Mentalization-Based Treatment for a Physician With Borderline Personality Disorder
Publication: American Journal of Psychotherapy
Highlights
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This case presentation describes how mentalization-based treatment can reduce affective, impulsive, interpersonal, and other symptoms of borderline personality disorder.
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Core techniques illustrated include adopting a basic therapeutic stance of “not knowing,” prioritizing empathic validation and stabilization of the patient’s reflective capacities, and jointly reflecting on challenging interpersonal and emotional processes activated within the therapeutic relationship.
Editor's Note: This article is part of the special issue “The Expanding Scope of Mentalization-Based Therapy,” with Guest Editor Lois Choi-Kain, M.D., M.Ed. Although authors were invited to submit manuscripts for the themed issue, all articles underwent peer review as per journal policies.
Claire was a 30-year-old Caucasian woman who presented for treatment with depression, suicidal thinking, and self-injurious behavior. Raised in the Midwest, Claire had moved to Boston to complete her residency in obstetrics and gynecology. Claire was an only child who felt only conditionally cherished by her parents. She had experienced her mother as highly intrusive and controlling, yet easily injured when Claire displayed “negative” or “critical” emotions. Claire’s father was generally passive, never intervening to mitigate her mother’s reactivity.
Claire thus learned to avoid attracting notice and “be a good girl” by excelling in school, joining athletic teams, participating in extracurricular activities, and always appearing happy to prevent upsetting her mother. When Claire left home for college, the facade began to crack. Phone conversations with her mother and perceived rejection by classmates triggered extreme emotional instability. Claire oscillated unpredictably between intense anger toward others and self-hatred, once declaring, “I am bad, disgusting, ugly, and worthless. No one wants to be with me, and that is never going to change.”
Claire fantasized about suicide in these moments. She even wrote suicide letters to her family that remained unsent. By the time she reached residency, she had started cutting herself with razors. She said the cutting felt like a well-deserved punishment, but it also gave her a momentary feeling of internal peace, “shutting off” her mind and relieving emotional distress by creating physical pain. Claire felt like she was leading two lives: as the highly functional and knowledgeable doctor who cared for her patients and as her “depressed” self, who was so incapacitated that she could receive care but could never provide it.
Claire was referred to a hospital clinic specializing in mentalization-based treatment (MBT) after a monthlong inpatient admission precipitated by increased self-injurious behavior and a plan to overdose on her psychiatric medications. Claire was enrolled in a standard outpatient MBT program involving psychoeducation, weekly group therapy, weekly individual therapy, and peer supervision for the therapist to optimize adherence to the treatment model. Individual therapy began with the standard MBT frame-setting practices of giving and discussing the diagnosis of borderline personality disorder, developing a formal safety plan, and establishing shared priorities for treatment.
Claire identified her primary goal as remaining out of the hospital, which would involve reducing her depression, suicidal thoughts, and self-injurious behavior. The therapist conceptualized these problems as stemming from underlying struggles with reflecting on mental states in herself and others (mentalizing). Together, Claire and the therapist synthesized these ideas into a written formulation reviewing Claire’s emotional triggers (e.g., criticism by her mother, feeling ignored by colleagues), strengths in mentalizing (e.g., a high capacity for self-reflection when calm), and challenges with mentalizing (e.g., rigid beliefs about her badness, feeling compelled to cut herself to manage intense feelings, tendencies toward intellectualization and abstraction). Claire agreed that this formulation accurately outlined her problems and a treatment plan she could trust.
The earliest phase of treatment focused on exploring what Claire called “my depression” through MBT’s basic “not-knowing” stance. This approach conveys empathic interest in exploring inner life through questions about what is not currently known or clear. As the therapist invited Claire to elaborate on the nature of her feelings, Claire described her depression in generally physical terms (e.g., lack of energy, desire to sleep) or vaguely psychological terms (feelings of deadness and numbness). Despite the therapist’s attempts to generate uncertainty and self-reflection, Claire remained adamant that “my depression is not ‘about’ anything—there’s no content to it.”
When a therapist is confronted with unyielding nonmentalizing, a core MBT principle is to divert focus away from the intractable area to a related domain where more self-reflection is possible. Through such diversions, the therapist found that Claire could reflect more meaningfully about her self-hatred than about her “depression.” He began to use the basic MBT techniques of clarification (“Describe a recent time when you felt especially bad about yourself”) and affect elaboration (“What exactly made you feel so bad about yourself?”). These techniques promote more nuanced and flexible perspectives on emotionally or interpersonally challenging situations.
The ensuing exploration led Claire to express deep feelings of ugliness and insecurity and an enduring wish for a romantic relationship. These experiences created powerful feelings of shame, as Claire identified an abiding longing for something she doubted she would ever have. When distressing experiences appear, MBT therapists use empathic validation to communicate that such experiences are understandable, important, and have precedent within wider human experience. The aim is to support ongoing reflection by conveying that painful experiences can be meaningfully shared. As Claire felt increasingly understood, her previously impenetrable description of depression evolved into a multifaceted, poignant rendering of basic attachment needs she feared would never be met.
As therapy progressed, Claire revealed that she was in an intimate relationship she had previously kept secret. Meeting her partner had initially stirred Claire’s hopes for a lasting relationship, but she was dismayed to learn over time that he was interested only in a sexual arrangement. As the therapist probed Claire’s emotional experience of interactions she had with her partner (“What is it like to be together?”), Claire described temporary relief from painful emptiness when together, then a predictable return to self-hatred on separation.
The therapist understood Claire’s disclosure to indicate greater trust and improvements in mentalizing. He followed MBT’s hierarchical principles and began offering more of his own perspectives for her to consider, highlighting possible connections between her depression and how she felt and thought about her interactions with her partner. The joint reflection between Claire and the therapist yielded a new shared awareness of the interpersonal context of her depression.
After 5 months in treatment, Claire preferred to be alone rather than to continue a relationship that actively fueled shame. Although she was initially confident about her decision to end the relationship, resurgent intense loneliness and despair prompted strong urges to resume cutting herself and to seek hospitalization. Claire also gradually became angrier and more irritated by her perception of the therapist’s hesitation to hospitalize her.
By using MBT techniques for mentalizing the therapeutic relationship, the therapist directly invited Claire to explore and express her anger toward him. Without becoming defensive, he empathically validated her perception of his inaction as evidence of a lack of caring toward her. He further explored what he experienced as Claire’s overly narrow, physical definition of caring but held back any challenge or critique to focus instead on understanding how she had arrived at this position and how it had affected her.
Claire: I have been struggling so much here, but you aren’t doing anything to help me. All you want to do is talk about it.Therapist: So, you want me to do something more for you, Claire?Claire: Exactly. All of my therapists have hospitalized me whenever I become depressed. By not hospitalizing me, clearly you don’t care about keeping me safe, or even about me, for that matter.Therapist: I see, since I am not rushing to hospitalize you, it feels like I don’t care about you. I understand why it would make you so angry to work with someone who doesn’t seem to care. How exactly would hospitalizing prove I care?
As the therapist supported Claire in reflecting on her here-and-now frustration within the therapeutic relationship, the treatment entered a highly productive phase. Claire began exploring her experience that the only compelling form of caretaking involved her feeling incapacitated by illness while others took physical actions to comfort or contain her. Without arguing against Claire’s assumptions, the therapist shared his own puzzlement about her concrete understanding of care by using MBT’s not-knowing stance:
therapist: How are you so sure that the only way for me to show I care is to hospitalize? I don’t quite follow this idea that people only care when they respond exactly as you want.
Claire felt relieved by these discussions, elaborating on and eventually challenging how she arrived at her expectations of others. She still longed for the comfort of an inpatient setting, but as the therapist helped her reflect on her assumptions about the meaning of his inaction, she felt less angry with him and more understanding of his reasons for not rushing to hospitalize her.
The final phase of the treatment focused on Claire’s attraction to the “sick role” as a means to elicit caretaking from others. Recognizing this as a rigid, unreflective psychological state, the therapist empathically validated Claire’s feelings and helped her to elaborate on the sick role’s powerful pull and impact. Within the not-knowing stance, he provoked reflection about her conflation of having basic human needs with being “pathetic” or “sick.”
Therapist: This seems like a really important experience for you. What is it like for you emotionally?Claire: When I’m helping my patients, I’m not allowed to have any needs. They are the sick ones, not me. But it just builds up over time, and reaches the point where I need caretaking, too. That’s when I get depressed and want to cut.Therapist: You seem to be equating needs with illness. How are those connected for you?Claire: I don’t want to need anything from anybody. It makes me feel pathetic, disgusting. The only way that I feel justified asking for attention is if I am really sick, like so sick that I am unable to move or function.
Deeper understanding of her search for care led Claire to begin imagining how she might express emotional needs without becoming psychiatrically ill. When with friends, Claire spoke less about her psychiatric symptoms and more about work, relationships, and shared interests. Claire created a profile on a dating app and, to her great surprise, it was flooded with interest. Resuming dating after many years lifted her mood and provided a sense of satisfaction that came from moving toward her goal of having a stable long-term relationship. She threw away the razors she had kept for cutting and had saved “just in case I needed them.”
By the end of 1 year in MBT, Claire evinced notable functional improvements (e.g., improved attendance at work, no hospitalizations, no self-injury) as well as a subtle but notable shift in her experience of herself.
Claire: I can’t really say that I like myself yet . . . but I do feel a little less convinced that I am completely awful, and every once and a while, I actually feel okay. That gives me more hope for a life where I feel more connected.
Her inner life had become populated by a wider range of feelings, including a sense of forward momentum and improved self-regard.
Discussion
MBT is one of several manualized psychotherapies established for the treatment of borderline personality disorder (1). MBT was derived from traditional psychoanalytic concepts and attachment research and, more recently, has incorporated research on sociocultural learning (2). Outpatient MBT, as originally tested, combined weekly individual and group psychotherapy across 18 months and has been associated with enduring reductions in hospitalizations and self-destructive symptoms and with improvements in functioning 8 years after initiating treatment (3, 4).
MBT is distinguished from other established borderline personality disorder treatments by its primary aim of enhancing mentalizing, an essential psychological process for understanding mental states in oneself and others (5). This capacity is required for successful emotion regulation, management of behavioral impulses, trusting relationships, and a coherent and purposeful sense of self. Stable mentalizing promotes resilience, whereas severely unstable mentalizing threatens general psychological health and is associated with the core affective, impulsive, and interpersonal symptoms of borderline personality disorder (6).
MBT therapists stabilize mentalizing by titrating the intensity and complexity of interventions to first match and then gradually enhance the patient’s reflective capacities as they fluctuate with levels of emotional arousal and interpersonal stress. Core MBT techniques center on the not-knowing stance, a posture of steady curiosity that assists the patient in identifying and differentiating mental states within the self and others. This approach helped Claire shift from stock nonpsychological descriptions toward more curious examination of her inner life. Early-phase MBT techniques, including clarification and affect elaboration, helped Claire identify key emotional and interpersonal contexts for her symptoms and behavior, including longings for a relationship, mistrust of others, and self-hatred. The therapist’s repeated empathic validation communicated that others could understand these feelings and that Claire could manage her feelings through reflection within a trustworthy relationship, rather than through hospitalization. A later-phase focus on mentalizing the therapeutic relationship helped Claire to diminish her dependency on eliciting concrete caring responses from others through the sick role, freeing her up to seek help from friends and romantic partners in less burdensome ways.
Conclusions
This case illustrates implementation of core MBT principles and techniques that are readily applicable outside of specialized treatment settings across 1 year of individual psychotherapy targeting typical symptoms of borderline personality disorder. The outcome illustrated reductions in affective, impulsive, and interpersonal symptoms of borderline personality disorder as well as functional improvements and contributions toward identity consolidation.
Footnote
The authors have confirmed that they obtained informed consent from the patient described to present their case. Additionally, details of this case have been disguised to protect the privacy of the patient.
References
1.
Choi-Kain LW, Finch EF, Masland SR, et al: What works in the treatment of borderline personality disorder. Curr Behav Neurosci Rep 2017; 4:21–30
2.
Fonagy P, Luyten P, Allison E, et al: What we have changed our minds about: part 1. Borderline personality disorder as a limitation of resilience. Borderline Personal Disord Emot Dysregul 2017; 4:11
3.
Bateman A, Fonagy P: Randomized controlled trial of outpatient mentalization-based treatment versus structured clinical management for borderline personality disorder. Am J Psychiatry 2009; 166:1355–1364
4.
Bateman A, Constantinou MP, Fonagy P, et al: Eight-year prospective follow-up of mentalization-based treatment versus structured clinical management for people with borderline personality disorder. Personal Disord 2021; 12:291–299
5.
Bateman A, Fonagy P: Mentalization-Based Treatment for Personality Disorders: A Practical Guide. Oxford, UK, Oxford University Press, 2016
6.
Fonagy P, Luyten P: A developmental, mentalization-based approach to the understanding and treatment of borderline personality disorder. Dev Psychopathol 2009; 21:1355–1381
Information & Authors
Information
Published In
History
Received: 18 April 2021
Revision received: 10 August 2021
Revision received: 1 October 2021
Accepted: 20 October 2021
Published online: 12 January 2022
Published in print: March 23, 2022
Keywords
Authors
Competing Interests
Mr. Drozek receives book royalties from Routledge Publishing. Dr. Unruh receives book royalties from Springer Publishing.
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