Mentalization-Based Treatment for Adolescents with Borderline Traits

Abstract

In this chapter, we apply the mentalization construct to provide a framework for understanding not only emerging personality disorder in adolescence but also adolescent breakdown more broadly (see also Chap. 12, current volume). We summarize the neurodevelopmental changes that occur in adolescence and how these temporarily compromise different facets of mentalization. We describe the principles and structure of mentalization-based treatment for adolescents (MBT-A), which incorporates monthly sessions of mentalization-based treatment for families (MBT-F). We then discuss the particular relevance of the mentalization construct for understanding self-harm in adolescence and describe the results of a recent pragmatic small-scale randomized superiority trial comparing MBT-A with treatment as usual (TAU) for adolescents with self-harm.

Appendix

Example of an MBT-A formulation

Background Information

When you were referred to this service you reported a 2-year history of feeling depressed and harming yourself. At times you have felt so depressed that life did not feel worth living. You thought your parents’ divorce 3 years ago, your mother’s subsequent depression, your father’s drinking and his recent violent relationship with his girlfriend all played a role in making you depressed. You spoke about feeling guilty as if it was all your fault. Before you came to us for help you entered into a relationship in which you allowed someone to treat you in a disrespectful manner, almost as if you were being punished. All of this made you feel terrible about yourself.

Personality Style

From what you told us and based on the tests you completed, it seems as if you tend to be an introverted person and that you value time on your own, as it helps you to feel calm. When you are with friends you can feel very worried that you will be hurt or that you will not be liked. When you feel like that, you hold yourself back, but in doing so you do not give people a chance to like you, which in turn reinforces for you that they do not like you.

It also seems that at times you are able to form passionate attachments to others, but then you can become suspicious and anxious that you may be rejected. It seems that relationships can at times make you feel a rollercoaster of different feelings, from love to anger. Sometimes your mood can also swing from sad to happy. Sometimes you can feel so overwhelmed emotionally that your mind goes blank and then you can feel numb. The problem with this coping strategy is that it then makes you feel disconnected from what you or other people feel, and then it is sometimes difficult to understand what is going on and so action feels as if it is the only thing available to you—it is at these times that you have a tendency to harm yourself.

You often relate to others in a self-sacrificing manner and at times even allow others to take advantage of you. You also at times tend to present yourself in a negative light to others. You can feel deep pain as your mind often dwells on past pain and misfortunes. This is very sad, because then you are not able to see your own good qualities.

Treatment Plan

We propose to offer you a treatment in which we suggest a combination of individual therapy once a week and family therapy once or twice a month delivered by the community team.

Crisis Plan

Trigger factors that you and I identified are times when you feel rejected, humiliated, or bad about yourself. As we have discussed, these feelings do not just arrive out of the blue: they are likely to have been triggered in a close relationship. When you have those feelings you tend to rush into an action to take the feelings away. When you feel like that again, I would like you to try to stop the action by trying to delay it for 10 min. Then, use the 10 min to try to reflect on what was happening a few moments before you had the bad feeling. That might help you to understand more clearly what it is that you feel, as well as what might have happened in a close relationship that may have contributed to the feeling. Once you have this understanding more clearly it may be easier to think about a solution or to see things from a different perspective. Once that has happened you may not feel as if you need to rush into action any more. If that fails and you still feel as if you might harm yourself, try to explore alternatives to self-harm:

Do something physical and strenuous like going for a run, try to distract yourself, talk to a friend or someone you trust, or try to think about a person you know who loves you and imagine what that person would feel and say to you if you were to talk to them.

Sometimes you harm yourself when you feel emotionally numb. When you get into such a state of mind, try to remember that it is not a good state of mind for you to be in and it is harmful to you. Try to bring yourself back to reality—do something to occupy yourself, like talking to someone, playing a game, writing a poem, painting, or watching something on TV that can hold your attention. Don’t just sit and stare into space with your mind full of negative thoughts about yourself.

If all else fails, call the clinic and ask to speak to me and I will call you back when I can.

Vignette from MBT-A

This is an example of a session with a 15-year-old male who was referred to our service with a history of cutting himself, taking overdoses and having great difficulty in managing relations at school. He also has a strong history of violent outbursts and impulsive behavior, including one incident in which he was reprimanded by the police for attacking another youth. He grew up with his mother and two half siblings from different fathers. His mother had a past history of drug abuse. The young man experienced life as unpredictable; he grew up surrounded by volatile relationships and experienced consistently inconsistent boundaries. This upbringing meant he had very little ability to manage his own feelings and hence frequently fell back on concrete ways of trying to reassure himself of his safety and manage his feelings. This vignette from one of his sessions illustrates both his concrete mentalizing style and the therapist’s attempts to mentalize his feelings.

Patient: I broke up with Michelle. You remember I wanted to see her last Friday and she said she was busy. Later I found out that she was only busy for an hour and I could have seen her. So Saturday I thought “I am not having it, I may as well end it with her rather than wait around for her.” I sent her a text and said, “If you do not call by 5 o’clock it is over.” She texted straight back saying “I am sorry but I am a happy person and you are always moaning and it brings me down.” So I thought, OK whatever, and just left it.

Therapist: Gosh, what did that make you feel?

P: I felt nothing. I just don’t understand, I was always happy when I was with her. I don’t see how she could say I am always moaning. The only thing I moaned about was that she just never answered her phone. Any boyfriend would want that, isn’t it?

T: So when she did not answer her phone, what did you feel?

P: It felt as if she did not care. Jenny always answered her phone and that is how I knew she cared.

T: And when you felt she did not care, what did you do?

P: I would phone her non-stop and I would text and leave messages. It is not right to ignore me like this. I sometimes called her 20 times and she would ignore me. I then think she’s met someone else. And I sort of saw it coming, so Friday evening when I went dancing I flirted with people and then I met this new girl. So I thought I’d like to take her out, so I pretended to be drunk and then said to her that I would like to take her out. I thought if I pretend to be drunk and if she says no, then I will just say the next day that I was drunk and that I do not remember anything. Then I won’t have to feel embarrassed. So she did not do that, but said she’d like to go out with me. So Saturday when I dumped Michelle I already had the other one lined up, so I did not really care about Michelle any more. So now life has moved on and this weekend I will go out with her for the first time. And this week I felt really happy. This girl is really special. We have so much in common, she is pretty…

T: Can I just slow things down a bit to try and catch up?

P: Yes it is a bit fast isn’t it? I always do that, I always have one in reserve. The minute I see trouble coming I get one in reserve.

T: It seems to me all of this action about phoning her so many times and getting another girl in reserve are all ways in which you try and manage terribly anxious feelings inside you.

P: Yes but now I don’t feel it because the new girl answers her phone all the time, just like Jenny did, so it helps me.

T: So when Michelle did not answer her phone, what did you feel?

P: I felt anxious that she was seeing another guy and then I phoned again and again.

T: If I thought someone I like is seeing someone else, it would make me feel angry.

P: Yes, I felt like I could smash my phone up. I wanted to break her door down.

T: So part of phoning her so many times was also an angry thing?

P: Yes I suppose it is a bit smothering, maybe that is why she said I was moaning. But any guy will be upset if he is ignored…