Abstract
This case highlights multiple forms of nonreflectiveness commonly encountered in work with patients with BPD. Clinicians often feel tempted to employ therapeutic approaches that can inadvertently lead to increased rigidity, disengagement, demandingness, and dependency. Rather, clinicians should aim to stimulate greater reflection and curiosity through a humble and “not-knowing” therapeutic stance, while tailoring their interventions to address the particular forms of nonreflectiveness appearing in the moment, which can be distinguished as either black-and-white, disconnected, or concrete. For black-and-white thinking, avoid trying to change the patients’ minds overtly or more discreetly. Instead, empathically validate their perspectives, explore how they arrived at them, and cautiously share your own perspective to stimulate further reflection. For more disconnected experiences, try to “shift the frame” of the patient’s narrative, either by directing attention to aspects of the here-and-now clinical interaction or through surprising interventions that might abruptly prompt more meaningful reflection. For concrete thinking, avoid the impulse to take concrete action to appease concrete demands. Rather, explore the deeper meaning of the patient’s demands, empathically validate the underlying emotional experiences, and transparently share your own perspective on the scenario (including any dilemma you feel about “doing” versus “not doing” what is being requested).
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Notes
- 1.
The above ideas are a distillation of the main technical principles of mentalization-based treatment (MBT), one of the major evidence-based treatments for BPD. Mentalization is formally defined as “the mental process by which an individual implicitly and explicitly interprets the actions of herself and others as meaningful on the basis of intentional mental states such as personal desires, needs, feelings, beliefs, and reasons” ([1], p. xxi). More colloquially, mentalizing can be described as “thinking about thinking,” “holding mind in mind,” and “seeing others from the inside and ourselves from the outside.” MBT conceptualizes core BPD-related problems as caused by context-dependent impairments in mentalizing, such that, when patients are under increased interpersonal stress, they are more at risk for all of the nonreflective processes considered in this chapter. The treatment model provides accessible strategies to stimulate patients’ mentalizing processes in the clinical moment. This work over time helps to strengthen patients’ reflection on their thoughts and emotions in the context of their relationships, resulting in improvements in BPD’s characteristic instabilities in emotions, self-esteem, relationships, and behavior. For further information about MBT, see the publications listed below, and especially the comprehensive treatment manual [3].
References and Recommendations for Further Reading
The above ideas are a distillation of the main technical principles of mentalization-based treatment (MBT), one of the major evidence-based treatments for BPD. Mentalization is formally defined as “the mental process by which an individual implicitly and explicitly interprets the actions of herself and others as meaningful on the basis of intentional mental states such as personal desires, needs, feelings, beliefs, and reasons” ([1], p. xxi). More colloquially, mentalizing can be described as “thinking about thinking,” “holding mind in mind,” and “seeing others from the inside and ourselves from the outside.” MBT conceptualizes core BPD-related problems as caused by context-dependent impairments in mentalizing, such that, when patients are under increased interpersonal stress, they are more at risk for all of the nonreflective processes considered in this chapter. The treatment model provides accessible strategies to stimulate patients’ mentalizing processes in the clinical moment. This work over time helps to strengthen patients’ reflection on their thoughts and emotions in the context of their relationships, resulting in improvements in BPD’s characteristic instabilities in emotions, self-esteem, relationships, and behavior. For further information about MBT, see the publications listed below, and especially the comprehensive treatment manual [3].
Bateman A, Fonagy P. Psychotherapy for borderline personality disorder: mentalization-based treatment. Oxford, UK: Oxford University Press; 2004.
Bateman A, Fonagy P, editors. Handbook of mentalizing in mental health practice. Washington, D.C.: American Psychiatric Publishing; 2012.
Bateman A, Fonagy P. Mentalization-based treatment for personality disorders: a practical guide. Oxford, UK: Oxford University Press; 2016.
Choi-Kain LW, Albert EB, Gunderson JG. Evidence-based treatments for borderline personality disorder: implementation, integration, and stepped care. Harv Rev Psychiatry. 2016;24:342–56.
Fonagy P, Gergely G, Jurist EL, Target M. Affect regulation, mentalization, and the development of the self. New York: Other Press; 2002.
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Drozek, R.P. (2018). Stimulating Reflection and Curiosity. In: Palmer, B., Unruh, B. (eds) Borderline Personality Disorder. Springer, Cham. https://doi.org/10.1007/978-3-319-90743-7_2
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