their worth derives from having a specific type of job, right? And that if they don't have that job that's successful enough, then they're bad. Okay? You do the same thing. Okay, sorry. Well, I want you to kind of do the teleological equation toolkit and like actually like, what's the equation here? And they'll say,

okay, it's that my worth depends on me having this job. My worth equals having the job. Okay, great. So what's the case for that? How does that impact you? But then getting to the intervention point we're discussing, I want you to imagine, can you imagine, having this job and still feeling bad about yourself?

Of course. I always feel bad about myself. Interesting. Okay. Can you also imagine not getting the job in a world in which you could still feel like you had value? Can you just even picture it if it's highly unrealistic? Okay. I'm seeing something else that you're doing here. It's like you have this, in teleological mode, you have this concrete, you know, like this concreteness, and you're asking them to go into kind of a pretend or playful place.

I guess you're right. Can you imagine, right? Can you picture something the opposite? Can you picture opposite? Exactly. Yeah. I like your point. That's a good point.

It is kind of like inviting imagination of these possibilities that may not be true, but mentalizing is itself imagination, right? Because we don't see mental states. Yeah. So you're imagining the opposite in both situations. Yeah. as a way to kind of like bring some looseness or flexibility. Exactly.

You're kind of disrupting the equation. That's what we got to do. We got to help patients disrupt their own equations. And the cool thing is, is when they do, everything feels less pressured. So with that patient who feels like you don't care about them when you leave and they consider it more broadly, most likely they're going to put a little less pressure on you if they really do the exercise. Similarly, the person, this is a little harder, but the person who believes that all their self-worth resides in this job, then if they have moments of really imagining, you know what,

it's true if I got the job, I would still hate myself because I've hated myself since I was like 16 years old, it puts a little less pressure on getting that job. And so once we loosen the equation, everything that stems from the equation gets more flexible and kind of open in a way. Okay. You said earlier you want people to stop doing the things that dissociate them. Definitely. One thing that jumped into my mind was like short form video, you know, how prevalent that's becoming. Yes.

How many hours we can watch that. Oh, my gosh. Benging on Netflix or video games. You know, there's all these, like, modern ways that we dissociate into other worlds, right? Into, you know, are they all bad? Are you saying we need to stop all of those things? Or, like, what are we actually talking about? Thank you.

Yeah, it's a really, really thoughtful question. So it's not categorical. So there's no, like, list of these dissociated behaviors in MBT. It's got to be tailored. How does the person use them and what is their impact? So that's ultimately, when you're working with a patient in MBT and sort of building the formulation, patients will list all the behaviors that they feel compelled to engage in. Or they're going to list the behaviors that they feel like separate themselves from their emotion.

And they're like literally just like lists that people can choose from to kind of arrive at that. So it's tailored to the individual. And then the question is, if you with your own patient really get it, wow, it seems like you're like using, you're using these things to get away from yourself. Would you be up for working on that? So I will tell, I'll tell a story about a patient that I published about in a psychoanalytic journal. So it's, I'll go the de-identified root of this. But I have a patient that I started seeing when he was in his early, early, early, 20s, who was, had never been in a relationship, had tried dating women, but, you know,

struggle with ED whenever they're sort of come close to kind of like, you know, fooling around and he would feel humiliated by that. And so he was very isolated, didn't date, just focused on work all the time. But he spent all of his time with technological devices. You know, he was basically playing video games all the time, watching you. YouTube all the time. It was all just porn. It was just all screens all the time.

And I don't know how this happens happened, but I started to become concerned. Like, it's like you're, and he was so disconnected. Such, like, so, like, wooden in his presentation. Wooden. Yeah, like it's a good descriptor. It's like he would talk in a monotone.

So I basically started like, it really seems to me like you're using these things to not feel your feelings. Like, oh, yeah, definitely. like, well, would you be interested in not doing that? And so he says, okay, so he starts gradually shedding these things. And he basically, we ended up, it was really hard, David. It was like he, we had to do, like, he had those, I don't know what they're called,

but parental locks on some of these things. So he couldn't visit certain websites and all this stuff. But what was amazing about it is this man would just start. to show affect spontaneously. He just would start to kind of feel his feelings. And he ended up, basically, it turns out, it's going to sound like totally out there, but this is a true story, turns out he's gay.

Okay. And he had no idea he was gay. And he had no idea he was attracted to men. And through this work, he started realizing, oh, man, I'm not attracted to women at all. And, you know, he ended up. like basically like you know starting to date you know he had you know never had never worked out with women for reasons he could never quite explain so you wouldn't ask him the why question about that

because he has no idea why right um and then now he's in a like long-term committed relationship with with somebody that he's been with for you know five six years and um i would propose and he actually he says not i would propose he says if i had not stopped using those screens i never would have realized this about myself so this is not me making an argument against screens. This is me making an argument against dissociative behaviors. If our patients are engaging in these behaviors that are separating themselves from themselves, that should be a treatment target. You know, it's interesting. I was reading some of the research on like short form video. Oh, cool. Okay. Yeah. Like how, how it's, how toxic it is to the brain,

and when it's toxic to the brain. And the piece of the literature that I think directly connects with what you just shared is that it was the worst when people were going to it for anxiety or going to it to cope. Yeah. So if they were turning to this thing

to help them dissociate in the midst of distress, that's when actually there was negative, the most negative impacts of it, right? There we go. Yeah, you're right. And so this guy, you know, and people hide all sorts of things from themselves, right? And for good reason. Yeah. Right. Maybe there were good reasons why he hid that piece of himself from himself, right? And, you know, for him, it was so horrific that that he had to continually find ways to dissociate. And so that I think is the beauty of psychotherapy. It's like, what is this thing that you find so reprehensible that you're dissociating from yourself all the time?

Definitely. And is it really as bad as you imagine? Like, is it, like, is it as awful as you think it is? Well, you're really underscoring there the sort of conjoining of pretend mode with teleological mode. So let me explain. It's that if I think this quality or characteristic, like, say, you know, the one sexual orientation or something makes me bad, then I'm going to be disconnected from those desires, right? So the certainty is linked with what we're dissociating.

So we got to hit it on both fronts. We got to treat the certainty, the self-judgment, the shame, all the opinions or the convictions the patient has about what makes them bad, but then we got to help them access those parts of themselves. And we got to, I would say, we got to hit it on both fronts. Have you ever read Tolstory? Any toll story? No, I haven't. No. I just, yes, I would mix them all up, but no, I've never read Tolstoy. Toll story, the biggest books were Anna Krenina and Warren Peace. Okay, no, I never read, yeah.

Later in life, he wrote this book called the Kreutzer Sonata. Okay. And it was fairly autobiographical in a lot of ways. And so it's a short story in which a man murders his wife, who he imagines his wife has started to have this like affair. And he comes to this point in this argument in this book that if you're really a Christian, you should be completely abstinent from sex completely. Okay.

And then he wrote a follow-up saying that he actually believed this to be the truth. So I believe that? Tolstory, yeah. In his later life. And his wife was very upset that he wrote this story because she, so the Quarters Sonata is this musical piece that his wife is playing a duet with this man. And this is what angers him to this point of killing his wife, right? Okay. In the short story, he didn't actually kill his wife.

but he had that degree of he understood envy to the degree right and he understood this murderous rage yeah and through his writing and through his belief structure he he felt like the the real problem was sex and sexuality so we should completely be abstinent wow okay i didn't know that about tolstoy this doesn't seem healthy and um and so it's interesting because i like uh In his journals, he was very obsessive. He was very self-punitive. Oh, yeah. His wife wrote about his marriage and stuff.

And she wrote about, she paints a more narcissistic picture of him. His kids writes long things about him as well. He had 12 kids, I think 12 or 13. And a couple of them wrote, somewhere more idealizing of him. but he was a little bit more distant than I think he likes to portray and so he's a complicated person but what made me think about it

was here's the guy before psychotherapy existed who was incredibly insightful about human nature about internal emotions but he was never able to come out the other side into a connectedness. It always stayed in a very obsessive, narcissistic, or, like, masochistic, depressive,

like, very punitive towards himself, very, like, very regimented. He, he... It sounds like a little OCP, too, maybe. OCP, yeah, a little bit, yeah. Some people have thought that. And, you know, at one point, he tries to give away his estate.

He was born wealthy. He tries to give it away. and his wife and his kids like, you know, try to stop him. And so he gives away most of his wealth. Wow. And to them, he gives, you know, he's left with very little. But anyways, the thing that made me think about this was one, because I've been reading it recently and just it's, I've been trying to kind of think about, okay, what were, what were his gaps in mentalizing, right? Where were, where was he?

Because he, he saw it. I think in this character. He saw this murderous rage. And he wasn't like, and he saw from the perspective of this person and this envy, but he never had a second person in the room. Meaning what?

He never had a person to bounce off the other. So he had characters in his stories that would bounce off the things, but not in a way that would actually change him. I love it. Because to be changed, you kind of have to have another mind. Yeah.

And so... I love that. I love that point. Yeah. It's sort of consistent with what you were saying about the kind of therapist who kind of colludes with a patient's devaluation of their partner. Like, I would say that's partly the problem in that setup is it's only one mind. You know, it's the therapist is aligning with the patient's mind. And you're really making the point that psychosovo's,

You know, MBT really believes this, that like psychotherapy by definition is about the kind of, I don't know, collision or engagement of two minds. Of two minds, yeah. Yeah. And just to your, I had known all that about, about Tolstoy. And so I really think it's highlighted a couple of things clinically that are really important that I would want to underscore from a mentalizing problem when you talk about what are his gaps in mentalizing. one, it definitely seems like there's a ton of self-judgment around desire and really like self-punishment around desire. Like kind of like not just the certainty that I'm bad,

but kind of like an almost effortfulness to kind of extinguish desire. And then certainty that these desires are bad, And then the idea is that certainty ultimately perpetuates dissociation. Like my guess is, despite the fact that he had 10 kids. Yeah, right. There's a way in which he wasn't able to comfortably inhabit his own sexual wishes. And really, like, to that point, and I see this with patients all the time, where oftentimes the patients were, like, really struggle to comfortably inhabit their wishes.

they can speak very, very cruelly to themselves. They can be mean to themselves. They can kind of talk to themselves in a really, really aggressive manner. And I would say there, David, that's the dissociative behavior. Self-criticism is also a dissociative behavior. So then I have to, you know, with patience,

I'm going to say, listen, I know you believe all these negative things about yourself. And I don't know what we're going to be able to do to kind of fully address that. We can work on it. But I'm interested in this question. What I'm also concerned about is the language you use, the way you speak to yourself. Would you be up for actually trying to kind of work on this in this treatment and do it less?

And a lot of times I think that when patients, just like the patient stops using the screens, because that's his dissociative behavior, when other patients stop being as cruel to themselves, then they experience different emotions and desires. But often I think about self-criticism as like an effort to cauterize desire and wish. You know, and once we can, if we can disrupt that, then you'll start to see patients start to have

a broader array of their own experiences. Okay. Yeah, interesting. So it's the self-criticism as a form of dissociating. What are they dissociating from then? Oh, I mean, I see this with, vulnerable narcissism all the time, it's often the desire for care. So the desire for care is more scary than the desire to be punitive towards themselves? Oh, definitely, because self-punishment is, it's like, I'm in charge, I'm relying on me, I'm bad,

it's about me and my standards. And so oftentimes they'll just be really mean to themselves and try to push down those wishes for connectedness because it's easier to be. mean to themselves and it is to face like rejection or abandonment actually. Okay. Yeah. I see that. So, yeah, I think those are really important processes. And that's like the progress in treatment.

Like a lot of people with narcissism when you're working with them in treatment think, I need to, I need to kind of like make it less about my desires. And I'm like, well, yeah, maybe. And maybe we should actually help you experience some of those desires without being mean to yourself or having. them. And that's, you know, that can be a part of these treatments, actually. Yeah, I was thinking about that.

Like, if I had told story in my office, like, maybe the envy is an awakening of his care and love because at times he feels very loveless towards this other person, you know? But then what if we were to put these things to words, you know, the protective. of how do we protect the connectedness rather than murder's wife, for example. You know, like it's like it's the furthest extreme, but this like the murderous rage is to protect the family, right? To connect, to protect. And is there is there a positive sort of understanding of the emotion in an adaptive sense, right? The envy is there as an adaptive way of

protecting something that's very important to you. And yeah, if this were to be lost, if the connectedness to this person were to be lost, which he devalues simultaneously, right? So he's devaluing of her all the time. And then he's also like this extreme envy. I actually think it would be a lot of fun for you to read this and for us to have a longer discussion on this. Yeah, that'd be very fun. I read one of my favorite books was like Crime and Punishment by CSFSC. I love crime and punishment. It's It's actually similar themes, maybe because they're both Russian, I guess, right? You know, I find Tolstory is harder for me to connect with. Like, I feel like it's, Dostoevsky, I feel like arrives at this, there's beauty, there's an existential beauty, and there's this kind of like, it's like, it's like, I feel like he arrives at a place that I feel more resonant with.

the toll story. Well, I mean, I'm not saying by comparison, but I really resonate with Zosiewski. Yeah, it's quite beautiful. Toll story, I'm left with this feeling of like, okay, I feel like, I feel like this was, this was a really difficult read. Like, I'm thinking about having the cohort read it

and discuss it on the podcast. Oh, really? That's so cool. But then I'm simultaneously hesitant to because it's such a, it's like a painful read. This makes me think, I mean, granted, I'm learning this all from you, and, you know, we never are supposed to diagnose somebody through another person's reports. However, this is the experience that, you know, you can have with people with sort of, like, really notable obsessive-compulsive personality disorder, because there's a way in which

in OCPD, it's such a world of shoulds that, like, breath and life gets strangled. Yeah. and there can be this experience I do a lot of treatment of folks with OCPB and some folks, there are just so many shoulds. It almost feels like you're just, it almost feels there's a sense of dread or deadness or something like that.

And so it's an interesting thought of like, to what extent can that be communicated through art, actually? You know, and that if, you know, there's a way in which our character structure has to, like, be communicated. through what we create. And I wonder if what you're describing is almost like, it reminds me a little bit of how I can feel

with some patients who are very, very strict with themselves and very masochistic, actually. Massacistic, yeah, definitely. Massacistic is like, how do I get love? Love, I have to suffer to get love. Right, yeah. And, like, what is the meaning? What is meaningful?

I have to suffer for something to be meaningful. Right, definitely, yeah. It's got to be earned in a way. It's got to be earned, yeah. Yeah. So, whereas obsessive, it's like, I have to create order to feel okay. Like, and the orderliness and the obsession, obsessions,

obsessions through just the thoughts, right? you could be someone could be just very much caught in their thoughts and they could do very little action or they could be very compulsive and do not have a lot of thoughts but just do compulsive compulsive compulsive behavior it's a little bit different than the oCD in my mind because with oCD they're um it's it's more of that doubting and it's more the doubt leads to the compulsion and they're doing it like four to six hours a day whereas like oCPD it's more of the the personality organization. Yeah, and the other part, you know,

I think that, and this is where some of these constructs can converge, is with OCPD, there's obviously the scrupulosity, this excessive focus on ethics, this need to always perfect oneself ethically, you know, which can be absolutely exhausting. And it sounds like, you know, to some degree that was present with,

you know, just, yeah, no, Tolstoy. But also, makes me think because a lot of the work that I did prior to coming to, you know, mental health was I was in grad school for philosophy. Okay. And my favorite philosopher was, was Kant. I don't know how much you know about Emmanuel Kant. But he has a very, it is a beautiful model of ethics, like, you know, organized around the kind of the inherent worth of the person. Which I bring into mentalizing and think about a lot still. and he was so self-negating and feeling like the only ethically good act that we,

the only thing that had ethical value is essentially if it kind of could often work against our wishes and desires. You know, so there is this sort of moral perfectionism that you can see, which, again. There's a little bit of masochism in that, right? In that, exactly. Yeah, yeah. Yeah, it's interesting to think about masochism as part of like the moral perfectionism of OCPedia. Yeah. Well, yeah, it could be this kind of like persona where

in order to do something truly good, I have to suffer or I have to basically take away my own desire. Whereas I'm more in the in the lens that, you know, it's good to operate where there's a multiplicity of wins. Yes, yes. You know, like we enjoy our our patients, our patients get better, our patients get helped. You know, it's okay to enjoy this job, right? And to enjoy the connection that we feel with people, feeling, you know, it's such an honoring place to actually enjoy the work too. I can't imagine my own therapist that I see secretively not enjoying it.

Yeah, yeah. No, it's, yeah. I like what you were saying, and I mean, this sort of just like, and think about there's this, I don't know how much you talked about this in this podcast, but essentially MBT has been, and this is actually the last chapter of the book, is sort of about this construct that's been probably like the newest theoretical innovation in MBT that Anthony has really developed with Peter's help is called the vantage points for mentalizing.

Actually, I call them that, you know, but also Anthony will refer to it as, quote, social mentalized, but it relates to what you're talking about, which is that there's, it's basically what's the position that we're standing in to try to understand self and other. And so essentially, there's I mode, you mode, and we mode. So I mode is where it's really all about like our perspective, right? and like what we want, how we're experiencing things and a lot of our patients. Wait, wait, you just went, you said I, but then we, you said we, what we want.

Oh, I'm sorry, I shouldn't have. Okay, good point, good point. It's not interesting, though, because it's so hard for you in your experience to ever think purely about yourself. That's funny. Okay, good catch. I love that.

So I mode is like my perspective, what I want, how I see it, right? Some patients, we all know those patients, right, where there's more kind of in an eye mode. We all can fall into that ourselves as well. Then there's U mode where it's more of where we get caught up in the other person's perspective, and we're prioritizing what they're going through.

And a lot of patients can just flip-flop between those two modes. And really what I think you're talking about, when you're talking about the kind of just joy of connectedness is really what MBT says we're going for now, which is we mode, which is that's where

I'm in my own experience, I'm simultaneously considering yours, and together we are working to do something and to collaborate and be connected to each other from a shared position. And so that's really the idea MBT is proposing now, that is, that's the point of psychotherapy.

You know, that is the point is we are trying, that's why we need two minds in the room, because if not, patients will just easily fall back into eye mode. And so it's this idea that if we can consider each other and work towards something beyond like each of us, that we're going to actually have a greater sense of meaning, purpose, and connectedness. So that's kind of MBT's newest theoretical innovation, which also has, as you can imagine, like really important implications

for, like, clinical practice as well. Really good, yeah. Wonderful place to stop. Yeah. I think that's a good place to stop. Yeah. I think the weeness, you know, like, makes me think of Dr. Tar,

always talked about, like, you know, the importance of the we, right, in the room. What are we thinking about? And I also think about like this kind of like, you know, pop culture codependency is a word that's often used. And I dislike that word because I think we're all interdependent. And I think if, or like emmeshment, you know, it's like another buzzword, right? Whereas like we all are like very much connected in a way, right? that's like, it's like, it's torture to not be connected.

It's torture, isolation in a prison is torture for the worst psychopath. Even for the worst psychopath, it damages their brain permanently to be in isolation for years. Yeah, definitely. And so, yeah, there is a strong importance of connectedness. And, yeah. No, I love the point. And there's a way in which, like, I think with those ideas about enmeshment or codependency, there can be like a pathologization of kind of the need for connectedness.

And that's not good for any of us, you know? And oftentimes when we're too enmeshed, that's not real connectedness. That's more like you mode, really, where it's just sort of like it's all about you. There's no, there's none of me, right? And so we need to then kind of like, what's the, how do we kind of treat? that, how do we help patients increase their connectedness themselves while also considering others more? And that will lead to actual weeness, you know? And so we don't want to pathologize the need for connectedness because that's what we're working for. Right. I think that what you're

saying is that we could over pathologize good things in pop culture vernacular, which is something I've been thinking a lot about, it's like maybe the patholization, patholization. Pathologization, right? I know, it's too many syllables. Yeah, yeah. But emmeshment and it's like where is it toxic, right? Because there is a place of true toxicity when someone enters into a cult, right? Oh, totally.

Yeah. A cult being like, you know, a singular leader is now. his needs are the only needs that matter, right? And everyone is there to serve this person's needs. Like, those environments do exist. To say that they don't exist is silly. You know, there are some people who create cults and operate cults for their own pleasure

and for the lack of pleasure of anyone else in the cold, right? Yeah. But I think a lot of emmeshment or codependent, or codependency, it's really interdependency. Like we're synergistically connected in a positive way with people. And sometimes we're, it's more intense than others and sometimes less intense.

And so there's probably good reasons for it to be intense at times and good reasons for it to be less intense at other times. Totally. And I think the best case scenario is if we can be, connected as long as there's enough us and enough other. That would be the idea. So I do think that's been a bit of a theme of the discussion today is the two-mindedness of psychotherapy, but in this model, kind of like the two-mindedness of relationships that kind of like make sure we're in the room,

and then there's another person in the room, and that is going to be, I think from an MBT perspective, that's going to be their best recipe for feeling connected to others, but also for helping patients change through psychotherapy. Okay, so in summary, like mentalization, the approach is to mentalize their own internal experience, to not dissociate from their own internal experience, to mentalize the experience of others, including you, the therapist, and then the togetherness is its own mentalizing process. There's a weeness in the room, and we're looking at that as well.

Exactly. So we have perfectly said, yeah. Okay. All right, we'll leave it there for today. Thank you so much for coming on. And, you know, I think that this book that you have written will put links in the show notes and on the website. And if people want to check it out and give you feedback, if they want to send me a message or send it directly to you, I will forward it to you if it's been helpful. And, you know, I think it'll be a good addition to the importance of psychotherapy.

and the importance of the two-person connectedness. Awesome. Well, David, I always love talking with you. I just really just enjoy you as a person and just love the conversation. So thank you for having me. All right. Good to talk with you. Okay, we'll leave it there for today.