Mentalization-Based Treatment for Personality Disorders

%% 6W6rvs0X ts: 2026-09-15T09:48:25Z %% "Depressed patients without comorbid BPD also experience mentalizing difficulties, and they may too sometimes function in the psychic equivalence mode; for such patients, this will show itself in a marked absence of "pretend" or "play" ways of seeing the world, a heavy sense of depressive reality, and a static view of inner mental states (see Box 3.3)." (p. 82 | 15-09-2026)

Pre-mentaliserende modi volgens Bateman & Fonagy (2004): 1. Alsof-modus: Innerlijke ervaring los van externe wereld; afgesplitst van het zelf; voelt ‘te weinig echt’. Tegenoverdracht: verveling. - In extremum: dissociatie, derealisatie. - Voelt voor de luisteraar leeg, betekenisloos. - Tegenstrijdige overtuigingen - Gevoelens matchen gedachten vaak niet. - “Pseudomentaliseren” - Kan door patiënt gebruikt worden voor eigen voordeel, om compassie te krijgen bijv. - Managed: by interrupting nonmentalizing process 2. Teleologische modus: Mentale toestanden alleen echt als er fysiek bewijs is; ‘Het is pas zo, als ik zíe dat het zo is.’ - External mentalizing focus - Tegenoverdracht: actie, overnemen. - Patiënt reageert vaak met “acting out” - Managed: niet verleid worden tot handelen 3. Psychische equivalentiemodus: Interne en externe wereld gelijk; eigen beleving = realiteit; geen ruimte voor andere zienswijzen. - Mind-world isomorphism; er zit écht een tijger onder het bed. - Concreteness of thought - Similarities with PTSD flashbacks - Managed: by avoiding being drawn into nonmentalizing discourse.

Psychic equivalence is inevitable if emotion (affect) dominates cognition. Teleological mode follows from an exclusive focus on external features to the neglect of the internal. Pretend mode thinking and hypermentalizing are unavoidable if reflective, explicit, controlled mentalizing is not well established

Preface

• Nonmentalising in the patient cannot be met by mentalising in the clinician. It can be met only by "switching on" mentalising in the patient.
• Every session starts with listening to the patient's narrative and the clinician finding something in the story that he can empathize with. This process is called empathic validation. Often the clinician seeks the patient's basic emotion. It is this experience that is validated, rather than subsequent social or secondary emotions.
• Non-contingent responsiveness at this point is likely to trigger non-mentalizing or generate avoidant attachment strategies.
• The story the patient brings is then clarified quickly in the sense of events and facts, but thoroughly surrounding the events with mentalizing. this establishes their pre-morbid state of mind. What were their hopes? What was their experience when they were doing something? What thoughts intruded into their mind? What feelings did they identify? And can they reflect on it differently now?
• Realize the strong relationship between affects and interpersonal relationships, which reciprocally interact. Unmanageable emotions impinge on relationships, and relationships stimulate powerful feelings.
• Feelings can often not be identified accurately, but are primarily experienced as inchoate bodily experiences. Helping the patient identify a range of feelings is part of the clarification and exploration component of MBT.
• Emotions often need to be normalized. Patients often experience their emotion as wrong, invalidating their own internal perceptions and feeling ashamed. In fact, their affect may be appropriate but excessive or at other times inexplicably absent.
• The next phase is identifying the current affect related to the session, not just to the focus of the story. For example, if a boyfriend did something bad and they are angry, then at the same time they may feel that the clinician will judge her for it. This last affect is the affect focus.
• It is the goal of the clinician to make implicit dimensions of mentalizing explicit. For example, if a clinician keeps pushing on a topic and the patient keeps retreating, then the clinician may say that this happens and suggests that the patient is frustrated, and that they too are getting a little frustrated.
• This is laying the groundwork for mentalizing the clinician-patient relationship, which is done through the use of transference tracers (?).
• Mentalizing the relationship requires the clinician to empathically validate the patient's perception of him. The clinician actively avoids invalidating the patient's experience. He needs to work out his contribution to the patient's experience of him by thinking aloud about it and asking the patient to explain how she has come to that conclusion.

Chapter 1 - What is mentalizing?

- Mentalizing is the ability to understand actions by both other people and oneself in terms of thoughts, feelings, wishes and desires. It is a very human capability that underpins everyday interactions. Without mentalizing, there can be no robust sense of self, no constructive social interaction, no mutuality in relationships, and no sense of personal security. - Mentaliseren gaat over het begrijpen van acties van jezelf of anderen als voortkomend uit mentale processen. - Zonder mentaliseren, geen zelfbesef geen sociale interactie, geen wederkerigheid en geen persoonlijke integriteit. - Mentaliseren omvat een heel scala aan capaciteiten. Zoals de capaciteit om je eigen gedrag als coherent georganiseerd door mentale staten te zien. Of om jezelf te differentiëren, psychologisch gezien, van anderen. dit zijn capaciteiten die de neiging hebben om afwezig te zijn in mensen met een persoonlijkheidstoornis. Zeker bij momenten van interpersoonlijke stress. - Mentaliseren gaat ook of vooral over intentionele mentale processen. - Die mentale processen zijn ondoorzichtig, We voorspellen ze. We doen aan 'inference'.

[!note] Relateren aan predictive coding

Mensen met epistemisch wantrouwen, bijvoorbeeld door een voorgeschiedenis met psychotrauma, hebben weinig reden om anderen te vertrouwen, en zullen nieuwe informatie doorgaans verwerpen.

- Anderen begrijpen in termen van mentale processen is bijna altijd lastiger dan een uitleg op basis van de fysieke wereld (foreshadowing voor de prementaliserende teleologische modus?) - Mentaliseren gaat over het zien van jezelf van de buitenkant en anderen van de binnenkant. - MBT gaat over "mind-centeredness". - Mentaliseren staat centraal in zelforganisatie en affectregulatie. - Je eigen capaciteit om te mentaliseren komt voort uit verzorgende, aandachtige ouders die als kind jóúw mentale staat adequaat begrepen. En er woorden aan gaven voor jou. Spiegelen. - De kwaliteit van het spiegelen van affect door hechtingsfiguren speelt een grote rol in de vroege ontwikkeling van affect regulatieve processen en zelfcontrole. - Mentaliseren is een transactioneel en intergenerationeel sociaal proces.

Mentaliseren kan:

• automatisch of gecontroleerd zijn;
• over jezelf of over anderen gaan;
• over interne of externe eigenschappen gaan;
• cognitief of affectief zijn.

==Anki==

Mentaliseren is een werkwoord, het is een activiteit van jezelf. De niet-wetende, nieuwsgierige houding moet centraal staan, want je zult het vaak bij het verkeerde eind hebben.

Maar hoe herken je effectief versus niet-effectief mentaliseren? Bij jezelf versus bij de ander. Bij de ander, o.a. perspectief innemen.

• Je herkent de inhoud en de vorm
• Inhoud: "gewoon", inhoudsloos, zondebokgedrag, weinig te maken met binnenwereld.
• Vorm: overgedetailleerd, veel aannames, stellig of rigide, woorden die complexiteit beperken. Zo is het nu eenmaal.
• Non-mentaliseren; communicatie stopt. Anti-reflectief. Telefoon pakken, uitrekken. Geen verheldering, geen uitleg.

Automatisch versus gecontroleerd mentaliseren is een wisseling die automatisch gaat. Als een ouder zijn kind ziet huilen, dan moet er nagedacht worden over waar dit vandaan komt. Of als een vriend merkt dat de intonatie van zijn vriend verandert, dan is er misschien iets gebeurd wel een moeilijke herinnering of associatie voort heeft gebracht.

Als iemand alleen op automatische aannames vaart, die vaak te simpel zijn, dan ontstaan er problemen. In feite kan elke psychologische interventie begrepen worden als het uitdagen van automatische mentalisaties. Waarmee de patiënt wordt gevraagd hun aannames bewust te maken en erop te reflecteren.

Erything we know about the other person except what is relevant to support our point of view. Therefore, the degree to which an individual finds themselves affected by interpersonal stress may make a critical difference to their mental-, izing skills across life experiences. It seems likely that the threshold for switching to an automatic (fight or flight) style of mentalizing will be lowered in people who have been exposed to stress or trauma in early life. There may also be a genetic influence on the ease with which people are likely to switch to this auto-matic, uncontrolled mentalizing mode. There is also some evidence that the activation of the attachment system is linked with the deactivation of mentalizing. Imaging studies (e.g., Nolte et al.,2013) have shown that the brain areas normally associated with maternal and romantic attachments appear to suppress activity in brain regions associated with different aspects of cognitive control, including those associated with making social judgments and mentalizing. Anything that stimulates the attachment system (beyond stress-induced arousal), therefore, seems to bring with it a general loss of mentalizing capacity. A traumatic experience will arouse the attachment system, and attachment trauma may do so chronically.

The hyperactivation of the attachment system in people with a trauma history may account for the dramatic loss of mentalizing capacity experienced by some individuals in emotional situations that trigger their attachment-seeking instincts. Attachment trauma probably hyperactivates the attachment system because the person to whom the child needs to turn in a state of anxiety (their attachment figure, usually a parent) is the very person causing the fear in the first place. The quick-fire triggering of the attachment system (p. 15)

Prementaliserende modi zijn belangrijk om te herkennen omdat ze signaleren dat niet herkende delen van het zelf geexternaliseerd kunnen worden, het “alien self”. Dit lijkt op projectieve identificatie: het externaliseren van het alien deel van het zelf.

Mentaliseren is essentieel voor de zelf-samenhang, het falen ervan leidt tot fragmentatie.

Alien self (NL: vreemd zelfdeel)

Basically the externalization of the alien part of the self, wat psychodynamici projectieve identificatie zouden noemen. De ervaring van discontinuiteit in het zelf wordt verminderd door een deel van het zelf te externaliseren door de ander te bewegen zich zo te gedragen als de geëexternaliseerde representatie vraagt. De persoon verlost zich van interne incoherentie door het incongruente gedeelte te externaliseren. Met mentaliseren zou je dit ook kunnen oplossen.

Voorbeeld: een kind belt bij onrust zijn ouders en praat gepanikeerd totdat zijn ouders ook merkbaar gepanikeerd raken. Opgelucht hangt hij op.

De noodzaak om dit deel te externaliseren is zeer groot bij mensen met persoonlijkheidsstoornissen omdat dat deel vaak kwaadaardig is, voortkomt uit destructieve hechtingsfiguren, en ongeëxternaliseerd kan leiden tot ernstig zelfdestructief gedrag.

Als dat soort destructieve delen niet geëxternaliseerd kunnen worden kan dat ervaren worden als een aanval van binnen uit. Dit gaat over self-survival.

De clinicus moet de mate van regressieve enactments zorgvuldige controleren omdat te veel hiervan de mogelijkheden voor mentaliseren beperkt.

Hoe ontstaat dit? Als er sprake is van verlies van mentaliseren kan weet de patient niet meer wie ze zijn, wie de ander is, wat de ander van hen wil, etc. Om hier toch antwoord op te kunnen geven wordt een oude situatie herleefd: "ik begrijp dit als de ander mij niet mag en ik een slachtoffer ben".

Nonmentalizing begets nonmentalizing.

Als een uitgeputte moeder met een kort lontje iemand een destructief deel heeft doen internaliseren, dan is het alternatief voor succesvol externaliseren vaak destructief ongementaliseerde zelfkritiek, die als persecutoir kan worden in de psychische equivalentiemodus kan het een suiciderisico of zelfbeschadigingsrisico vormen.

Een afhankelijkheidsrelatie naar de persoon in wie de geëxternaliseerde alien self zich heeft ontwikkeld kan ontstaan.

Epistemic trust

De bereidheid om nieuwe kennis als betrouwbaar, generaliseerbaar en relevant voor onszelf te beschouwen.

De ander communiceert dit met ostensive cues.

Het vertrouwen dat we leggen in informatie over de sociale wereld die we van anderen krijgen, de mate waarin we die informatie als oprecht en relevant voor ons kunnen beschouwen. Dit stelt ons in staat om te leren en generaliseren. Gevormd door de mogelijkheid van kinderen om te leren van hun hechtingsfiguren. Het vertrouwen van kinderen in hechtingsfiguren generaliseert naar epistemisch vertrouwen op volwassen leeftijd.

Mensen met epistemisch wantrouwen zijn:

• Resistent voor nieuwe informatie
• Rigide, eigenwijs

Omdat ze informatie met diep wantrouwen aanschouwen en het niet willen internaliseren.

Mensen met borderline zijn vaak gedesorganiseerd gehecht, en reageren initieel op een overdreven vertrouwde manier, waardoor ze extra kwetsbaar zijn. Door hyperactivatie van het hechtingssysteem.

Er kan sprake zijn van epistemische hypervigilantie.

Het vernietigen van vertrouwen in sociale informatie is een centraal mechanisme in de pathologische persoonlijkheidsontwikkeling.

Clinici kunnen deze patiënten bestempelen als 'lastig te bereiken', maar ze laten slechts logisch gedrag zien in een leven waarin informatie van hechtingsfiguren niet te vertrouwen was.

Epistemisch wantrouwen en persoonlijkheidsstoornis: Een persoonlijkheidsstoornis is geen stoornis van de persoonlijkheid maar ontoegankelijkheid van culturele communicatie relevant voor het zelf uit de sociale context

Epistemisch wantrouwen is een falen van communicatie, het leidt tot een onverdraaglijk gevoel van isolatie. Bij clinici kan het tot frustratie leiden en een neiging de patiënt de schuld te geven. Clinici denken dat de patiënt niet luistert.

Therapeutic communication systems for BPD

Basically: 1. Communication of therapeutic model-based content, an ostensive cue for increasing epistemic trust, catalyzing therapeutic success. 2. The goal of increasing mentalizing as a common factor 3. Social learning in the context of epistemic trust, applying lessons learnt in the wider environment

Part of system 1 is the identification of mentalizing vulnerabilities; pathways to loss of mentalizing to be monitored carefully, identification of attachment strategies, developmental narrative, and more.

Because of the common factors theory, the truth of the MBT methodology lies not within the essential truth of its message but within providing a comprehensive framework in which the patient can understand their own situation, and instilling in them a sense of agency and a desire for change.

Part of system 2, increasing mentalizing, could be that whenever the clinician acknowledges their mind being changes by the patient, they ascribe agency to the patient. The patients feeling of having been sensitively responded to opens a virtuous cycle in which the patients own mentalizing capacity is regenerated.

MBT recommends an authentic "not-knowing" stance. Patient must think that another mind is useful for clarifying mental states. Focus on affect and interpersonal interaction. This provides the context of exploring complex states of mind within an attachment context (?) that would normally trigger loss of mentalizing. Minds change minds in a transactional manner.

Goal is also to rekindle the patients wish to learn about the (social) world.

Mentalizing is only an intermediate step, not the ultimate objective. That is system 3: learning from experience beyond therapy. This is the ultimate goal of the rekindling of the wish to learn socially.

It's about overcoming epistemic mistrust so that positive social information is now registered.

Improved understanding of social relationships through improved mentalizing allows patients to notice a sensitive response and feel understood in their own relationships.

Often, epistemic hypervigilance interferes with getting what is good in an interaction.

Patient-clinician alliance in a given session predicts change in the next, but meaningful change is only possible when a patient can use their social environment in a positive way.

Chapter 2 - Using the mentalizing model to understand personality disorder

Borderline personality disorder

The DSM criteria for BPD are a pattern of unstable intense relationships, inappropriate intense anger, frantic efforts to avoid abandonment, effective instability, impulsive actions, recurrent self harm and suicidality, chronic feelings of emptiness or boredom, transient stress related paranoid thoughts, identity disturbance and severe dissociative symptoms.

However, the alternative model is strikingly consistent with the mentalising perspective. It sets out four possible elements of impairment in functioning.

The first two elements relate to the self, the second two elements are interpersonal: 1. Identity, difficulties in experiencing the self as a unique entity with boundaries and a coherent sense of personal history. 2. Self-direction, impairments in the pursuit of short-term and long-term life goals. 3. Empathy, the ability to comprehend and appreciate others' experiences. 4. Intimacy, a lack of depth or the short duration of connection with others, and a limited desire or capacity for closeness.

The alternative model also describes five pathological personality traits related to personality disorder: negative affectivity, detachment, antagonism, disinhibition, and psychoticism.

Finally, the model proposes consideration of the pervasiveness and the stability of these traits, impairments in functioning and pathological personality traits.

There is considerable heterogeneity within the group classified with the DSM5 BPD diagnosis. Still, we can identify three related core features: emotion dysregulation, impulsivity, and social dysfunction.

Core related features of BPD

Emotional dysregulation

Overwhelming emotional arousal causes mentalizing imbalances and in terms of the dimensions, it involves being restricted to the affective polarity of the cognitive affective dimension. This is to a degree natural as a part of the fight or flight response, but in situations of social interpersonal stress, being able to function in a more cognitive and reflective way is important.

Psychic equivalence is the non-mentalizing mode most often associated with emotion dysregulation. Emotion is felt as overly real, and when sufficiently intense, it leaves no room for any doubt. It makes thoughts and feelings seem concrete rather than subjective, as being of the same weight and significance as a physical incident.

Impulsivity

• The most disquieting aspect of this is suicidality. For the rest, decreased attention, easily being bored, and also a lack of planning, limited consideration for consequences, excitement about risky activities, and also action without reflection, acting rashly. And what reflection there is, is likely to be hyper-mentalizing or pseudomentalizing. For example, someone may develop a reason retrospectively in terms of intentions and beliefs without offering compelling evidence. This may lead to sought after validation, but when it comes it is meaningless because they're also aware that they made up their explanation. The clinician helps them best by interrupting the nonmentalizing process, and the sooner the better.
• When mentalizing becomes highly impaired, it develops into the pretend mode of prementalizing, which can lead to impulsive behavior because it is not tempered by a measured hold on external reality.
• Impulsivity can also result from the teleological stance. In that mode, the individual cannot accept anything other than a physical action as a true expression of someone's intentions. None of the constant reassuring that a partner or parent might do feel real. It does not address the whole that the patient falls into at certain, especially lonely times.
• Self harm can be a way to make themselves feel real. Intentions can be proven only by observable outcomes, for example, aggression towards others.

Social dysfunction

• This is likely to be related to the characteristic pattern in BPD patients of fearful attachment, meaning attachment anxiety and relational avoidance, painful intolerance of aloneness, a marked hypersensitivity to social situations alertness to a hostile response from others, and greatly reduced positive memories of dyadic interactions.
• Related to mentalizing, they seek others to establish their own internal mental state.
• The chameleon effect, which is the unconscious tendency to mimic others' behaviour.
• Because others are so important to their own mental state, others pose a great threat to their sense of self. One way to meet this vulnerability is through aggressive or dominating behavior, which will cause others to respond defensively, often leading to conflict and intense affect.

Attachment, mentalizing and BPD

1. Early emotional neglect and it disrupted early social environment undermines some individuals to develop full mentalizing capacities. 2. Subsequent adversity or trauma further disrupts mentalizing in part as an adaptive maneuver to limit exposure to a brutalizing psychosocial environment. 3. Mentalizing is multidimensional thus different BPD patients will have specific impairments in these capacities.

Predictions following these views:

• Higher levels of insecure attachment strategies attachment disorganization in particular
• High levels of early emotional neglect and later drama.
• Complex patterns of mentalizing deficits.

People with borderline have more automatic mentalizing, more other focused, more exterior focused, and more affective. This leads to A type problems problems caused by the focus on this pole, and B type problems caused by the lack of focus on the opposite pole (Fig 2.1)

Overly automatic mentalizing; overvaluing intuition

Automatic mentalizing may lead them to be overly distrustful i.e., paranoid or overly trustful i.e., naive. Because they're not aware of their tendencies, conflicts can arise easily.

Self versus other

People with borderline traits can show excessive concern about their own mental state that develop without reference to social reality. This may lead to exaggerations of the self image in both positive and negative directions.

• Mind states of others can be overly influential, leading to a desire for rigid control of others and feelings to protect the self.

Internal versus external; hypersensitivity to the external at the expense of the internal

BPD patients can be hypersensitive to facial expressions. BPD patients tend to be excessively affected by the emotional states of those around them. Still, they're unable to make accurate assessments on anything other than surface judgments.

In MBT Interventions often need to start by accepting the patient's subjective experience, which can often be overwhelming rather than yielding to the temptation to review the evidence.

Cognitive versus affective; a failure of cognitive mentalizing

• Intense emotions aren't badanced by cognitions. Emotions dominate behavior, which leads to catastrophizing.
• Reality comes in a combined package with emotions if I feel pain, it will be hard to convince me that this is a product of my imagination, but with cognition, there is always doubt cognition is located in the self beliefs are in my mind, but emotions reverberate and are distorted by social context. You can't really argue with emotions.
• In addition, intense emotion disrupts the process that normally helps to regulate it, that is cognitive appraisal.

Antisocial personality disorder

The DSM-5 criteria can be summarized as a failure to conform to social norms in relation to lawful behavior, impulsivity, irritability, aggressiveness, recklessness, irresponsibility, and remorselessness. Prevalence of ASPD is very high in prisons with estimates ranging from a third to two thirds of inmates. People with antisocial personality disorders are experts at reading the inner states of others while being unable to develop any real understanding of their own inner world. It is thought that mentalizing may serve as a protective factor, preventing proactive aggression in spite of psychopathic traits. Thus it may present a target for intervention to reduce aggression in such individuals.

The mentalizing profile of ASPD across the four dimensions

• In short, individuals with ASPD can be better at external rather than internal cognitive rather than affective and automatic rather than reflective forms of mentalizing.
• In addition to which mentalizing dimensions are affected, it is also important how easily individuals lose the capacity to mentalize and how quickly they regain mentalizing after it has been lost.
• People with paranoid personality disorders often show rigid hypermentalizing with regard to their own internal mental states and lack any real understanding of others. At best, they are suspicious of others' motives, and at worst they see people as having malign motives and cannot be persuaded otherwise.
• People with ASPD stabilize mentalizing by rigidifying otherwise unpredictable interpersonal relationships with the use of prementalistic modes of thinking.

Automatic versus controlled

• Cognitions are disembodied and thus are easily distorted in largely self serving ways. For example, if it suits me to ignore critical aspects of reality such as the safety of the person I am with, I can drive at a dangerously high speed and report that my companion enjoyed the trip as much as I did. In the process I ignored external cues. When confronted, I might acknowledge their distress intellectually, but I would not attach any emotional salience to that understanding.
• People with ASPD feel that their ideas about the others, even if they are accurate lack meaning and therefore do not serve to regulate their own behaviour.

Self versus other; a failure to see the self in the other

• In a sense, in people with ASPD the sacrifice of self mentalizing frees up capacity for other mentalizing in a specific way by becoming selective experts in what others can do for them to meet their requirements.
• It must be said that the exceptional mentalizing capacity of some of these individuals is rare as a general statement the purpose of mentalizing the other for people with ASPD is not to facilitate social collaboration, but to exploit it for their own gain.
• They are good at reading other states from a cognitive perspective, but are unable to identify empathically with their states and be compassionate towards them. This partial recognition of the mind of the other is critical in permitting antisocial behavior.

Internal versus external; a failure to see the insight from outside

• Internal mentalizing is a focus on one's own or others internal states, that is: thoughts, feelings, and desires.
• There is a marked fewer references to internal states related to low reporting of psychiatric symptoms and interpersonal problems.
• People with ASPD show a particular inability to read facial expressions that convey affect.
• In ASPD, prioritising the external as opposed to the internal applies equally to the self and the other.

From an evolutionary perspective, there is an advantage to some degree of individuals who are unbothered by external cues of distress they observe in others depending on the specific environment, the proportion of such individuals will vary. Thus, such individuals may develop in two ways genetics and early development the attachment system may thus function as an early warning system to indicate to an infant the degree to which violent conduct may be required later in life.

Cognitive versus affective; a failure of affective mentalizing.

There's a poor understanding of self affect states, particularly of humiliation, and they are bad at identifying their own emotions.

ASPD and the prementalizing modes.

• In ASPD shame and humiliation are impossible to tolerate in psychic equivalence mode.
• Pretend mode is very important too, as a victim's mind becomes detached from the purpose's mind, making violence possible as if there is no psychological victim, or as if no connection can be established with the other mind. Thinking about thinking is not deemed meaningful, thus traditional therapy can often be fruitless.
• Teleological mode is applicable in the sense that retribution needs to be physical, status is often shown on the outside through cars and jewelry.

ASPD and the Alien Self

• People with ASPD place much significance in relationships.ither within a ganglike group or in a more personal context, these relationships tend to be hierarchical and rigidly organized. They serve an important function for self coherence in that they function as a place where the alien self can be externalized. These are often unbearable feelings. Partners are made mindless and subservient. The system, for example, the police, pick on them, follow them around, want to break them down. Rigid control of the other leads to a sense of self-certainty.
• When others seem to threaten these roles, e.g. a partner wanting more independence, this can trigger arousal, loss of mentalizing, a loss of agency and self, and a heightened perception of threat.
• Clinicians must challenge the rigidity with which relationships are conceptualized, but with great care because such a challenge may arouse feelings of violence and aggression, as a violent assertion of control is often an automatic response to such a challenge.

ASPD: Attachment, Violence and Psychopathy

The earlier the onset of problem behavior, the higher the risk for continued aggression and violence. These children have different family environments with less positive interactions, with more hostile, ineffective parenting.

People with ASPD and a history of violence have insecure dismissing patterns of adult attachment, tend to disavow the importance of attachment relationships and may deactivate attachment processes when possible.

It is thought that people with ASPD have attachment experiences that have been cruelly or consistently disrupted. Or perhaps an attachment figure created sufficient anxiety in the child about their thoughts and feelings toward him or her, for the child to wish to avoid thinking about the subjective experience of others.

It seems that the attachment system in individuals with ASPD is kept deactivated by a process whereby the other is seen as less than human and is frequently left unmentalized, treated as a thing rather than a person. In them, non-mentalizing thinking predominates. They experienced their own and those of other mental states in physical and bodily modes. Violent acts can occur either as a response to misperceiving the actions or intentions of others, or to evacuate intolerable mental affects linked to the alien self that cannot be thought about.

Psychopathy and ASPD share many features, but psychopaths also show additional interpersonal and affective features. There is non-psychopathic ASPD, primary psychopaths, where psychopathy appears secondary to antisocial behavior. And a group characterized by fearful psychopathy. The best distinguishing feature is the proclivity for instrumental aggression.

People with ASPD are prone for reactive aggression, in which trauma may play a great role, whereas in psychopathy They are potentially less vulnerable to trauma because of their emotional underreactivity.

MBT does not treat primary psychopaths. It is advised Not to include such individuals in MBT treatment programs.

The essence of treating ASPD is to stimulate affiliative bonds without simultaneously provoking the threat of shame and humiliation. At the same time, feelings of trust, honesty, and openness within the context of the attachment process have to be nurtured. %%end%%

Chapter 3 - Comorbidity

%% 6W6rvs0X ts: 2026-09-15T09:56:52Z %% "Finally, patients without BPD tend to have lower levels of epistemic hypervigilance (as discussed in Chapter 1), meaning that they may be more open to respond to their social context and social cues (including therapy). which can in turn support a speedier return to more balanced mentalizing." (p. 84 | 15-09-2026) %%end%% %% 6W6rvs0X ts: 2026-09-15T10:03:44Z %% "Attachment trauma in BPD is conceptualized as repeated experiences of being left psychologically alone in an unbearable emotional state" (p. 87 | 15-09-2026) %%end%% %% 6W6rvs0X ts: 2026-09-15T10:06:02Z %% "In post-traumatic flashbacks, memories lose their connection with the continuity of subjectivity and are experienced with the full force of the experience of physical reality (psychic equivalence). In dissociative detachment, the failure to mentalize affect generates a feeling of unreality (pretend mode; patients report "blanking out, "clamming up," or remembering their traumatic experiences as if in a dream. Oscillating between psychic equivalence and pretend modes of experiencing the internal world is a hallmark of traumatization (see Box 3.8)." (p. 89 | 15-09-2026) %%end%% %% 6W6rvs0X ts: 2026-09-23T09:39:26Z %% "All the inescapable pains of life are experienced with the immediacy of an open wound unprotected by the "skin" that mentalizing provides." (p. 90 | 23-09-2026) %%end%% %% 6W6rvs0X ts: 2026-09-23T09:40:09Z %% "Mentalizing provides a buffer between feeling and action —in effect, a "pause button" (Allen, 2001). Mentalizing puts the brakes on overwhelming emotions and impulsive actions, providing an opportunity for the motivations of self and other to be monitored and understood." (p. 90 | 23-09-2026) %%end%% %% 6W6rvs0X ts: 2026-09-23T10:08:26Z %% "In Chapter 4, we discuss the "switch" model of understanding the relationship between attachment, mentalizing, and stress. Individuals vary in how easily their attachment system is activated by stress, which triggers a switch from controlled to automatic mentalizing. Childhood trauma may shift the switch point between the two modes of mentalizing: people with a history of trauma often respond to increases in stress/arousal that would not be high enough to inhibit controlled mentalizing in others. In light of the precariousness of mentalizing in individuals with comorbid trauma and BPD, it is important for clinicians to monitor traumatized patients' readiness to hear comments about thoughts and feelings." (p. 91 | 23-09-2026)

• Switch model:

Stress > attachment system > switch from controlled to automatic mentalizing %%end%% %% 6W6rvs0X ts: 2026-09-23T10:30:35Z %% "The elaboration of meaning and affect through focused questions and observations by the dinician aids the process of gradually bringing the meanings and feelings together into a coherent narrative about the self. Foa, Huppert, and Cahill (2006) identified narrative coherence as a mechanism of change in exposure treatment for PTSD. Essentially, this process involves developing a narrative about the trauma that bridges the pre- and post-trauma self and that is forward-looking (see Box 3.11)." (p. 93 | 23-09-2026) %%end%% %% 6W6rvs0X ts: 2026-09-23T10:35:20Z %% "Reconstruction of the distant past is probably best viewed as a component of the work, in the context of a more overarching focus on exploring the current implications of painful and confusing early experiences." (p. 95 | 23-09-2026) %%end%% %% 6W6rvs0X ts: 2026-09-23T10:38:57Z %% "From the perspective of mentalizing theory, eating disorders are understood as an expression of a disordered sense of self. The solution to this incoherence is to equate the body/appearance with the subjective self in an attempt to restore a sense of coherence and pursue a sense of worth. The MBT approach is to improve mentalizing by enabling the patient to deal with his/her own mind and its affects, so that there is less retreat into the nonmentalizing modes of function in which feelings of dissatisfaction are physically embodied" (p. 96 | 23-09-2026) %%end%% %% 6W6rvs0X ts: 2026-09-23T10:46:32Z %% "The focus of MBT for eating disorders is on breaks in mentalizing and the emergence of nonmentalizing modes of functioning. The approach when this happens would be to "rewind" to the moment at which mentalizing broke down, explore the emotional context, and identify the affect state between the clinician and the patient (see Chapter 6). At this point, the clinician needs to also identify his/her own contribution to the breakdown in mentalizing (see Box 3.14" (p. 98 | 23-09-2026) %%end%% %% 6W6rvs0X ts: 2026-09-23T10:48:47Z %% "Minding the Body" sessions might involve body awareness sessions focusing on how one senses one's feet on the floor and one's legs and seat on the chair, in order to stimulate awareness of the body and shift attention from the objectified body to the lived-in, physical body." (p. 99 | 23-09-2026) %%end%% %% 6W6rvs0X ts: 2026-09-23T12:45:41Z %% "Individuals with BPD commonly excel in one particular form of mentalizing: intuitive empathy." (p. 105 | 23-09-2026)

• This can cause clinicians to assume these patients are also good at cognitive more reflexive mentalizing, confusing them.

%%end%%

%% 6W6rvs0X ts: 2026-09-23T12:55:45Z %% "Box 4.1 Questions that can reveal the quality of mentalizing • You described how your parents were with you—do you have any idea why they acted as they did? • Do you think what happened to you as a child explains the way you are as an adult? • Can you think of anything that happened to you as a child that created problems for you? • As a child did you ever feel that you were not wanted? • In relation to losses, abuse, or other trauma, how did you feel at the time and how have your feelings changed over time? • How has your relationship with your parents changed since childhood? • In what important ways have you changed since childhood?" (p. 106 | 23-09-2026) %%end%%

%% 6W6rvs0X ts: 2026-09-23T12:58:06Z %% "Importantly, the assessor needs to see past "canned" or "borrowed accounts of symptoms, complaints, or the nature of problems more generally. These accounts have often been learned from other professionals, patients, family and friends, or the Internet." (p. 107 | 23-09-2026) %%end%% %% 6W6rvs0X ts: 2026-09-23T13:00:53Z %% "For instance, a borderline patient's hypersensitivity to emotional states in others, generating a high proclivity for emotional contagion, often leads to vicious interpersonal cycles, marked by attributions of hostile intent, induction of guilt and shame, impulsive outbursts of aggression, and subsequent rejection by others (Fonagy & Luyten, 2009)." (p. 107 | 23-09-2026) %%end%%

Chapter 9 - The mentalizing focus, clarification, affect elaboration, affect focus, and challenge

Clarification

• Neem me mee met wat gebeurd is. Niet zo snel. Kun je langzaam gaan en me vertellen wat in je omging op dat moment zodat we elkaar goed begrijpen. Klopt het dat? Terugkijkend, denk je dat waren andere momenten waarop je dat gevoel ook had.

Affect elaboration

Een voorwaarde is dat de patiënt begrijpt dat emoties een belangrijke bron van informatie zijn en vaak een soort vroege waarschuwingstekens zijn of van zich ontwikkelende problemen. Belangrijke voorwaarde is nieuwsgierigheid.

• Met jouw ervaringen lijkt het me niet verrassend dat je je op deze manier voelt.
• Benoem emoties. Label ze.
• Exploreer de afwezigheid van motiverende emoties.
• Identificeer gemengde emotionele toestanden.

Normaliseren van emoties

Ik ben niet vreemd of een freak, maar ook gewoon een gevoelig persoon met normale gevoelens, maar die ze wel te sterk ervaart. Niet de overreactie normaliseren, wel de emotie zelf. 'Iedereen zou angstig zijn wachtend op een toetsuitslag.'

Identificeren van emoties

Identificatie is belangrijk om getroost te kunnen worden. Dit is een van de uitzonderingen waarbij het oké is om als therapeut aan te geven hoe jij een sensatie zou beschrijven.

Afwezigheid van Motiverende emoties

Zijn twee manieren in de situatie dat je uitgeerd raakt van de hopeloosheid die ervaren wordt door de patiënt. 1 is een affect focus, 2 is een challenge van de affectieve pol naar de cognitieve pool.

Gemengde emotionele staat

De emotie aan de oppervlakte kan een onderliggende emotie verbergen die helpt om de patiënt te begrijpen.

Affect focus

Gaat over het affect in de kamer. Gedeelde affect tussen patiënt en therapeut.

Chapter 10 - Relational Focus of Mentalizing, Transference Tracers, and Mentalizing the Relationship

People with BPD exercise interpersonal avoidance as a strategy leading them to live lives that often feel second best.

"Transference tracers" are interventions that link the content, for example, patterns of behavior, and process of the session either to the patient- clinician relationship (an inward movement) or to the patient's life outside (an outward movement), but they do not have the depth and complexity of mentalizing the relationship. They are a significant and necessary aspect of mentalizing and point the way toward mentalizing the relationship. The aim of tracers is to move therapy toward the here-and-now aspect of interpersonal interactions, to identify attachment patterns and their consequences, and to focus attention on salient interpersonal interactions. (p. 270)

Transference tracers link content to either: a) patient-clinician relationship (inward movement) or b) the patient's outside life (outward movement). Linking statements assume a trajectory from the impersonal (e.g. the department building) to the personal (clinician/him or herself). The hotter the session, the more impersonal you must go. Transference tracers are always current.

Integrative mentalizing

This is about enriching the patients experience after careful elaboration and identification of connected emotions.