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MBT in Secure Settings

MBT in Secure Settings. Dr Jon Patrick. Trying to think under fire…. The Importance of Mentalization.

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MBT in Secure Settings

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  1. MBT in Secure Settings Dr Jon Patrick Trying to think under fire….

  2. The Importance of Mentalization • “We will misinterpret people if we misunderstand their motives, become distrusting if we assume people are malevolent, and be unable to love and feel loved if we cannot find ourselves in someone else’s mind.” Bateman, Brown and Pedder 2010

  3. What is Mentalizing?

  4. Treatment Vectors in Re-establishing Mentalizing in Borderline/Antisocial Personality Disorder Impression driven Controlled Implicit- Automatic Explicit- Controlled Appearance Inference Mental exterior focused Mental interior focused Certainty of emotion Doubt of cognition Affective self:affect state propositions Cognitive agent:attitude propositions Emotional contagion Autonomy Imitative frontoparietal mirror neurone system Belief-desire MPFC/ACC inhibitory system 4

  5. Why is Mentalizing important? • Self-awareness and a sense of identity. • Meaningful and sustaining relationships. • Self-regulation and self-direction.

  6. Good Mentalizing • In relation to others’ thoughts and feelings • Opaqueness • Contemplation and reflection • Absence of paranoia • Perspective-taking • Genuine interest and open to discovery • Forgiveness • Predictability

  7. Non mentalizing videos 1 Vicky Pollard….. 7

  8. Non mentalizing videos 2 Basillllllllllll! 8

  9. Non Mentalizing Excessive detail gets in the way of considering motivations, feelings or thoughts Focus on external social factors such as the nursing staff, the clinical team, other patients self and other in psychotherapy Focus on physical or structural labels eg tired, lazy, clever, self-destructive, depressed, short-fuse

  10. Non Mentalizing (2) Preoccupation with ‘shoulds and should nots’ Denial of responsibility Blaming or fault-finding Expressions of certainty about others’ minds Always, obviously, never

  11. Non-Mentalizing Features Inside equals outside Seeing is believing Pseudo- mentalising Psychic Equivalence Switching off Teleological

  12. Still face video 12

  13. What goes wrong….. Potentially Premature Fostering Care So…. Drugs Mental illness Resilience

  14. Mr X Early trauma and neglect Sexual offence against another minor Diagnosis of LD (?2ndary to emotional neglect) Consistent relational problems Difficulty moving from high to medium security

  15. The Antisocial Mind • Primitive affects • Inadequate affect regulation • Emotions of toddler • envy, shame, boredom, rage and excitement • Lack of guilt, fear, depression, remorse and sympathy

  16. Mentalizing in ASPD Antisocial characteristics stabilize non-mentalizing by rigidifying relationships. Loss of flexibility makes the person vulnerable to sudden collapse in sense of self when their schematic representation of a relationship is challenged. This exposes feelings of shame, vulnerability and humiliation that cannot be controlled by representational and emotional processing…….but only by violence and control of the other person.

  17. Joe Pesci’s Teleological Drinks 18

  18. Mentalization and violence • Violence occurs when there is an inhibition in capacity for mentalization. • Mentalization protects against violence. • Violence in ASPD is a defensive response to feelings of shame and humiliation, which have their roots in disorders of attachment.

  19. Aims of MBT To promote mentalizing about oneself To promote mentalizing about others To promote mentalizing in relationships

  20. Why is MBT helpful in forensic? • Characterised by complex relationship difficulties • “Giving a language” as difficulties include inability to name affect, thus often get confused and emotional • Mentalizing as a natural process for all!! • Teaching a skill, not a concept or theory • Dual focus/components of our MBT programme • Psychoeducation (MBT-i) • Therapy group

  21. What is MBT? The mentalising hand Stop – look - rewind Therapist stance

  22. Emerging evidence … Bateman & Fonagy (1999) – RCT of MBT for BPD vs TAU/control. Sign ↓ hospitalisations, ↓use of medication, ↓suicidal and para-suicidal behaviours Follow-up study (Bateman & Fonagy, 2001) –gains maintained over 18/12 after treatment completion and continued to show statistically significant improvement Ongoing - multi-site pilot MBT for violence in ASPD. Refine MBT for ASPD →future RCT Plus BJPsych 2013

  23. A pickle!

  24. A good result

  25. Conclusion Hard work but fun! Important to feel like a team Liberating – mistakes…great! Trying to keep each other on-model

  26. Q and A

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