Comorbid Antisocial and Borderline Personality Disorders: Mentalization-Based Treatment

Anthony Bateman
St. Anns Hospital, London m m

Peter Fonagy
University College London
Mentalization is the process by which we implicitly and explicitly interpret the actions of ourselves and others as meaningful based on intentional mental states (e.g., desires, needs, feelings, beliefs, and reasons). This process is disrupted in individuals with comorbid antisocial (ASPD) and borderline personality disorder (BPD), who tend to misinterpret others motives. Antisocial characteristics stabilize mentalizing by rigidifying relationships within prementalistic ways of functioning. However, loss of exibility makes the person vulnerable to sudden collapse when the schematic representation is challenged. This exposes feelings of humiliation, which can only be avoided by violence and control of the other person. The common path to violence is via a momentary inhibition of the capacity for mentalization. In this article, the authors outline their current understanding of mentalizing and its relation to antisocial characteristics and violence. This is illustrated by a clinical account of mentalization-based treatment adapted for antisocial personality disorder. Treatment combines group and individual therapy. The focus is on helping patients maintain mentalizing about their own mental states when their personal integrity is challenged. A patient with ASPD does not have mental pain associated with anothers state of mind; thus, to generate conict in ASPD by thinking about the victim will typically be ineffective in inducing behavior change. & 2008 Wiley Periodicals, Inc. J Clin Psychol: In Session 64: 181194, 2008. Keywords: mentalization; mentalization-based treatment; antisocial personality disorder; borderline personality disorder; self; violence

Correspondence concerning this article should be addressed to: Anthony Bateman, Halliwick Unit, St. Anns Hospital, St. Anns Road, London N15 3TH, UK; e-mail: anthony@abate.org.uk

JOURNAL OF CLINICAL PSYCHOLOGY: IN SESSION, Vol. 64(2), 181--194 (2008) & 2008 Wiley Periodicals, Inc. Published online 9 January 2008 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jclp.20451

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Most personality disorders (PDs) do not present to clinicians in a pure form. Comorbidity is the rule rather that the exception. Our focus here is on patients diagnosed with antisocial personality disorder (ASPD) comorbid with borderline personality disorder (BPD) who have committed acts of violence. This admixture of personality features complicates the clinical picture that is presented to the clinician, who has to take into account the phenomena of ASPD and the possibility of violence to others in treatment, as well as the danger of self-harm and suicide common in BPD. There is limited evidence available about how to treat such individuals and, if we were to start from rst principles, an understanding of the processes underpinning this complex psychopathology would inform treatment innovation, which, in turn, would then be subject to empirical investigation. Kazdin (2004) has outlined a sequential program for the development of psychotherapy based on these principles. The rst stage follows from the proposition that treatment should reect what we know about the processes that directly bear on the onset and course of a clinical problem. In violent patients with ASPD/BPD, we need to understand the interrelationship of the phenomena and if possible, demonstrate that a specic process or lack of process is present in a sizable proportion of individuals with this comorbid presentation. We believe that the process of mentalization is linked to the phenomena of personality disorder, and in this article we suggest that a focus on mentalizing is relevant to the treatment of violent patients with complex personality pathology. A clinical vignette from a group session followed by an associated individual session during treatment of patients comorbid for ASPD/BPD will illustrate some of our points. Mentalizing and Personality Disorders Mentalizing simply implies a focus on mental states in oneself or in others, particularly in explanations of behavior (Fonagy, Gergely, Jurist, & Target, 2002). That mental states inuence behavior is beyond question. Beliefs, wishes, feelings, and thoughts, whether inside or outside our awareness, determine what we do. Explanations of behavior in terms of others mental states (mentalizing) are relatively vulnerable compared with explanations that refer to aspects of the physical environment (nonmentalizing). The latter are far less ambiguous because the physical world is less readily changeable. When taking a mentalizing stance the mere contemplation of alternative possibilities may lead to a change in beliefs. Thus, a focus on mind leads to far more uncertain conclusions than a focus on physical circumstance because it concerns a mere representation of reality rather than reality itself. We may act according to wrong beliefs about others mental states and underlying motivations in a particular situation, sometimes with tragic consequences. For example, we may believe that people mean us harm as they run towards us and react accordingly, when, in fact, they are concerned for our welfare and wish to push us out of the way of a car we have not seen. Normal people will, at times, move from understanding themselves and others according to what is in the mind to explanations based on the physical environmentI must have wanted to because I did it. However, we have suggested that rapid and frequent shifts from mentalizing to nonmentalizing modes of experience is characteristic of borderline personality disorder (Bateman & Fonagy, 2004). In this article, we suggest that abnormalities in mentalizing are also a signicant problem in ASPD.
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The phenomena of ASPD/BPD are a consequence of a shift from mentalistic modes of function to prementalistic ways of perceiving the world. The prementalistic modes of organizing subjectivity, which emerge have the power to disorganize relationships and destroy the coherence of self-experience that the narrative provided by normal mentalization generates. This move most frequently occurs when the attachment or afliative system is activated. As soon as emotional states are aroused in the context of an interpersonal interaction, ASPD/BPD patients become vulnerable to loss of mentalizing because stimulation of the attachment system actually inhibits mentalizing itself (Fonagy & Bateman, 2006). The consequence of the inhibition of mentalizing itself is a reemergence of modes of experiencing internal reality that antedate the developmental emergence of mentalization, namely psychic equivalence, pretend mode, and teleological thinking. Nevertheless, in addition, there is a constant pressure for projective identicationthe reexternalization of the self-destructive alien self (Fonagy & Bateman, 2007). Psychic Equivalence Mentalization gives way to psychic equivalence, which clinicians normally consider under the heading of concreteness of thought. No alternative perspectives are possible. There is a suspension of the experience of as if and everything appears to be for real. This can add drama as well as risk to interpersonal experience, and the exaggerated reaction of patients is justied by the seriousness with which they suddenly experience their own and others thoughts and feelings. A patient had a dream about a giant wave destroying thousands of people. When she woke up in the morning, she heard that there had been a huge tsunami. She became terried and believed that she had caused the disaster and eventually took an overdose of paracetamol because she could not cope with her emotional state. A patient who had been sexually abused by her grandfather had ashbacks of him coming in to her bedroom. She barricaded her door at night. Even though he had died a number of years ago, her image of him entering her room was experienced as current rather than a memory from the past and she reacted accordingly. Pretend Mode Conversely, thoughts and feelings can come to be almost dissociated to the point of near meaninglessness. This is pretend mode. In these states, patients can discuss experiences without contextualizing them in any kind of physical or material reality. Attempting psychotherapy with patients who are in this mode can lead the therapist to lengthy, but inconsequential discussions of internal experience that have no link to their genuine experience. A patient talked about her childhood explaining how it linked to her suicidal behavior. It seemed logical and understandable, but knowing it did not alter her level of risk or improve her self-destructive patterns. It simply justied her behavior. Teleological Mode Early modes of conceptualizing action in terms of that which is apparent can come to dominate motivation. This is teleological mode. Within this mode, there is a primacy of the physical and experience is only felt to be valid when its consequences are apparent to all. Affection, for example, is only true when accompanied by physical expression. A patient believed that her new boyfriend did not want to see
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her anymore because he did not meet her at the agreed time. In teleological mode, she believed that if he wanted to see her he would have been there. When he contacted her an hour later to let her know that he had been stuck on an underground train that had broken down, she swore at him and told him that she never wanted to see him again. Later she cut her wrists. Alien Self Finally, with the dissolution of the self, aspects of oneself that are experienced as alien are projected and seen as belonging to others. Relationships become rigid and xed and the other has to be controlled forcibly to keep hold of alien parts of the self. The alternative is complete collapse of the self and destruction of the self becomes preferable. In a teleological mode this is dangerous, i.e., physically, by self-harm and suicide. The need for the other as a vehicle for the alien self can become overwhelming as the patient experiences it as a matter of survival and an adhesive, addictive pseudo-attachment to this individual may develop. We assume, as suggested by Winnicott (1956), that when a child cannot develop a representation of his own experience through mirroring (the self), he internalizes the image of the caregiver as part of his self-representation. We have called this discontinuity within the self the alien self. We understand the controlling behavior of children with a history of disorganized attachment as persistence of a pattern analogous to projective identication where the experience of incoherence within the self is reduced through externalization. The intense need for the caregiver characteristic of separation anxiety in middle childhood that is associated with disorganized attachment, reects the need for the caregiver as a vehicle for externalization of the alien part of the self rather than simply an insecure attachment relationship. This method of stabilizing the mind and the self is carried through to adulthood. The experience of fragmentation within the self-structure is reduced by this process of externalization. Loss of mentalizing destabilizes the self provoking an uncertainty Who am I? Who are they? What do they want? Who am I in relation to them? No answers are available to the individual and panic ensues. As it does so, the individual attempts to recapture a sense of self by schematic representationI understand this if he does not like mehe is victimizing me and I am a victim. To manage this state of mind, individuals project aspects of themselves that are destabilizing and see them in the other. The alien aspects of the self are most dangerous to the individuals integrity and narrative structure. The Self and Violence A rapid, attachment-dependent movement between these different modes of experiencing the self and the world is characteristic of BPD, but is modied by the co-occurrence of violent ASPD. In comorbid ASPD1BPD, the mental processes are more stable in contrast to the rapidly uctuating states found in BPD itself. Yet the patients hold on understanding the mental states of others is tenuous and can be suddenly and catastrophically lost as the attachment system is stimulated. Stability is maintained by interpreting the world according to teleological understanding much of the time, but in many instances, we suggest that stabilization of mental processes arises from the rigidity of the externalization of the alien self. This presents serious problems for the treating clinician. The rigidity of the system has to be challenged and yet the challenge might induce violence.
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In ASPD/BPD, the alien self is rmly and rigidly located outsidea partner may be seen as mindless and needing to be told what to do; a system portrayed as authoritarian and dangerously attempting to subjugate. This stabilizes the mind of the patient. Threats to these schematic representational structures, which could be a system being overly nice or pleasant or a partner demanding an unacceptable level of independence, lead to arousal within the attachment system, which triggers an inhibition of mentalizing, which, in turn, leads to fears of inability to control internal states and the threat of the return of the alien self. It has been suggested that threats to self-esteem trigger violence in individuals whose self-appraisal is on shaky ground because they exaggerate their self-worth (narcissism). Patients with ASPD/BPD inate their self-esteem by demanding respect from others, controlling the people around them, and creating an atmosphere of fear. This maintains pride, prestige, and status, and ensures the experience of the external location of the alien self. Loss of status is devastating as the alien self is returned and reveals internal states that threaten to overwhelm them. Experience becomes more rmly rooted in psychic equivalence. Such patients are momentarily unable to mentalize, to see behind the threats to what is in the mind of the person threatening them, and so they have no way of keeping out a rapidly lowering selfesteem and loss of position. Emotional capacities such as guilt and love towards others and fear for the self may protect from engaging in violent behavior, but the loss of mentalizing and the embryonic ability of these patients to experience such feelings prevent mobilization of these inhibitory mechanisms. Fear for the self is absent and the dangers associated with violence become secondary. The onset of pretend mode means the risk of being caught is unreal and an illusory sense of safety and lack of reality is manifest. The internal state no longer links with external realityIt happened like in the movies; it didnt seem real. Gilligan (2000) creatively and persuasively focused our attention on the regulation of shame as a key factor in the pathology of ASPD. The shame associated with loss of self-esteem is also experienced in psychic equivalence mode and is so devastatingly destructive that the patient has to do something immediate and urgent if he is to survive. He cannot accept the return of the alien self, which will induce overwhelming feelings of shame, and so he inevitably attempts to control the source, which is seen as out there. Aggression towards the source of danger cannot be limited to nonphysical aggression such as shouting. This can only occur if mentalizing is retained and awareness of the mental state of the other remains, at least partially. Recognition of the other person as having a separate mind inhibits violence; the loss of mentalizing allows a bodily attack as the other person becomes no more than a body or threatening presence. So it is to violence that we now turn to understand in more detail this nal element to the complex picture. The common path to violence is via a momentary inhibition of the capacity for mentalization. Mentalization protects against violence. Some individuals, constitutionally poor at recognizing mental states in others through facial expressions or vocal tones, may not fully acquire the ability to mentalize and thus inhibit their natural violence. These individuals are callous and unemotional. They remain unencumbered by the recognition of others mental states and are unaware of the effects of their actions or expressed desires on others. As a result, they remain unaffected by negative responses and in line with the terrible threat that such individuals represent, we dismiss them as psychopaths. We are not concerned with this group here.
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Others never had the opportunity to learn about mental states in the context of appropriate attachment relationships. Or, alternatively, their attachment experiences may have been cruelly or consistently disrupted. For yet others, a nascent capacity for mentalization has been destroyed by an attachment gure, who created sufcient anxiety about his thoughts and feelings towards the child for the child to wish to avoid thinking about the subjective experience of others. It is important to retain an awareness of the possibility that violence may be rooted in the disorganization of the attachment system. A child may manifest an apparent callousness that is actually rooted in anxiety about attachment relationships. Yet, in fact, they are not callous and unemotional, but terried and potentially striving for a more reliable attachment. It is this group that we are more concerned with here as a harsh early childhood could signal greater future need for interpersonal violence as a means of expression of underlying mental states. In support of this model are studies (Jaffe et al., 2004; Shonk & Cicchetti, 2001) that demonstrate that the association between childhood maltreatment and externalizing problems is probably mediated by inadequate interpersonal understanding (social competences) and limited behavioral exibility in response to environmental demands (ego resiliency). We argue that the group whose aggression is high in early childhood and continues into adolescence and early adulthood is likely to have had attachment experiences that failed to establish a sense of the other as a psychological entity. We propose a synergy between psychological defenses, neurobiological development, and shifts in brain activity during posttraumatic states such that mentalizing activity is compromised. The shift in the balance of cortical control locks the person with maltreatment history into a mode of mental functioning associated with an inability to employ alternate representations of the situation (i.e., functioning at the level of primary rather than secondary representations), an inability to explicate the state of mind (metarepresentation) of the person they face, and a predisposition to enter a mode of mental functioning associated with states of dissociative detachment, where their own actions are experienced as unreal or as having no realistic implications. Treatment has to address all of these facets. Mentalization-Based Treatment Mentalization-based treatment (MBT) has been developed for the treatment of BPD and is fully operationalized for that disorder (Bateman & Fonagy, 2006). It has been shown to be effective in randomized controlled trials in a partial hospital program (Bateman & Fonagy, 1999) and is currently being investigated in an intensive outpatient format. It is now being adapted for patients with ASPD. The primary aims of MBT are to create a therapeutic environment in which mental states of self and others become the focus of concern. To this extent, it may be especially suited to the abnormal processes associated with ASPD/BPD patients who need to extend their ability to maintain mentalizing when self-esteem is threatened by developing some mental functioning at a secondary level of representation. Clinical Modes of Mentalization-Based Treatment Mentalization-based treatment is offered to patients in the form of combined group and individual treatment. Patients are seen every 2 weeks, but sessions alternate between individual and group modes. Group therapy is an excellent context in which to address the difculties presented by patients who disregard normal social processes and fail to take into account common interpersonal sensitivities.
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It provides the possibility for them to develop a better understanding of their role in social processes, and how their interactions with others can provoke distortion in social understanding and interpersonal interaction. As we have already suggested, if a person feels angry with someone or feels misunderstood or treated unfairly, he or she has to manage his or her mind rather than rid themselves violently of the physical cause of the discomfort. The dangers of mentalizing group psychotherapy with ASPD/BPD become obvious when we consider the aim is to promote serious and detailed consideration of the motives of self and other when emotions are aroused and to nd ways of managing the alien self without resorting to control through violence. Once rigidly held schematic representations are challenged or even questioned, violence will not be far off. Patients with both ASPD and BPD nd group therapy problematic partly because of their compromised ability to understand the motives of others, but our current experience is that they can attend regularly for a prolonged period of time if the sessions are interspersed with individual sessions in which they review their role and behavior in the group as well as addressing other personal concerns. In the following illustrative clinical vignette, we report a group session in which the patients form an agreed understanding of a violent event. Their understanding is temporarily accepted without question by the cotherapists. This clinical material will be discussed in relation to our earlier outline suggesting that it is the loss of mentalizing processes that lead to violence in patients with ASPD/BPD. Although this is not addressed fully in the group, it is considered further in the subsequent individual session with the patient who again reported the episode of violence.

Case Illustration Group Session The group is formed by 6 patients, all of whom have a diagnosis of comorbid ASPD and BPD. They are aware of their diagnosis and have been attending the group and individual sessions for 6 months. One patient, Kieren aged 28 years, is absent. The group members are aged between 25 and 36. All have been in prison in the past for violent offences. Steve and Patrick are currently on probation having been released from prison early for good behavior. John is 32 years old and was brought up in a rough part of Northern England. He presented with depression and indicated that he wanted to change himself so that he could have a better relationship. He had been violent to his partner on a number of occasions and was currently living separately from her. Steve is 28 years old and has spent most of his life dealing in stolen goods and sometimes in drugs. He also has a number of offences for fraud. He presented for help because he was drinking too much and it was getting him into too many ghts. He had also been involved recently in extortion and blackmail. He lives with his mother and father who themselves have a criminal history. Patrick is 36 years old and has a number of children by different partners. He asked for help because he and his current partner had recently had a baby boy. He stated that he wanted to be a better person for his son. Michael is 25 years old and is the only member of the group to work. He works in a warehouse and his employer suggested he seek help for his anger. Following an anger management course, he was referred for further treatment because he had many problems related to his childhood including sexual abuse and physical violence while in care homes. His parents had abandoned him when he was 4 years old. Peter, who is 31 years old, had similar problems, but was
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more depressed at presentation to the services. The group began with John talking about an incident that had occurred a few days ago. John (J): I stabbed someone the other night. He was causing me a lot of problems and so he had it coming to him. Steve (S): What did he do? J: He was in my at. I had let a number of the young people on the estate come into my at to use it as a cooch (drug den). They know that I let them do it sometimes and I quite like it. Anyway, I told them it was late and so they had to leave. Then one of them said that I had pinched his cigarettes. I said What did you say? He repeated himself and so I told him that I had not and he had better leave. He then started swearing at me and told me that I was a thief. I warned him that he should shut up and get out. Patrick (P): You warned him then? J: Yes. P: That was good. You had done what you should. After that, it is up to him. J: I warned him again actually. Because he continued to accuse me of stealing his cigarettes so I said again that if he didnt shut up and get out he was getting what was coming to him. P: Then he deserves everything that was coming to him if he carried on. J: He then started to go, but as he was still talking when he packed his things I picked up the kitchen knife and went for him. His mates got hold of me and held me back so I couldnt reach him. They thought that he was out of the at, and so let me go but when he got outside he started to shout back at me that I was a thief and cheat. So at that point, I ran out and stabbed him. Couldnt help it. He had crossed a line. Therapist (TA): What line are you referring to? Michael (M): Thats obvious, isnt it? He had warned the guy and he carried on. You cant allow that to go on. TA: Can you say more about what that is? M: Well, he had warned him and he just carried on. Thats disrespectful. Steve (S): Yes, you need to understand that these people were in his at and you cant be disrespectful like that. If you let that go, there would be real trouble. Peter (P): Yes. Big trouble. TA: I am beginning to understand that there is something about this that you all understand, but I am not quite there yet. J: Look, they were in my at with my permission, but that does not allow them to do what they want, does it? TA: I understand that, but in this situation it leads to someone being stabbed and my concern is how circumstances can lead you to do thatyou suggested that you could not help yourself so something pretty important had happened in you. S: Its obvious to me. If you let someone get away with that you never know what will happen next time. They will assume that they can do anything. He gave him his chance to get out gracefully, but he did not take it. John followed the rules, but the other guy broke them and you cant allow that. TA: Can you help me with a bit more about the rules? J: Well, if you disrespect someone and they warn you, you should get out or expect a ght. I dont care when someone warns me, although I know that they have given me a chance, but I stay and go for it. If I lose, I accept that but I dont care what happens to me, so I usually win. Most other people worry a bit
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about what happens to them and so they dont go quite as far as I do. But the rules are the rules. Therapist (TB) to J: As I understand it, then this man disrespected you and then behaved a bit like you do and stayed to challenge you, which you couldnt allow. Can you say what the challenge to you is? J: If I let him get away with what he was saying and his accusations, the other people would have told everyone around the estate and then people would think that I was weak. I wouldnt have any respect from anyone then. P (interrupting): Yes, you have to understand the sort of place we live in. If you didnt deal with situations like this, people would laugh at you and that would be you nished as a person. TA: Can anyone say what Patrick means by being nished as a person? M: I know what he means. If you dont stand up for yourself then you are nothing. TB: Nothing? M: Yeah, nothing. You would be nobody and people might even start to take advantage of you. People are frightened of me and so keep away. I am someone. Everyone knows that they cannot mess with me and I want to be left alone. If I am not left alone then something happens. The other day someone didnt move out of the way when I was walking along. At rst, I left it and stepped aside, but as he passed I just felt that I couldnt let that happen. He was challenging me, and so I ran back and smacked him in the face. He wont do it again. But he was treating me like I was nothing and that is not on. TB: Can you just say what it is like to suddenly feel in danger of being nothing? (silence) S: You dont wait to feel it, you just sort out what you have to sort out. TA: What if someone doesnt know the rules or if their mind is elsewherefor example, that this person you hit for not standing aside when you were walking along. Maybe his mind was elsewhere. (silence) TA: I realize that none of us have mentioned the person who was stabbed. It seems that we have forgotten about him. Was he OK? M: Hes not important. He had it coming to him. I dont think about people after something has happened unless I have a score to settle. Then I keep it and plot to get my own back later. I dont do remorse stuff. It does your head in. S: Its no good being guilty about it all. Anyway, both these guys deserved what they got. TA: Being punched in the head for not moving aside? S: Depends on the circumstances. This guy was probably giving him that look that says he is defying you and so he shouldnt do that. (The group continued with some discussion about the look, what it was and what it meant.) John describes a context in which he has invited young people into his at to use drugs. Here he is in charge, they are in his debt, and he has their gratitude. He can feel safe in the knowledge that all those around him accept his superior status in a hierarchy. The moment that an individual challenges him by accusing him of theft, his anxieties are aroused and he feels threatened. The therapists attempt initially to explore this challenge and what feelings it induces in him (a common mentalizing technique), but the other patients quickly start to ask him if he kept to an accepted code of conduct, in this case a warning that something will happen unless the challenge is withdrawn. The revelation that two warnings were given is reason
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enough to suggest that the act of violence is probably justied. The underlying feeling state is initially avoided; the discussion focuses on the importance of respect. All members of the group consider respect as necessary for survival. A return to the theme is indicated by their unease about the look which, in essence, is one of disrespect. However, it is just before the return to the theme of disrespect that there is an indication of what is of most alarm to John and to the rest of the group becoming nothing. John expresses concern about losing respect, Patrick about being nished as a person, and Michael as being nothing. It is clear to them all that loss of face is not an option, and they have to rid themselves of the cause of the threat to maintain their sense of pride, dignity, honor, and, in the end, their own self. Indeed, they ask the therapists to understand the world in which they livewhich is unforgiving, talionic, and where it is a daily struggle for survival. This seems to be accepted by the therapists who gradually become bystanders in the discussion of the violent act, seemingly agreeing with the patients about the responsibility of the victim for what happened. The perpetrator is seen as being within his normal mind when stabbing him. To this extent, we believe that the mentalizing capacity of the therapists is temporarily switched off by patients who present horrifying material without concern. The therapists become identied with the aggressor rather than placing themselves in identication with the victim. To do so would leave the therapists themselves concerned about being the recipients of violence and yet at the same time, they cannot completely identify with the violent patient as that too is dangerous. The patients seek to control the alien self, in this case, a torturing and humiliating self, by developing a nonmentalizing explanation. The victim deserved it because he was warned and you have to do this sort of thing otherwise you do not get the respect you should. He cannot countenance any such feeling of humiliation in himself. At the same time, the group disrupts the mentalizing of the therapists using a power dynamic that fuels the victimvictimizertherapist interaction, through the impact of conscious and unconscious coercion. The roles of John, the victim, and the therapists can be seen from this perspective as representing a dissociating process; the victim is dissociated from the group as not usHe was warned and he knows the rules. It is his choice if he ignores them by John and the group. The therapists are warned that they have to understand the culture that is inherent in the way they live. The therapists then abdicate their role for a brief time by colluding with the idea that the problem lies with the victim. The task of the therapists as observers of the process is to maintain mentalizing as much as possible and to avoid this risk as well as the risk of schematically representing the perpetrator as a demon and the victim as a helpless innocent. This is equally nonmentalizing. The therapists in this vignette attempt to maintain a mentalizing stance and ask for clarication and understanding from members of the group to identify the meaning of words which are implicitly accepted as having an agreed denitionthe rules, disrespect, nished as a person, being nothing. To explore these areas, the therapists recruit other patients to expand on the relatively underdeveloped statements that are made. This is characteristic of mentalizing groups in which therapists try to stimulate a process of understanding between members of the group about what they understand is going on in the minds of each other. The therapists also participate actively: in this vignette by expressing their uncertainty about the explanation of events. Finally, they briey indicate that something intolerable had
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taken place in John, but he does not explore it further. As a matter of principle, we ask therapists to explore more explicitly such affective change in more detail. Although this group session allowed the patients to identify the role of respect, the importance of hierarchy, their recognition of avoiding becoming nothing, it did not address the underlying dynamics involved in the violence. In part, this was related to the problems the therapists had in actively maintaining their mentalizing stance, but it was also related to recognition that to insist on too much exploration in the group might have been experienced as forcibly returning the humiliating alien self. The group protected John from this perhaps because they were unconsciously aware that not to do so could lead to further violence. In MBT, it is commonly in the individual session that some of these serious actions can be explored in more detail, and this was done in this case. Individual Session The individual therapist was aware of the content of the group and so at the beginning of the session, in line with our normal practice, he told John what he knew about what had been discussed. Therapist: I understand from Dr A that you reported stabbing someone since I last saw you. It might help if we can talk about that a bit more, although I understand that you talked quite a bit about it in the group. J: Yes, well, I told the group that he deserved it. I warned him and he took no notice so he had it coming to him. Rules are rules. T: You have mentioned the rules to me before. It sounds like you feel he broke the rules. J: He did. He knows the rules. He was in my place as well, so he should have been more careful about it. I dont know what happened anyway. T: Tell me a bit more about what it is that you didnt know. J: I keep trying not to do these things. If I keep doing them, I wont be allowed to see my kids. The f______ social worker will just see me as dangerous. I am not dangerous. These things just happen. T: From my perspective that seems to be what is dangerousthese things just happen. Can you help a bit to see what it is that does happen? (John then reiterates some features of the events already discussed in the group.) T: What is it about all that which you feel is the most signicant bit? J: Dont know. T: Can you push it a bit? J: Well, I think it is something to do with worrying about how people will see me. If I let people call me names and tell me what I am, then I wont be treated as I should be. T: I can see that you felt that not to respond would be seen as weak and it might give you more trouble in the future as far as you could see. What is that like to feel weak? J: I cant live like that. I have to have people respect me. Otherwise, I dont know that I could live there. You dont know what it is like to live in these places. I wouldnt be able to go out and some of my mates would avoid me. I am not a troublemaker, but other people do stuff and then trouble happens. T: I can see that you try to avoid trouble most of the time, but you nd it difcult at these times when you dont know what happens. I am still curious about what changes at these points.
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J: I just see them looking at me and that starts it. T: Theres that look again (referring to earlier discussion of a look). It really does something to you. J: They think that they have got one over you (colloquial for winning a personal competitive interaction) so you have to show them that they have not. T: One over what? J: (sighs) I dont know. (silence) T: What is it like in you when someone seems to be getting one over you? J: It is not good. My mind goes at that point, and I know I have to do something about it. It all just happens. (pretend mode) T: Yes, it seems that it is at those times that you struggle. What happens to your mind? J: It goes blank and that is it. T: To my way of understanding, you see a look which is a challenge, and it is that challenge that you have to win. If the other person doesnt respond in the way you want, you start feeling that they might win something and then your mind goes blank. J: It is not always like that. Sometimes I can ignore it, but this time it was in my house and so it was more of me that he was going for. I think that the group therapists thought that I was a troublemaker and that I shouldnt have done it. Do you? T: I am not sure how your mind moved on to that. Where did the group therapists suddenly come into it? J: They seemed to think that I was causing some of it and being the trouble and shouldnt have done it. Do you? T: I dont think you should have done it, but you have helped me begin to understand that you felt you had no choice. But I think that the most important part is seeing if we can help you manage whatever happens when the look happens without having to attack someone. That leads you into trouble when you are trying to avoid it. It occurred to me to ask if you had ever felt that I was giving you the look. J: Oh, no. You are my doctor. It is here that I am trying to sort it out. T: Perhaps if it happens though, you can let me know. J: Hmm. Anyway, I wasnt sure that I wanted to go back to the group really. The others were quite helpful, but I thought that the therapists didnt really understand. T: Tell me more about that. J: Being in the group just made me feel that it was my fault that this thing happened. I dont want to feel like that. It is wrong anyway. So the best thing is not to go back to the group. T: It sounds like you are wondering if I am going to make you go back to the group. J: You cant, but do you think I should? T: Yes, I do. You see, I guess that by staying away (teleological response to a feeling) you want to make sure that you dont have to feel anything more about what has happened, but if you can work out what is going on it might help another time so that your mind does not just go blank (encouraging mentalizing). This clinical dialogue is a transcript from a tape recording made as a part of an ongoing pilot project into treatment for ASPD and so is highly accurate. It illustrates a number of points about mentalization-based treatment. First, the therapist is active
Journal of Clinical Psychology: In Session DOI 10.1002/jclp

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about his investigations of the events related to a violent episode. It is not left to the patient to bring up the topic. We explore violent acts in the same way as we explore acts of suicide and self-harm in our treatment for BPD. Second, the therapist claries that he is aware that the topic has been discussed in the group therapy, indicating that the condentiality is between members of the treatment team rather than held with any one therapist. This policy is known by the patients prior to treatment and should not be a surprise to them. Patients with ASPD seem to have little concern about it, which is in contrast to patients with BPD who have complained on a number of occasions about the lack of condentiality in individual sessions. Third, the therapist tries to maintain the focus on the action and is not easily deected from his task. The patient is helpful in this regard, as he does not really attempt to move away from the topic. Should he do so, the mentalizing therapist will try to stop and stand and maintain the focus for as long as possible. Fourth, the therapist tries to move to a consideration of the detail of mental states and internal feelings of the patient. However, this is hard for the patient who nds it difcult to identity his feeling states. Fifth, many of the therapist statements are inquisitive, but always balanced with some supportive and validating component. In MBT, we commonly try to see things from the patients point of view while asking them to stretch their minds to other perspectives Gradually, we hope to be able to move to more detailed work within the treatment session itself. This therapist attempts to do this towards the end of the vignette by referring again to the look, but the patient moves away quickly. In doing so, he illustrates a nonmentalizing response to the extent that he gives a specious explanation about why the look could not occur within the session. The patients rapid move away from any consideration of the therapist to a discussion about the group therapists exemplies the difculty these patients have with transferential experience, which is in marked contrast to patients with BPD who rapidly invoke the patienttherapist relationship in discussing their problems. Patients with ASPD tend to avoid the intensity of the relationship itself and therapists have to respect this while not avoiding it completely. Finally, the therapist also states his point of view when asked a direct question by the patient rather than placing it back to him to explore. Patients who operate in psychic-equivalent mode nd exploring other people minds in fantasy provocative and thoughts can rapidly become facts, leaving the therapist vulnerable to accusation. It is better to inform the patient what is on your mind in a way that encourages further dialogue about the focus of discussion. Clinical Issues and Summary Although we have increasing evidence for positive outcomes using MBT with patients with BPD, we have little information on outcome for those with concurrent ASPD and BPD. In this pilot project, the overall aim was to reduce violent episodes by helping patients maintain mentalizing at the point at which is it likely to be lost. Certainly, a focus on mentalizing engages the patients in treatment who have attended regularly over a year. Therapists can expect a reduction in violence if the group and individual therapy facilitate greater exibility in the patients rigid mentalizing. This cannot be done in the short term and so treatment is for 1 year, but even that might be overoptimistic and a longer period may be required.
Journal of Clinical Psychology: In Session DOI 10.1002/jclp

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We have always emphasized that the application of MBT for personality disorders requires not only a focus on techniques that facilitate the development of mentalizing, but also an avoidance of those that decrease it. In patients with concurrent ASPD and BPD, therapists have to focus on the more stable aspects of the mind found in ASPD rather than concern themselves with the rapidly uctuating states of mind of BPD, which are hidden within the stability of the ASPD. Patients with ASPD do not have mental pain associated with the others state of mind; thus, to generate conict in ASPD by thinking about the victim will typically be ineffective in inducing behavior change. It would only be of help if that type of conict was aversive to them. In the act of violence described in this article, there was no consideration of the victims state of mind, and not a single patient expressed any concern about what happened to him or what was going on in his mind that made him behave in the way he did. The inability of the patient with characteristics of ASPD not to experience psychic pain in this way suggests that they will not respond to aversive interventions, such as time out, contracts, or punishment, but might begin to respond to withdrawal of positive reinforcement of their self-regard. Most mentalizing interventions contain within them some aspect that helps patients feel that the therapist is trying to understand what is happening in their mind rather than attempting to make them to conform to some predetermined way of living. The overall aim is to engender a mentalizing process about events that just happen and about inner experiences that are perplexing. References
Bateman, A., & Fonagy, P. (1999). The effectiveness of partial hospitalization in the treatment of borderline personality disorderA randomised controlled trial. American Journal of Psychiatry, 156, 15631569. Bateman, A., & Fonagy, P. (2004). Psychotherapy for borderline personality disorder: Mentalisation based treatment. Oxford: Oxford University Press. Bateman, A., & Fonagy, P. (2006). Mentalization based treatment: A practical guide. Oxford: Oxford University Press. Fonagy, P., & Bateman, A. (2006). Mechanisms of change in mentalization based therapy of borderline personality disorder. Journal of Clinical Psychology, 62, 411430. Fonagy, P., & Bateman, A. (2007). Mentalizing and borderline personality disorder. Journal of Mental Health, 16, 83101. Fonagy, P., Gergely, G., Jurist, E.L., & Target, M. (2002). Affect regulation, mentalization and the development of the self. New York: The Other Press. Gilligan, J. (2000). Violence: Reections on our deadliest epidemic. London: Jessica Kingsley. Jaffe, S.R., Caspi, A., Moftt, T.E., & Taylor, A. (2004). Physical maltreatment vicitim to antisocial child: Evidence of an environmentally mediated process. Journal of Abnormal Psychology, 113, 4455. Kazdin, A.E. (2004). Psychotherapy for children and adolescents. In M.J. Lambert (Ed.), Bergin and Garelds handbook of psychotherapy and behavior change (5th ed., pp. 543589). New York: Wiley. Shonk, S.M., & Cicchetti, D. (2001). Maltreatment, competency decits, and risk for academic and behavioral maladjustment. Development and Psychopathology, 37, 317. Winnicott, D.W. (1956). The antisocial tendency. In D.W.Winnicott (Ed.), Collected papers: Through paediatrics to psycho-analysis. (pp. 306315). London: Tavistock.

Journal of Clinical Psychology: In Session

DOI 10.1002/jclp