Psychiatry & Psychotherapy Podcast - Mentalization Based Therapy (MBT), with Dr. Anthony W. Bateman, MA, FRCPSYCH and Dr. Peter Fonagy, Ph.D., FBA

Episode Date: February 23, 2024

In this episode, we are joined by Dr. Anthony W. Bateman and Dr. Peter Fonagy to discuss their expertise on Mentalization.  Mentalization refers to the capacity to reflect upon and understand one's own state of mind and the states of mind of others.  This involves recognizing and making sense of one's own and others' emotions, beliefs, needs and desires.  People use this tool consciously and unconsciously to make sense of others and themselves. Often done automatically, a person may form beliefs about the people they interact with, making assumptions about their mental states. These beliefs tend to have a strong influence on the mental state of the person, whether or not they are correct. By listening to this episode, you can earn 1 Psychiatry CME Credits. Link to blog. Link to YouTube video.

Welcome back to the podcast. I am joined today with Dr. Anthony Bateman and Dr. Peter Fornegue. And this is an episode on mentalization-based therapy. We're going to talk about borderline personality disorder. We're going to talk about how they got to the development of one of what I would say is the key psychotherapies for borderline personality disorder that work. We're going to talk about their pivotal paper, maybe about reflect, collective function and how that impacts the outcome therapists have with their clients, welcome to the podcast. It's a pleasure having you guys. I thought we'd start out maybe just talking a little bit about your story and how you met and how you started working together. Dr. Bateman, I understand you're a psychiatrist and you were working in a unit with borderline personality disorder and some

antisocial personality disorder. Is that correct? And then, you know, Dr. Fornegutie, you were paired up together to run research in this unit. Is that how it started? Yeah, to a large extent, I'd say it did start like that. We met in the main, I suppose, when we were both training the psychoanalysts. And I was working in the health service in the UK, in North London, and Peter was working both in the health service and in the university. and I took over a service for people who turned out that, as I discovered, to have borderline personality disorder.

I wanted to engage in research, and Peter's an expert in research, much more so than I was. And so I toddled along and said, Peter, well, you know, how do we do this thing called research? He said, oh, come on, you know, let's pull all this together. And that's how it started. So we had a whole patient population and we had a research expertise and then some clinical expertise and we just pieced all that together. What do you remember from that, Dr. Forney? Well, I have a slightly different slant on it because Dr. Bateman, as usual, is exceedingly modest. And he is a person who is committed to helping.

his patients. And he was confronted with a group of patients that were urgently in need of assistance, but at the same time, he did not have the staff that would be able to offer the assistance that was required. So he was faced with the task of creating a mode of intervention that would make these patients somehow accessible to this competence and skill level of the staff that were available to him. And that's really how MBT started. I came from an attachment background, and he came from an adult psychiatry background, and we piece the two things together, and I think that's how MBT was created. I don't know, Anthony, whether that's your recollection, or have I,

looking at history as I usually do through roasting its spectacles. No, I think that's very fair. And it was the recognition around that time, a borderline personality disorder and attachment that was coming through in research and so on that allowed us to sort of begin to join that up together in a particular way. And as Peter says, that's where MBT came through. I think we should say that at that beginning, that was the time. when this concept and idea in attachment research of mentalizing and mentalization was also

beginning to develop and be fleshed out. And that was Peter's work and other people at UCL and elsewhere who are fleshing that out. And we then actually integrated that into an approach towards people with borderline personality disorder. And Dr. Fornegue, I was looking at some of your background trying to understand a little bit about your story. You were raised in Budapest and you were born in 1952 that is yeah that is absolutely accurate not that i necessarily want to remember either of these facts but uh it's accurate i was born hungarian and i guess i've remained one really won't be another but i was actually a refugee to this country in uh... nineteen sixty seven sixty eight and uh... uh... uh... uh... uh...

gradually was quite an unhappy person not being able to speak English and being stuck in England and not being able to join the educational system, which is fairly closed in this country. So I had therapy, and that's what I guess brought me to, as an adolescent. And I think that's what brought me to mental health and psychology. and all that. So I read that you were quite depressed initially. You didn't come with friends or family, so you came here, you were all by yourself.

It sounds like you were an adolescent, and there was a psychotherapist, a child psychotherapist, Anne Hurry at the Anna Freud Center, who saw you. Indeed, indeed. And she, you know, at the time I was kind of failing exams as if there was no tomorrow. I had considerable educational difficulties, amongst others. It was also at suicidal ideation

and lots of symptoms that I would now be very worried about as a clinician. And then had a very good therapy with Anne Harry. And as it happened, I got stuck in London, UCL as a university admitted me with an educational track record that now nobody would look at, with very low expectations of my exam results, and I have remained loyal to both these organisations, UCL and NFROID ever since, which I'm actually quite pleased about because most people do not get the chance in life to actually repay some of their debts, and I had. So that was good.

Anthony, do you have a similar story? Not quite as exotic, to say the least. I'm a northern Englander who were brought up in Northern England, but had my traumas here and there as I went through my rather rumbustious adolescence and oppositional adolescence to some degree, partly related to actually going to a boarding school at that time, which caused me some disturbance, to say the least, although I managed my adaptation and so on. But I tended to deal mostly with my problems, actually, as they were, through peer group affiliation. I was very great. for little gangs, you know, trying to joining up with mates and things and really taking no

notice of adults and things who I found rather discourteous to me overall, but I was certainly discourteous to them. I am sure, and I'm sure they mostly remember that. But so anyway, I went through that English system and then came out the other end. I did way beyond my academic abilities, funnily enough, really. I managed to skate through somehow and go to one of our major universities. And from there, that sort of settled me to some degree. Okay. And you were going to be a vet for a while and somewhere along the line you shifted. Yes, yes. I thought they were probably easier to get along with than humans in some way being a vet. So I was, yes, for a time. And then I gradually became much more interested in humans. I thought they were interested in greatly.

And so I transferred to medicine. That's absolutely right after four years. Was there a period that you started doing your own psychotherapy as well? I guess being a part of the analytics center, you must have at that point. Yeah, that was somewhat later. So I then wasn't sure what branch of medicine I wanted to be in and so on, and I mucked around for a bit, which is quite common in those days, doing different jobs and moving around. And then I then did a light on psychiatry, and I did a job in psychiatry, and actually was influenced very much by two main people, really. One was somebody called Heinz Wolfe, who was quite a well-known psychodynamic psychiatrist at the time,

and a very warm character. It also been a refugee as it happens in 1937 or something like that, 38, from Germany. But he was very influential and interested me in Freud at the time. And then another one, a little bit later, Jeremy Holmes, who was very interested in attachment and attachment theory. And so I was influenced by them, and that led me to psychotherapy and psychotry and so on. So then I went into my own therapy. And from there, I then became more interested in psychoanalysis as a way of thinking and working.

And so trained in that. And it was from there, in a way, I think Peter will agree that I was then not working in a psychoanalyst in a way, but working in a social mental health systems. So in the social system, you know, you've got a population of half a million. providing mental health services to, and a high number of them had borderline personality disorder that was a service I was in, and therefore adapting some sort of treatment, which was easily learnable by mental health staff and actually implementable and also implementable to large groups of people.

You know, we had 1,000 referrals a year, now it's 2,000 and things like that. this is not small numbers. We have to be able to manage and treat effectively, and that's where MBT became organized. Yeah, so it seems like, you know, it's a long path to become a psychoanalyst, right? And when I read your initial paper, it sounded like you were training the nurses to be mentalization-based therapist, basically. Is that correct? Or who was actually giving the mentalization-based therapy? Yeah, as Peter pointed out, the original studies we did was we developed the program and agreed that and then trained the local staff that we had to implement that program.

And they were mental health nurses mainly. They weren't just nurses. They were maybe occupational therapists, counselor level staff. And they were then trained in borderline personality disorder plus mentalized. and mentalizing interventions, yes. And it's limited training, additional training. We originally gave three days plus supervision and so on. And that was the beginning of the research project, yes.

Three days training and then supervision. On top of your current mental health training, but with then supervision and discussion. And that supervision was twofold. It was peer supervision, so everyone delivering met together and also with a senior person. like myself or one or two other people.

Okay, so this pivotal study, I think we should just jump into the pivotal study just to show people how amazing these outcomes were. It was called eight-year follow-up of patients treated for borderline personality disorder, mentalization-based therapy versus treatment as usual. And so this started with 18 months of partial hospitalization they were receiving one time a week of personal therapy, three times per week they were doing

mentalization-based therapy and some art therapy, I think, another two times a week. So it was nine hours of therapy per week, which I calculated to be over 18 months, 648 hours. And then they followed them up with an additional 18 months of twice a week mentalization based groups for another 18 months. So that was 144 hours. So a total of 792 hours versus treatment as usual. And treatment as usual, it sounds like they were going to, some of the patients were going to partial, some of them were kind of going to outpatient psychiatrists.

But they weren't in this like very systematic, you know, research. search study where you were going to follow these people for 18 months and then 18 months. Anything you want to add on that before we get to the results? I'm just trying to clarify two things, really, for people. One is that that was a very early study, and that's right, and it was a comprehensive program, which was over a period of 18 months, and the people were in a partial hospital program, so it was a mixed program, and we followed them after discharge, and we offered them at the time because they requested it actually was very user-led. They requested follow-long

sort of support and we organised that in a group. They actually didn't use it, but nevertheless that was what they requested and it was offered. They didn't use it much. And we then followed them up after that for, as you say, it was eight years after the original randomisation. So that's one whole study. We did another study, which is a much more focused study, major study trial, which was about patient, group plus individual, an hour and a half group and an hour individual, for 18 months. And they were then followed up and we published that data as well for five years following along, which these are the longest follow studies with a control group comparator of any treatments really in the borderline personality disorder field. So that's the second series of

studies. There'd been lots of other independent randomized controlled trials around MBT, but those are the two main ones that we were, we conducted. Yeah. Yeah, there's a lot of people have done subsequent studies. I want to just pull up this study for people who are watching on YouTube, they can actually see this table. I'm pulling up the actual table from the study here. And one of the things that jumped out to me when I read this study years ago now was the drop in the number of suicide attempts was so amazing. So suicide attempt total number, the mean for the mentalization based group was 0.05, whereas the treatment as usual is like 0.52. So this is like a huge reduction in the amount of suicide attempt number. Anything you want to say on that specifically,

like what that means practically? Well, what it means is, in a sense, is that they manage to stabilize themselves enough overall, not to have to self-destruct and, you know, they manage to inhibit their impulsivities and so on across time. But what's really important is, the first thing is that those suicidality sort of measures dropped relatively quickly in the MBT group overall in the partial hospitalization. group over six to nine months and and that's really important and secondly when they've dropped they tend to remain low so in other words you keep your gains and you keep your gains over long term yeah i saw that in um in figure one it's this is a great article to read if anyone wants to to read one article on mentalization to kind of get them started i would recommend this one i'll

I'll cite this in the article we write with this episode. The other thing that jumped out to me about this study, which was so amazing, was the medication reduction. And it's truly remarkable. So they measured how many, over the follow-up five years, how many of those years were they on three or more psychiatric medications? And in your mentalization-based group, it was like 0.02.

So it wasn't even like, it wasn't that long, right? Whereas in the treatment as usual, it was two years out of the five. The patients were on three or more psychiatric medication. Was this a surprise to you as a psychiatrist? I'm just wondering what it was like when you were seeing this data or when you were in the midst of it. As a psychiatrist, it doesn't surprise me because I was never convinced that the medications were that helpful

for individuals with borderline personality disorder. And since this publication, though, that's been borne out by other data, you know, on looking at medications for borderline personality functioning and so on. So it doesn't surprise me, but in that sense, because in a way,

once the individuals in treatment begin to realize they can manage themselves, they can take some sort of, self-control, if you like, and they're able to mentalize themselves, they're able to hold that together, they maintain a level of self-esteem through their mentalizing, they're able to manage their sort of social stressors in life around them by understanding others' motives better or recognizing them and responding to them in a reciprocal way, all of which mentalizing helps you do, that you don't actually need to be taking something to damp yourself down or reduce anxiety

and so on, you're actually in a level of self-management at that point. So it wouldn't surprise me if the treatment's working. That's great. So, okay, one of the things that I just want to comment on and get your thoughts on was the total amount of hours of treatment. And I've always thought, like, you know, a lot of my listeners are probably forced to discharge patients after like two to three months, right, in America. So in America, you go into IOP three days a week, three hours a day. Like after about two, after about 30 sessions, like I'm really fighting with like the insurance companies. And inevitably, patients have to be hospitalized and that resets the amount of days. They can do partial. So sometimes they go back to inpatient, little med change, back to IOP, back to partial, back to IOP, copy, repeat. It, it,

takes long to get people completely stable. I don't know, do you have any comments on that? Like, because I think this is a really important concept that can give a lot of hope for people with borderline per size sort as well, like, hey, if you're doing weekly therapy for one year and you don't feel like you've got into the place that you wanna get to, you may need more treatment,

you know, like this may require a lot of treatment actually. Any thoughts on that? Yeah, I mean, the question is, of course, what is it that happens over a longer period of time? And as we have done more research and more work in this area, we're understanding better that not everything that improves because of the hours that people have with the clinician. A lot happens outside in their lives that helps them maintain themselves

in a better organized, less self-destructive, less crisis-driven, less dependent way, because they use their relationships with others better. So I think what our treatments achieve, and what perhaps 30 sessions do not achieve, but longer treatments perhaps achieve better, is a capacity to relate to others in a way that will inherently improve the capacity to relate to others. That it becomes a virtuous cycle rather than a vicious cycle of constant rejection, undermining disappointment that makes people avoid relationships that could help them understand relationships better.

So what I think mentalization-based treatment achieves, and I think probably most other treatments work in similar ways, is a better understanding of why and how other people relate to you the way they relate to you. And then you understand them better. They understand you better because you behave towards, them in ways that they find more easy to understand. And the quality of relationships improving, not just within the therapy, but throughout

the person's life, is what that sustains them for those eight years following treatment in the place that where they want to be. So I think these factors hang together. And what we hit upon with Anthony all those years ago, and I really don't. want to remember how many years ago that was, Anthony, but I'm sure you do. But what we hit upon was really this essential quality of all therapies, probably, of improving an individual's capacity to interact and relate with other people in ways that will benefit them in their relationship with others. So it's kind of setting up a positive feedback loop, getting them out of a vicious cycle

of relationships where their actions undermined and probably in very severe ways disrupted the potential of these relationships to benefit them. And, you know, it's I think one of the, probably one of the most important findings of psychotherapy research is how much therapeutic alliance

as it is called generally underpins the outcomes of therapy. We believe that what therapeutic alliance is in fact reflecting is a mutual understanding or mentalizing of

the analyst or the therapist, of the cognitive behavior therapist, of the patient and the other way around. Beautiful. Yeah. I'll jump to this study that I recently found like a week ago. And I was so happy to find this right before this interview. It was looking at therapist effectiveness. So this article is called Therapist Reflective Functioning. therapist attachment style and therapist effectiveness.

This was published in 2017 by Collegon et al. And what they found was so they're measuring like the OQ45 of different therapists that are treating a bunch of patients. So they're measuring a good outcome questionnaire that can judge session to session change. and then they look at the best therapists versus the therapists with less patient improvement. Okay. And they're trying to find, like, what is that factor that is common in the best therapists compared to the worst therapist?

And they found that 70%, 70.5%, to be exact, of the variance in therapist's effectiveness could be attributed to reflective functioning. And then I looked up the manual for reflective functioning. And Peter Fonigy was like the main author. So I was like, let's go. So reflective functioning is 70% of like what makes one therapist better than another therapist. So one of my questions was, okay, thinking about your lives, have you improved in reflective of functioning. If you were to describe like, okay, so they measured it in the adult attachment

interview. They're looking at the responses. They're looking at sort of the depth of the answers in the adult attachment interview. Like, did that, was there, was there a psychological-mindedness? Was there a reflectiveness that was in capacity to how they describe their relationship with their mother or their father, their different things in their attachments early on? So first question is have you guys seen an increase in your own reflective functioning? And then the second question might be like, how can, how is mentalization and reflective function similar or different? And maybe you can answer both at the same time.

Anthony, why didn't you go with the first one? Why don't you go with both and then? The first one, I only can comment on in a way, but you're probably better to ask someone else, which is about, has my reflective function change, and so on and so on. I sure as hell hope so, of course, over time in various ways and so on. But it's very interesting, and Peter will give you more detail. But in a sense, I think that when we started out with MBT,

one of the things that was around was a sort of level of acceptance of uncertainty, that we sort of don't know what this is. this is this borderline functioning. What's going on for this person? And this is MBT now in a sense that actually you're a rather authentic sort of puzzlement about someone else's state of mind, where is coming from, and actually what's driving it and what they're trying to put across, what are they trying to make you understand which you're finding puzzling and so on. All those sorts of things, I think, were very pleasant for me. And it's where I began with assessing young people who had made serious suicide attempts. And I was really puzzled by this

Unlike Peter talked earlier, never even occurred to me to do something like that. So I thought, God, where is the earth? Why would someone want to do that? They're 21. They've got the future ahead of them. They're young. They're good-looking, beautiful, handsome, you know, and so on. I couldn't understand any of it.

And I think that attitude actually I suddenly discovered was incredibly important. It led people to tell you more things because they didn't feel you were trying to judge them or you were trying to sort of make them into something which you thought they were or weren't, but actually they hadn't expressed and things like that. So I think it was very important. I think you go through a phase, though, which I've recognised in myself at times,

and I think it's very easy to do as a clinician of sometimes becoming really rather low reflective function. You think, I've seen this before. Oh, this borderline stuff. Oh, I've seen hundreds of, you know, you sort of suddenly lose your capacity to, recognize everything from its individuality and it's where it's coming from, you sort of start categorizing, pushing together. And mentalizing an MBT, as it were, opposes that. It's completely

the opposite direction. And so in engaging in MBT, in a way, you're just learning all the time. And I think it pushes you towards that. And you have to maintain that, I think, across time. And And that I think I've managed to do, I have to say. But the best people to ask about that sort of thing are others. I do think others often are able to tell you something that you don't quite like to recognize. And others will tell you how good you are at mentalizing or not or what your points are where you're not so good at mentalizing. So don't forget, ask others who you can trust in and they'll probably tell you and you'll listen. And that's good mentalizing. that's good i i think um for those of you are just kind of getting an initial sort of idea on what mentalizing base therapy is there is this humility which you have not knowing there is this patients that you want to kind of identify what are the prospective differences going on between you and the patient there is this um legitimizing and accepting different perspectives there is a um you're you're actively curious into the life of the patient, how they see things.

So I think it sounds like, Dr. Pateman, you were embodying those things without even having invented what you were embodying you because of your just natural curiosity and wanting to understand. Dr. Forting is smiling. Go ahead. No, I think that your recognition of Antoni's underlying personality does you credit. I would say. Constantine is someone who has remarkable honesty and transparency and humor and is obviously very relatable and is kind of ordinary. And I think these aspects do embody a good MBT therapist, but they probably embody a good

human being, let alone a good psychotherapist. It's a seeking of synchrony with another human being that I think Anthony is particularly strong on and that I think I'm commenting on as he requested as an outside person on his mentalizing. I do feel that another aspect of that, which is also,

embodied within the MBT manual is an egalitarian stance. So not assuming that we know better, much more assuming that if anything, we know a little bit less than our patients, and that we are approaching a clinical situation with openness to learn with curiosity, but also an openness to discover something. that surprises us that we didn't know before. And I do feel that that shift in power relationship is particularly important with some individuals who present with a diagnosis of borderline personality disorder

because they are so used to having to accept the truth that others bring to them. And so really recognized as the, the people who bring the truth. Yeah. So, okay, and circling back to Dr. Forting, do you think your reflective function has improved? And maybe just give us a definition of how what you see reflective function is.

But, you know, reflective function is the capacity to understand mental states on its own and others in an attachment context. So it is challenging because any strong emotion undermines yours and my capacity to think in mental state terms. So, you know, we had, when we discovered, when we used that manual for the first time, we asked people about their own childhood, and their own parents

and why they thought that their parents behaved towards them the way they did and so on. But they aware of the relationship between their parents and how they were historically and how they were now having changed, so on. So they had to reflect on attachment relationship. And we had these participants, actually, in the first study we did, were rather well-heeled, middle class or even quite because of where we recruited them

quite well-educated and extremely reflective in some context. But we had attorneys, lawyers, baristers who were obviously extraordinarily able in reflecting on the mental states of the jury, others, you know, people in generally, as soon as they started talking about their own parents, they collapsed. They couldn't reflect. They didn't understand. And this, we were able to fortunately demonstrate, predicted powerfully to the quality of relationships they developed with their children,

even before those children were born. So we could predict how comfortable their children are going to be with them on the basis of how comfortable they were in talking about their attachment relationships with their own parents. The more comfortable, the more reflective, the better able to elucidate the likely, feelings of their parents towards them and their feelings towards their parents in a credible, coherent way, the better the children were. And that was another longitudinal study.

That predicted until the children were into their late adolescence. So we measured at 18 months, at middle childhood and into adolescence. And the, capacity to reflect on mental states, predict it forward to the quality of the relationship all the way through. And that brings up interesting things, just going back to the variance. So you might expect, just from that, wouldn't you, Peter, that the reflective function of the clinician is going to have real impact on outcomes overall. So the capacities of the clinician are going to be incredibly important, you would think,

from that. And also, you know, the extent of the sort of generalizability of mentalizing and mentalizing interventional processes towards parents who with young children or, you know, problem in families and so on. So MBT and mentalizing in various forms is now delivered, you know, to different groups in order to improve, if you like, their reflective function in relation to the attachment processes that are involved in, which of course is their children and their adolescence or their, and so on. I think everyone in the audience is thinking,

where I'm mentalizing, maybe some of them are thinking, okay, like, what is it different about being in an attachment which would color your ability to see reality, right? So the reflective function, you could have amazing reflective function. Like, let's say you were a therapist. Towards someone, you don't feel like a strong attachment towards. But then once you get in this strong attachment, like, what is it about that that changes the way that we view what's going on?

That's for Peter. Well, I mean, at a very simple, very simple level, it's conflicting emotions. So it's the intensity of emotions that you experience in the context. of a relationship that's important to you, that you depend on or that you really care about, that actually then generates indifferent capacity to reflect. Why does that happen? It probably happens at the very simple level

just because as soon as the networks in the brain that under pin attachment relationships are activated, your capacity to mentalize other centers in the brain, particularly prefrontal areas, temporal pridal junction, get inhibited. And we know that. We have demonstrated it. Other people have demonstrated it.

So at that simple level, there's probably a relationship that's evolutionary, it does make sense, because, you know, when you're thinking about who do you want to, you think about who do you love, who do you want to have relationship with that you'll have children, measuring, trying to assess their social trustworthiness

through mentalizing probably wouldn't work well for the gene pool. You'd think too much and you probably wouldn't find the right person. It's much more an intuitive experience. It's probably there's a good reason for that being a bit of, of a negative relationship. But I think also there is, again, a sense in which if you experience a powerful emotion, that in some ways undermines mentalizing and you are unable to understand or even pay attention to the feeling of others and others suddenly feel incomprehensible,

then you try and control others. through manipulation, through shouting at them, through doing things that actually will create a relationship that's frightening, that's undermining, that's frustrating, that coercive, that's distressing, that will then in turn generate further powerful emotions, that will further inhibit mentalizing that will further limit your ability to understand. So what I'm getting at is that these are powerful circular processes, and particularly in an interpersonal context, when one person's powerful emotions, obviously, and their coercive behavior will actually generate powerful emotions in others.

Wow. And that sort of brings us back to MBT as well. And this is part of Peter and Mind partnership over so many years, is translating this then as well into that clinical therapy situation. So if we now have a clear principle, which is well underpinned with science to a large extent, that the attachment processes inhibit mentalizing. And so mentalizing then is off. And that will create interactional processes which further inhibit mentalizing and emotional. sort of tsunamis that in fact we have to enshrine in MBT a management of that anxiety, that stimulation, not too much, not too little. So to keep mentalizing functioning,

whilst attachment is still active rather than tipping each other over. So you're in a way almost trying to rehearse constantly the sense of keeping the mind functioning to a mentalizing level, whilst attachment is active. Okay. The only evidence I have to bring to this that I think should mention, just because you raised before, that Dr. Bateman and I, having worked together a number of decades, I cannot remember a single argument that we have had. And there certainly have never been any raised voices that I can report.

Hitty remarks, I would say occasionally. if you were not, only from me. So there's never been a client that's created splitting between you guys at all? I can't remember one. Was there any? Okay, well, you know, common with borderline per size is splitting different parties. So this is impressive.

Well, I don't think, you know, yes and no. I mean, in a way, one of the important things is in many treatments for BPD, particularly a team approach once, is managing that sort of differences in perspective. And differences in perspective are in a way harnessed in MBT. We kind of like differences in perspective because we have to see where they're all coming from. And then we have to work out in some way actually some sort of coherence in responsiveness or, you know, understanding that has to be done. Okay. That's good.

That's good. Yeah, I think it might be helpful. I know that there are some terms that are unique to mentalization-based therapy. I have found them helpful. It's like when someone with borderline persuasion sort of gets physiologically aroused, stressed out, usually from some interpersonal attachment stress, they go into some different modes which take them out of like a healthy mentalizing capacity. One of those is psychic equivalence mode. Can you, I know you don't love the word. I don't know if you love the word. But in one of your interviews, you said you didn't love the word. That would be me. I always say, I don't like them, no. Because everybody else hates them. So I kind of, oh, yeah, I hate it as well.

I go along. But, yeah, I mean, people worry about them because they're kind of sound like terrible jargon, you know, and so on. But they do have a sort of underpinning meaning and understanding, certainly. So you never say to a patient, you're in psychic equivalence mode right now. Well, I wouldn't, but some people do in fairness. We do do it in MBT. We do a first part where there is some level of joint work about understanding the framework. And the framework, in a sense, is losing mentalizing, catapultures into these low, ineffective mentalizing functioning.

And when it's not working properly. And then our brain kind of gets rooted into them. And they're different kind of ways of the mind brain working. and one of them is called psychic equivalence. So we just have to recognize it and beginning to recognize when we might be tipping into it, when we're actually in it and claw our way out of it, is really important in treatment.

So, yeah, they have to recognize it. So maybe we should define the term just for people who don't know what that means. Can you define psychic equivalence mode? How does, when someone enters into that, what are they doing differently? And maybe I can, Anthony, do you mind me having a go? I'll give some examples.

Okay, so I mean, basically, it's the easiest way to recognize it is an unnatural certainty and suspension of doubt that you are seeing the world the way it is. Because in psychic equivalence, your reality is defined by self-finding. experience. What you, the equivalence, the term comes from the equivalence between the world out there and what's in your mind. So you know how the world is. And the world is exactly the way you know it to be. It just is. The internal is equivalent to the external. You could call it inside out thinking if you want to, but you recognize. it because people insist and they seem certain. And what MBT therapy tries to do is just try and

introduce a little bit of doubt where previously there was only certainty. Anthony, over to you. No, absolutely. A lovely description of it. And getting that doubt in there is just the key in the a little bit of uncertainty, that gives us some flexibility for everybody. And typical examples, you know, that people will recognise would be things like flashback is a moment of psychic equivalence. So I tend to have an image, for example, from the past, which is actually experienced as current reality. So I behave according to it. I run, I get out, I do all sorts of things. But it's a psychic equivalent moment in essence. like a statement from a patient like, Dr. Bateman, I can tell that you are angry at me.

Yes. Because of how you're looking at me right now. And I can tell you are, you're angry at me. Yeah. That would be indicative of a sort of psychic equivalence. There's not been checked out there. It's certain their self-experience of representation and thinking of an experience that someone's angry with them is what that person is. They don't say, for example, which they might if they're mentalising, so it's a quick indicator in the clinical situation, they don't say, well, what makes you look at me like that?

And then I could say, in what way am I looking at you? Oh, what was in my mind at the time? Oh, I know. And then I might be able to express in MBT, what was in my mind about it, and then say, what were you making? Well, I thought you were angry with me. Oh, right. Okay. So you can follow the conversation through so they begin to check it out rather than assume it. Okay, so let's roll play this. Okay, Dr. Bateman, are you ready?

Oh, okay. Okay. Dr. Bateman, I think you're acting the way you are because you are trying to persecute me. You're trying to make me feel awful. Gosh, what a horrible thing for me to be doing. Tell me what actions I've just been doing that brought that into your mind. Well, you and the group were paying attention to the other members more than me, and I think you knew that I had something specifically to say to you today. And you wanted to not hear me, and you're ignoring me on purpose,

and you want to do that because you hate me. Maybe that's a terrible thing. So you were sitting in the group with me actually in that state and seeing me in that state that whole time? I mean, how did you manage that? Oh, I felt awful. I felt absolutely awful. And I think you knew.

And I think that I think you were purposefully ignoring me. That's a terrible thing for me to do, actually. I must say, But just give me a sort of sense, well, what stopped you mentioning it to me at the time so I could actually begin to find that out? Well, I think I would have felt shame telling the group that. I think I would have felt embarrassed telling them all what I knew. What would have made you so shamed of that? I think it would have reminded the group that I'm not your favorite.

Okay, am I, is this, let's pause from the role player. I'm just trying to take a sort of not-known stance and trying to work out. What's my responsibility in this to some extent? Because I may have been behaving in a way that actually created that in your mind, you know, in some way for all sorts of things. But we need to work that out. So it's not just that you're having a delusion here. You know, there's something occurring and it's causing a lot of stress for you. And I might be part of that.

And so we're going to try to work that out. if I can just comment on that so Anthony started out by being very supportive to you and saying you know that must be awful you're just sitting there you know then he tried to clarify and elaborated you know what were you feeling at the time you know

what was it that I did how did that affect you and then you started talking about shame and you without knowing it, you started mentalising. Oh, okay. You started, yeah, I was feeling ashamed, and, you know, I didn't want to let the group know

that, you know, I suddenly didn't feel like Dr. Bateman's favorite, and you started thinking about yourself in a very different way, looking at yourself from the outside. That's basic mentalizing. Then you could have God, although you stopped the roleplay, but Anthony would have got to, you know, how does it change our relationship?

You know, should I try harder, you know, when you are feeling like that, what can I do to, you know, to make, stop you? I don't want to make you feel like that. And you start relational mentalizing. And that's when you try and get cut across that vicious cycle of having an unproductive relationship that undermines mentalizing.

And you start. suddenly get into, yes, I can use this relationship with Anthony in a way that makes me feel better about myself. Okay. That's good. I like that. That's fun. Was that common at all for something you would hear? Yeah. Okay. Yeah. That's about me neither. Anthony is not usually this good, you know, but just for the podcast. He pulled himself together. I'm mentalizing that you're mentalizing him as performing just exceptional. You're trying to make me feel better about myself, so I will. That's good.

So, okay, I'm curious how you guys would differentiate more of transference, focus therapy, and mentalization-based therapy, because it both seems to be working on the interpersonal, what's going on, and here and now between you. and the client, like, how is it different? How is it the same? Is this another hour discussion? Do we not have... Well, I think it's probably a long discussion.

And, you know, the overlaps are huge, I would argue, overall, probably. And I think the overlaps between MBT and other treatments for borderline personality are actually larger than the differences. So it's not just with TFP, say, Transference Focus, psychotherapy, it's with dialectical behavior, therapy as well and so on, you know, with particular. I think there are some differences. They might be related partly to the aims different a little bit in a way. I mean, obviously the underlying sort of theory is a bit different for each of them, but I think the aims are a bit different. I think sometimes the therapist attitude

might be a difference in terms of the sort of positioning and in relation to a the patient, and I think probably some of the processing sort of aspects may be different as well. Okay. I just add one thing to what Anthony said. The big difference would be that in Transference-focused therapy, probably there are more theoretical assumptions about what's in the patient's mind than we would make. you know, that there is a model. What we would say is that, well, they do have inability to mentalize,

that create problems for you, where you find relationships more difficult, and therefore you would be more likely to be in a state of emotional dysregulation that underpins probably causes poor mentalizing and so on. but we wouldn't necessarily put that with aggression or splitting or any particular mechanism would necessarily be part of the model. So we would not equip our therapists as a richer toolkit as transference for psychotherapy. The converse of that is that our training,

is, you know, a few days. And training in transference focus psychotherapy is longer. So, you know, it's because our model is, as I hope that we illustrated to you from the beginning, we try to make our model simple in order for it to be something that people could do relatively easy with relatively little training. Okay. So this is just like a taste, of course, a mentalization-based therapy.

But kind of as we wrap it up, what are some of the things that you would want people to know coming out of here, like mental health professionals, people that have never heard about mentalization-based therapy? And then the second question I'll ask is, what's like a next step that you would recommend people take if they want to learn more about this? I mean, the take home for me very often that I like,

I like from MBT, as it were, and just from discussing, I'm talking very straightforwardly here, is that it moves people, I like people to take home that you've got to take an interest in the mind of the person in front of you, not just in what they do. And very often there's quite a concentration on what someone does, rather than what they're kind of how their minds working and functioning and how they can use that and so on. So moving from behaviours to minds and so on, I think it really, important sort of sense here. And also that it's, you know, take home a sort of inherently relational processing system that they can carry with them that's going to give them in good stead outside, you know,

wherever they go sort of thing. I mean, for the kind of next steps, it seems to me reading about it and taking some interest in it at different levels, you know. know, it's one thing to be done like you have in a way or, you know, your professional work and so on. And then, you know, maybe some straightforward sort of training, sort of interest and education around it and so on. And then practice, technical practice and so on. Excellent. Dr. Fornegut, any closing reflections, closing thoughts?

Well, just be aware that when you are puzzled about what to say to a patient in psychotherapy, the likely reason for that is that your patient has at that moment stopped mentalizing enough to be able to communicate in a way that you would understand. And rather than beating yourself up or thinking about what your supervisor would say in that situation or whatever, rather than just stop and rewind and think, well, what was it that we were talking about when I stopped understanding and just asked the question, you know.

Look, I understood really well when you're talking about your sister and the difficult relationship with that. But then the next thing that you went to talk, I didn't realize it, can we go back? And that kind of recognition that your lack of understanding, is a loss of communication underpinned by a loss of mentalizing in the relationship

between you and the patient. To me, it's a major discovery that stopped thinking about how terrible it is that I don't know what to say to my patients. And rather than thinking, well, maybe I just, you know, we stopped mentalizing together, so maybe we just go back to the last moment where we did mentalize. That's good. That's really good. I enjoyed watching you guys together.

This is, you know, I think a great partnership over decades, right? And I can still feel the love between you guys. I'm mentalizing that at least. Hopefully it's not, I don't think it's just a projection. I think it's accurate. But I think there's been some great, great advancements for the help of many, many people. And I hope that whoever's listening to this can, keep digging into this. There's a lot of resources out there and hopefully I'll have you guys

back on in the future to dig deeper for my audience as well. So we'll leave it there for today. I love to. Thanks for inviting us. Thank you, David.