Mentalization and Dialectical Behavior Therapy

Mentalization-based treatment (MBT) is a psychosocial treatment for borderline personality disorder (BPD) that has gathered significant support both in controlled research trials (Bateman & Fonagy, 1999, 2001, 2003, 2008, 2009) and in increasingly widespread application (Bateman & Fonagy, 2012). While MBT structures treatment around goals, agreements between therapist and patient, and crisis planning protocols, the defining feature and purported active ingredient in MBT is mentalization. Therapists adopt a curious, not-knowing stance, monitor attachment and mentalizing capacity, and use interventions aimed to restore or maintain the capacity of patients to mentalize. The MBT therapist shares a written case formulation with the patient that highlights the way in which problems with mentalizing were influenced by early attachments, have played a role in relationship patterns, and are likely to manifest in psychotherapy. Alongside the individual therapy, patients are provided psycho-education and structured exercises to bolster comprehension about mentalizing. Patients participate in group therapy during which they mentalize in order to to generalize their capacity.

Allen, Fonagy, & Bateman (2008) have claimed:

Given that MBT is supported in controlled research trials, that it was originally designed for treating borderline personality disorder, and that the focus of MBT is the strengthening of capacities in the patient—all of which are features of dialectical behavior therapy (Linehan, 1993)—mentalizing may be of interest to DBT therapists.

Both MBT and DBT share some proximal aims: establish a secure attachment relationship in therapy, use empathy and validation in a reciprocal relationship, strengthen patient capacities to reduce emotional dysregulation and impulsive behaviors, and enhance self-awareness, attentional control, and flexible thinking in the contexts of emotions and relationships.

All of this is especially interesting given that MBT and DBT are derived from such different foundations. Mentalization-based treatment comes from psychoanalysis, attachment theory and research, and developmental psychopathology. Dialectical behavior therapy synthesizes acceptance-based approaches, behavioral science, and dialectical philosophy. Mentalization-based treatment has a more unitary focus than DBT, with MBT centering on an instability in mentalizing as the underlying problem in borderline personality. Dialectical behavior therapy does not posit an “underlying problem,” but focuses on changing targeted behaviors with a range of strategies to address a range of controlling variables (Linehan, 1993). In this review we will define mentalizing and specify some of its essential facets, consider how the conceptual underpinnings of MBT might influence the importation of mentalizing into DBT, scan the packages of DBT strategies to see if mentalizing already exists in DBT and whether it would be compatible with DBT, and consider whether and how the DBT therapist and patient may benefit from a mentalizing focus.

Mentalizing is surprisingly difficult to grasp, perhaps because it is so ordinary and ubiquitous—“the capacity that makes us human” (Allen, Fonagy, & Bateman, 2008)—yet named by an unfamiliar term. Further, a behaviorist might at first recoil from the frequent use of the term “mental states” since it sounds imprecise and as if it refers to hypothetical “mentalistic” entities. In fact it simply refers to constellations of cognitions, emotions, perceptions, and sensations that are activated in concert with one another. For instance, desires and intentions are “mental states.”

As Allen, Fonagy, & Bateman (2008) state, “we are mentalizing when we are aware of mental states in ourselves or others—when we are thinking about feelings, for example.” (p. 3). “The gist of mentalizing is holding mind in mind” (authors’ italics, p. 4). Further: “More elaborately, we define mentalizing as imaginatively perceiving or interpreting behaviors as conjoined with intentional mental states.” (p. 4). So whenever we are aware of a behavior, of our own or of someone else, being part of a “mental state,” part of the mind, we are mentalizing. Consider an example often used in teaching mentalization. If I simply notice a physiological event—“my heart is racing”—as a fact, without reference to any of my mental states, I am not mentalizing. My awareness is simply the awareness of a fact, a piece of reality, without a “mental” context. As soon as I notice my associated anxiety or thoughts, I am beginning to mentalize. If I elaborate further on the possible causes of my racing heart, and consider my options in response, I am mentalizing further, with greater richness and flexibility. The MBT therapist wants to promote mentalizing that is grounded in reality, is understandable with reference to intentions, is rich in content, and is sustained in the context of intense affects and attachment activation.

One author of this paper (CRS) met with a 35-year-old patient in psychotherapy. She presented with the concern that her tendency to be overly conciliatory to others was interfering with her hopes to attain a higher-level management position in her company. One morning, on the way into a session from the waiting room, while holding a cup of coffee, she asked if she could bring coffee into the office. She was implicitly mentalizing, guessing (inaccurately) that the therapist might object. While the therapist thought the question sounded polite and respectful, he also thought it was a bit surprising and unnecessary because he usually had coffee during sessions with her. In wondering why she had asked his permission, he was mentalizing about her mental state. As the session began, the therapist, from a “not-knowing” posture, indicated his sense of surprise to the patient, and he invited her to consider why she felt the need to ask about the coffee. He was making a gentle inquiry, inviting her to mentalize explicitly about her intentions and concerns. Under the gentle pressure of inquiry, the patient responded defensively, as if she were being attacked by the therapist. She was briefly at risk of losing her capacity to mentalize, but upon reassurance that no attack was intended, she began to reflect on (mentalize) her own behavior regarding the coffee, and she quickly connected it to her tendency at work to be overly polite and conciliatory. In this kind of reciprocal mentalizing, the implicit is made explicit, and the process as described, which included inquiry about the self and the other, is typical when both parties sustain the capability to mentalize in psychotherapy. It moves the process forward. It is when mentalizing breaks down that the trouble begins, as we shall discuss.

It must be clear by now that mentalizing is commonplace. When we wonder why we suddenly feel uncomfortable with no obvious cause, or when we ask why someone says something that we don’t understand, we are mentalizing. When we know when to speak and when to listen in a conversation, we are mentalizing. As we write the words for this article right now, we are mentalizing by imagining what your state of mind will be as you read them.

When are we not mentalizing? First, if we are trying to understand the geologic origins of a large rock in the center of a field, we are not mentalizing. Mentalizing is a profoundly social construct. Still, at times we fail to mentalize in relationships, which is likely to set the stage for interpersonal and emotional difficulties. Mentalization-based treatment experts describe “prementalistic states” at times that mentalizing goes off line (Table 1). If we (as the client) cling to the thought that someone hates us, despite evidence to the contrary, we (wrongly) consider our thought to be identical to reality, and we are operating in a mode of “psychic equivalence.” The MBT therapist would work to move the patient to a mentalizing mode. When we are simply talking, such as intellectualizing, in a manner that is only loosely related to reality and not connected to authentic emotional responses or appraisals—in other words, if “full of malarkey,” the MBT therapist might consider the speaker to be in “pretend mode,” and would work to move to a mentalizing mode. Lastly, if we need to provide concrete demonstrations of how we feel or how others feel about us in interpersonal communications, for example self-harm as a sign of suffering or having someone drop everything to take care of us, we are operating in “teleological stance.” Here again, the MBT therapist would aim to restore mentalizing.

The MBT therapist tries to sustain a “mentalizing stance” toward the patient and himself. This involves several characteristics. The therapist is curious and inquisitive, proceeding with a not-knowing attitude. In other words, he is interested, assuming that certain behaviors arose from states of mind, but without assuming what those states are in advance of inquiry. He tries to remain “experience near” in his thinking and inquiry. He is not looking for “content,” or to catalyze insight; he is more interested in fostering a mentalizing process. He repeatedly invites the patient into a collaboration, mentalizing along with him. The mentalizing therapist is relatively transparent, using self-disclosure of his own thought process and his feelings in the service of modeling his own mentalizing process. In doing so, he heightens the authentic, reciprocal, conversational, flexible, and spontaneous nature of the interaction.

There is such a thing as more and less skillful mentalizing. More skillful mentalizing will include these three qualities: accuracy, richness, and flexibility. Accurate mentalizing means that the individual’s understanding of mental states (of self or others) is relatively close to reality. Mentalizing with richness means that the individual’s understanding is well elaborated, with considerable detail, perhaps invoking history and a meaningful, coherent, biographical or autobiographical narrative. For mentalizing to be flexible means that the individual is capable of considering various ways to understand the behavior of interest.

Mentalization-based treatment and the concept of mentalizing grew out of three main foundations: psychoanalysis, attachment theory and research, and developmental psychopathology. Coming from conceptual foundations so different from those underlying DBT, it is worthwhile to consider whether mentalizing brings with it assumptions and positions that are alien to DBT, even if the practice seems to be transportable into a DBT treatment.

Mentalization-based treatment is most clearly derived from psychoanalysis, and involves a persistent investigation of conscious and unconscious states of mind underlying a given behavior. The therapist assumes an internal “road map” of mental representations and narratives, and seeks to make the implicit explicit, whether in himself or in his patient. Psychoanalytic approaches to the understanding of borderline pathology congealed in the 1970s around two models, Kernberg’s (1976) ego psychology and developmental object relations theory, and Kohut’s (1977) pathology of the self, with a focus on the pathology resulting from failures of empathy in early development. While MBT is not a simple descendant of these two models, incorporating attachment theory and cognitive neuroscience as it does, it does seem to derive elements from both. It shares Kernberg’s elaboration of mental representations of the concepts of self and other, while also sharing Kohut’s focus on empathy, attachment security, and their re-enactments in the psychotherapeutic relationship.

Mentalization-based treatment differentiates itself from standard conceptualizations and practices of psychoanalysis such that it is the psycho-analytically derived model most accessible to the DBT therapist. While the MBT therapist pursues and prompts inquiries into the inferred “inner world” of mental representations and narratives, insight into past, present, and the transference is not the goal. His quest is to increase the patient’s capacity to mentalize, and to maintain mentalization in the context of intensified affective states and hyperactivated attachment. He is of the belief that more stable mentalizing will result in greater attachment security, more flexibility, and greater freedom to explore life and pursue goals. While the capacity to mentalize is more complex, more multifaceted than any particular DBT skill, the relentless focus on acquisition and generalization of a capacity is familiar in DBT. The “not-knowing” attitude of the MBT therapist as he approaches the patient (and himself) is consistent with DBT’s behavioral stance insisting on assessing rather than assuming.

The psychoanalytic patient is given instructions to free associate, not so in MBT. The patient in psychoanalysis is encouraged to elaborate on fantasies about the analyst, not so in MBT. Psychoanalysts tend to establish a therapeutic position of relative objectivity and technical neutrality; the MBT therapist is more active, more transparent, more self-disclosing, more explicitly empathic, and more playful than the psychoanalyst, more akin to a stance in DBT. When the MBT therapist works to “mentalize the transference,” he is referring to efforts to encourage the patient to elaborate on perceptions, thoughts, and feelings about the therapist, not to the more typical psychoanalytic work of illuminating and interpreting the transference as a projection of past relationships onto the therapist. All of which leaves a more here-and-now experience-near process-over-content stance that bears some resemblance to the stance in DBT. Just as one can usefully add Buddhist mindfulness practices into one’s secular life without importing any more elaborate Buddhist belief system (Thich Nhat Hanh, 1996), a DBT therapist could consider adding aspects of mentalizing into his practice without importing behaviorally dystonic psychoanalytic belief systems.

The psychoanalytically oriented inquiry of the MBT therapist into a behavior of interest takes a different shape than the behaviorally oriented inquiry of the DBT therapist. The MBT therapist contextualizes the behavior in a coherent narrative of the kind that is found to accompany secure attachment relationships, and encourages continuity of reflection to do so. The DBT therapist, while interested in narratives as a way of grasping and validating the patient’s experience and behaviors, “breaks the narrative into bits,” discrete behaviors that can be assessed as functional or dysfunctional, then modified or replaced by treatment. While the search-for-the-coherent narrative and the breaking-the-narrative-into-bits theories represent two directions that can be pursued in the same treatment, MBT therapists lean toward the former and DBT therapists lean toward the latter.

Attachment theory and research, beginning with Bowlby (1982) and elaborated by others (Ainsworth, Blehar, Waters, &Wall, 1978; Main, 1995; Meins, Fernyhough, Russell, & Clark-Carter, 1998; Meins, Ferny-hough, Fradley, & Tucker, 2001; Fonagy, Gergeley, Turist, &Target, 2002), is the second foundation of MBT. Space prohibits any meaningful review of this area and its relevance to MBT, but the outlines of the argument are as follows. Securely attached caretakers tend to accurately and flexibly imagine and interpret the mental states of the child, responding in a way that helps the child understand and manage his own distress. This is how secure attachment facilitates the development of mentalization (Fonagy, et al., 2002), and the process of mentalization facilitates secure attachment. A distressed child sends a nonverbal signal, such as crying, and the caretaker must interpret the child’s mental state and respond in a way that is both contingent (i.e. resonant) as well as marked, or differentiated as a metabolized and re-presented version of what the caretaker imagines as the child’s experience. If the caretaker is able to provide this type of marked and contingent mirroring when the child is emotionally distressed, the child then begins to develop a coherent sense of his own experience via the development not only of an appreciation for how his caretaker sees him but also how he experiences himself.

The lessons of attachment research are at the core of the formulations and concerns of the MBT therapist. The MBT therapist attempts to enhance both attachment and mentalization by providing marked and contingent mirroring, which simultaneously provides validation and alternative perspectives on the patient’s experiences. Like the DBT therapist, the MBT therapist balances an attitude of validating the patient’s point of view and experience, while also promoting the appreciation of other points of view to promote change.

The DBT therapist assumes that an important attachment relationship is central to DBT’s effectiveness. He bases his theory of causation of borderline behavior patterns on the hypothesis that the patient’s emotional dys-regulation emerged in the context of an invalidating environment, which overlaps considerably with the MBT formulation of the caretaking environment with deficiencies in responsiveness, attunement, and marked and contingent mirroring. And he places a high priority on noticing disruptions or rifts in the therapy relationship, on validating the patients’ experiences, and on repairing the relationship again and again. While DBT does not incorporate language associated with attachment theory as MBT does, the concepts are present. When Linehan (1999) found that individuals presenting with both borderline personality disorder and substance use disorders were less likely to form an attachment with their DBT therapists than those presenting with borderline personality disorder without substance abuse, she overtly added in several “attachment strategies” to augment the strength of the bond (Linehan, et. al., 1999). Even though the concepts and importance of attachment are already built into DBT’s theory and practice, still it may be of value for DBT therapists to study the emerging findings in this very active area of research.

The third conceptual pillar for MBT is developmental psychopathology. The capacity to mentalize would be an expected outcome in a good-enough environment, and failures to mentalize are thought to correlate with nearly all forms of psychopathology. It seems that autism is a most severe example of psychopathology in which the capacity to mentalize is stably limited, presumably due to a genetic basis. The patient with severe antisocial pathology shows a limitation in mentalizing capacity and the individual shows little or no appreciation of the impact on others. As mentioned, the pathology of borderline personality disorder is explained by a variable weakness in the capacity to mentalize, worsened in states of emotional arousal and activated attachment. Further, attachment researchers would categorize most individuals with borderline personality disorder as having a form of insecure attachment known as “disorganized attachment.” (Main & Solomon, 1986).

We now line up the complex practice of mentalizing alongside three overarching groups of strategies in DBT: change-oriented, dialectical, and acceptance-oriented. Dialectical behavior therapy’s change-oriented package centers on problem-solving strategies, which begins with behavioral assessment using the procedure of behavioral-chain analysis. From an MBT perspective, the conduct of behavioral-chain analysis can easily be understood as a structured form of mentalizing. The therapist proceeds by holding all preexisting assumptions about the patient at bay while engaging in a structured inquiry about the steps in the chain leading up to and following the problem behavior. The open-minded, not-assuming attitude overlaps with the mentalizing stance. The collaborative search for relevant sensations, perceptions, emotions, and cognitions, framed by the template of the chronological behavioral chain, parallels the collaborative process used by the MBT therapist and patient to mentalize the patient’s behavior and experience by elaborating on states of mind. The DBT therapist considers a wide range of possible explanations as the behavioral chain analysis proceeds, consistent with the flexibility of the most skillful mentalizing, and brainstorms with the patient about possible solutions.

It is a hallmark of skillful mentalizing that states of mind are understood to be representations of reality but are distinct from reality. Similarly, for the DBT therapist the behavioral chain, co-constructed by therapist and patient, is considered a template, a work in progress, a useful tool for illuminating controlling variables. The “story” embedded in the chain is a “story,” it is not reality itself, and it changes as more data is added. In conclusion, it seems that behavioral chain analysis in DBT is a structured form of mentalizing from the perspective of the MBT therapist, akin to Allen, Fonagy, & Bateman’s (2008) contention that cognitive modification in mindfulness-based cognitive therapy (Segal, Williams, and Teasdale, 2002) can be seen as a structured form of mentalizing.

MBT therapists also employ chain analysis to understand self-harm. Unlike in DBT, the purpose is not to find and provide behavioral solutions to the patient. Instead, the MBT therapist helps the patient to think about the interpersonal context of the intense affects that led to a collapse of mentalizing. Self-harm is seen as a byproduct of pre-mentalistic states (Table 1). In order to remedy this vulnerability to self-harm, the MBT therapist aims to sustain reflective functioning in interpersonal situations so that the patient can identify, assess, and then organize solutions to problems. In both models, the therapist helps the patient to have an organized way to assess a chain of events, to illuminate “the story,” and to consider solutions. But the DBT therapist is more likely to prompt and reinforce the practice of skillful behaviors as the solution, while the MBT therapist remains focused on reflective functioning and sustained mentalizing, assuming that this will lead the patient to be a more effective problem solver in her own right.

Therapists using MBT try to establish conditions that are most conducive to mentalizing, to finding balance between several dichotomies, to keeping the attachment to the therapist that is neither too hot (hyper-activated) nor too cold (detached), encouraging the mentalization of self and of other; and ensuring the mentalization of both cognitive and affective processes. MBT therapists are trying to find “the middle path” (without using the DBT term) and also finding the right balance of certainty and doubt. Dialectics is pervasive in DBT, finding middle paths between extremes, and promoting balance in the context of dys-regulation. The dialectician in DBT can feel at home within the MBT therapist’s interest in balance across several dimensions and in the high regard for improvisation, creativity, flexibility, and spontaneity.

So we find that in spite of obvious differences MBT and DBT share a number of features in the realms of what the DBT therapist considers the change agenda and the dialectical philosophy. Nowhere is this more true than when we consider how the mentalizing stance and interventions line up alongside DBT’s acceptance-oriented package, which includes mind-fulness practices, validation strategies, reciprocal communication strategies, and two of the four sets of skills (core mindfulness skills and distress tolerance skills). As Allen (2013) discussed in detail, mentalizing as a concept and practice is closely related to and dependent upon mindfulness as a concept and practice (pp. 113-133). Mindfulness consists of bare attention to what enters our awareness, attention to simply what is, without judging, elaborating, or thinking further about it. When we are mindful of the breath, we are aware of selected aspects of the breath; as attention strays from the breath, we notice the straying and simply come back to the breath. Kabat-Zinn (1994) defined mindfulness as “paying attention in a particular way: on purpose, in the present moment, and non-judgmentally” (p. 4) to the unfolding of experience moment by moment. Therapists in DBT engage in mindfulness practice themselves, and bring mindful attentiveness into therapy sessions as a way to enhance awareness, to see reality as it is, and to self-regulate. One of the four sets of skills taught in DBT is “core mindfulness,” core because this kind of attentive awareness in the present moment, without judgment, is a foundation and a preliminary step for the practice of other skills. Dialectical behavior therapy team meetings begin with a mindfulness practice, and teams use mindfulness to self-regulate.

Similarly, as Allen explained (Allen, 2013), mindful awareness of states of mind, sometimes described in MBT as “holding mind in mind,” is the first step of mentalizing. Self-awareness is core to both DBT and mentalizing in so far as it includes awareness of thoughts, feelings, perceptions, sensations, even consciousness. Central to both MBT and DBT is the position, which is also inherent in the practice of mindfulness, that what is going on in the mind is separate from reality, and that the practice of mindfulness strengthens this understanding. “Prementalistic states” in MBT embody difficulties in adequately coupling and decoupling reality from experience (Table 1). Once awareness illuminates the workings of the mind and the perception of reality, both MBT and DBT therapists follow the mindful path of acceptance, whether positive or negative: “what is, is.” Dialectical behavior therapy’s distress tolerance skills module is centered on the attempt to see reality clearly, to willingly accept it, and to learn techniques to tolerate the painful consequences of some aspects of reality.

While there is significant overlap between mindfulness and mentalization, the two concepts part ways. While the mindfulness practitioner simply notes an observed phenomenon in mental experience (e.g., a thought), and lets it come and go and transform, the mentalizing therapist elaborates further on the phenomenon, spelling out a coherent narrative of history and context in which it makes sense. For the MBT therapist, mindfulness is a foundation and a first step in mentalizing. For the DBT therapist, in practicing therapy and in teaching mindfulness skills to the patient, the emphasis is on simply noticing, or simply describing. This is used to see more clearly, to perceive reality more accurately, to strengthen attention, and to regulate the mind. As we shall see, the MBT process of elaborating on awareness can be found more clearly in the DBT therapist’s use of levels of validation.

Linehan’s teaching about validation in DBT has evolved over time. While at first she portrayed validation as the “sugar coating” that helps the patient to tolerate the “bitter pill” of CBT-based problem-solving strategies, validation has come to be seen as having a potent healing impact in its own right. It strengthens problem-solving, counters self-invalidation, teaches self-validation, strengthens the therapeutic relationship, and can directly help to regulate intense emotions (Linehan, 1993). Mentalizing—overlapping concepts of empathy, mindreading, mindfulness, metacognition, and theory of mind (Allen, Fonagy, & Bateman, 2008)—also overlaps DBT’s “levels of validation,” of which there are six.

The first level of validation entails careful listening in a “wide awake posture,” essentially mindful listening, which is also the first step in the practice of mentalizing. The DBT therapist assumes that whatever is being validated makes sense, somehow. The MBT therapist assumes that whatever is being mentalized will be found to be part of a coherent narrative. The stance in level one of validation is essentially as described in the mentalizing stance, including curiosity, inquisitiveness, and “not-knowing.” In DBT’s level two of validation, the therapist reflects back to the patient what he has received. This includes using the patient’s own words to verbally reflect or “mirror,” and using facial expression and body postures to resonate with the patient’s communication. Clearly, mentalizing relies heavily on the process of reflecting, much as is prescribed within DBT’s second level of validation. In addition, as was discussed above, the MBT therapist looks to use marked and contingent mirroring in the reflecting process, applying lessons learned in careful attachment research examining sequences between caretakers and young children. The DBT therapist’s reflecting process in level two might be enriched by studying this important developmental discovery.

In DBT’s third level of validation, the therapist articulates the unarticulated to the patient, adding something to what the patient communicated, a process of “mindreading”, reading between the lines of what the patient has said, while waiting to see if the patient confirms the accuracy or inaccuracy of the therapist’s comments. This might, in the context of mentalization, be the beginning of inquiry, of trial and error, of “feeling his way” in to the patient’s states of mind underlying the original communication. These first three levels of validation in DBT facilitate tuning in to the patient, doing trial and error mindreading, and getting “in synch” with the patient, all of which overlap considerably with the attentive awareness of the mentalizing therapist, setting the stage for accurate, rich, and flexible mentalizing resulting in further elaboration.

In the fourth and fifth levels of validation, the DBT therapist tries to make more specific sense of the way in which the behavior in question is valid, either by looking to historical background (Level 4), biological factors (Level 4), or current context (Level 5). It is in the practice of these two levels of validation that one finds the closest parallel in DBT to mentalizing in its fullest sense, elaborating the patient’s behavior in the context of thoughts, emotions, perceptions, actions, and environmental events. You might say, looking at DBT through the prism of an MBT therapist, that in the practice of mindfulness and the first three levels of validation, the DBT therapist is engaging alert attention, mirroring, or attunement much as the MBT therapist does initially, and that in the practice of levels four and five the therapist is inquiring and elaborating, finding the narrative in which the behavior resides.

Still, the manner in which the MBT therapist mentalizes, especially in the style and extent of elaborating, is not likely to be identical to the way the DBT therapist uses validation in levels four and five. First, the MBT therapist is “betting the store” on mentalizing and is probably seeking to find a richer and more extensive biographical narrative than the DBT therapist, who is looking to validation to balance the demanding and time-consuming work of behavior change through problem solving. Second, given that the DBT therapist’s highest priority is to find the validity of the patient’s behavior in the current context (i.e., Level 5), in the service of teaching the patient to self-validate, there may be a relative skewing of validation away from rich and coherent narratives about the past which would fit within MBT. It is even possible that the DBT therapist’s emphasis on finding the validity of the patient’s behavior in the current context-ℌnormalizing” the patient’s behavior could be anti-mentalizing in that it collapses the focus on having the patient spontaneously evaluate her own experience.

The sixth level of validation refers more to a stance than any one type of intervention, and it too overlaps with some recommendations for MBT therapists. This level entails the stance of “radical genuineness,” and refers to the radical level of honesty, transparency, and presence that the therapist holds throughout the interaction with the patient. The therapist, while maintaining the therapeutic role, acts toward the patient in a genuine way, “being himself” much as he would with colleagues, friends, and family members. He is not artificial, and it is validating to the patient in her whole self, indicating that the patient is worthy of receiving this kind of realness from the therapist. There is, implicit within “radical genuineness,” a kind of reciprocity between patient and therapist, a transparency. Mentalization-based treatment therapists too are looking for a high level of openness, transparency, honesty about their own states of mind, and reciprocity. In MBT sessions the therapist can be rather conversational, not adopting an artificial “therapeutic stance.” Mentalizing is thought to beget mentalizing, and in my experience, consistent radical genuineness begets radical genuineness. One subtle distinction between DBT and MBT on the technique of genuineness is that in DBT this type of self-disclosure functions to validate the patient, supporting her in moving toward behavioral change, whereas in MBT this level of genuineness is offered as a way to introduce alternative perspectives to the patient, which then may facilitate finding solutions.

Just as the DBT therapist moves back and forth between validation and problem solving, he also moves back and forth between two styles of communication, the reciprocal and the irreverent styles. Mentalization-based treatment’s mentalizing stance resonates with DBT’s reciprocal communication style. Reciprocal communication involves: responsiveness, warmth, genuineness, and the judicious use of self-disclosure by the therapist. Responsiveness is reminiscent of sensitive responding in the early attachment studies, or attunement. It refers to the way in which the therapist allows himself to have a genuine response to the manifest content of the patient’s communications, letting himself be affected, moved, or otherwise responsive. The patient will feel that the therapist has heard her, has taken it in genuinely, and is affected. Warmth is another element. Keeping the “temperature” of the therapy relationship somewhere between too hot and too cold, the therapist strives for warm responsiveness that will be most conducive for change-oriented work in DBT and for mentalizing in MBT. Beyond the warm, genuine, and responsive tone maintained as much as indicated throughout the treatment, the therapist uses forms of self-disclosure that are harnessed to strategic approaches and circumscribed within the personal limits of the therapist and the patient. By using self-disclosure, the therapist may be using it in the service of reinforcement, cognitive restructuring, skills training, validation, or to solidify the therapy relationship, among other options. Personal self-disclosure involves the sharing of personal or professional information, part of the transparency of the DBT therapist, which contributes to a collaborative, we’re-in-it-together, attitude. Self-involving self-disclosures include the therapist sharing reactions in the moment—warmth, irritation, frustration, joy, etc.—with the patient as harnessed for strategic purposes.

The overlap with the mentalizing stance is obvious. The MBT therapist is to be present, nonjudgmental, open minded, transparent, flexible, warm, and collaborative. In the view of the authors, the way in which the two treatments differ in the application of these similar stances is more a matter of degree than nature. Again, DBT’s reciprocal style, which accompanies the communication of acceptance, alternates with an irreverent style, which is the DBT change-oriented style. While the MBT therapist centers on the cultivation of a mentalizing stance throughout treatment by using gentle challenges to the patient (who is persistently in pretend mode rather than mentalizing mode), the DBT therapist centers treatment on a target-and change-oriented agenda, and will move between accepting and challenging, reciprocating and being irreverent, yet always promoting the change agenda.

Our first conclusion is that if one understands what is meant by mentalizing, one finds it in many locations in DBT: in the process of assessment, in the practice of problem solving, in the pervasive influence of dialectics, and most of all in the various strategies within the acceptance package in DBT. There are striking overlaps with mentalizing in the practices of mindfulness, validation, and reciprocal communication, and affinities between mentalizing and important aspects of behavioral-chain analysis.

Both MBT and DBT carry with them theories of change aiming to strengthen resilience in the face of emotions and relationships. In DBT the therapist, having established a secure and important attachment relationship, stays focused on behavioral targets, and brings problem-solving tools, including skills, to help the patient be able to change. During workshops, Linehan has at times described DBT as requiring two overriding activities by the therapist: on the one hand to be able to “get into hell” with the patient and understand it from the patient’s perspective, and on the other hand to have ways to “get the patient out of hell,” which in DBT involves the problem-solving strategies and skills.

While the MBT therapist shares the goal of “getting the patient out of hell”, there is a different conceptualization of how to do it. The therapist uses empathic attunement and marked and contingent mirroring to increase the patient’s self-awareness and attachment security. In that context the therapist enables various dynamic perspectives on self and other to evolve, providing the foundation for increased attentional, emotional, and behavioral self-regulation. The patient brings more flexible and accurate mentalizing to bear in response to what would be called “triggers” or “prompting events” in DBT, ultimately improving self-regulation capacities and greater freedom in exploring the world and moving toward goals.

It is one of the strengths of DBT to offer such a rich problem-solving repertoire and skills package. This requires micro-slicing a narrative into behavioral bits that can be evaluated and modified. To do this while maintaining and enhancing an attachment relationship (also much needed in DBT) is difficult. The therapist augments the behavioral change emphasis with mindfulness, validation, and the improvisation, speed, movement, and flow of dialectics. A familiarity with the role of mentalizing in fostering secure attachments, and an attempt to strengthen the patient’s mentalizing capacities through greater elaboration of the patient’s narratives during behavioral chain analysis, may strengthen the therapeutic arsenal of the DBT therapist. The mentalizing focus may serve both to strengthen the attachment to the therapist and to decrease problematic emotions and actions generated in pre-mentalistic states.

Given the degree of natural overlap between DBT and MBT, the DBT therapist can incorporate mentalizing in working with patients, counterbalancing the effects of breaking down behavioral patterns into treatable links with the benefits of strengthening metacognition, self-coherence, and attachment functioning. In the early stages of treatment in DBT, where a therapist and patient are working together to move from behavioral dyscontrol to behavioral control, the patient will typically be unable to maintain a flexible mindset and wise minded balance when exposed to emotionally evocative cues. At this moment in treatment the DBT therapist, while assessing for DBT’s typical skills deficits, might also detect the features of prementalistic states, alerting him to the likelihood that mentalizing has gone offline. The therapist might then use standard MBT techniques to reinstate mentalizing through a curious, not-knowing stance (much like beginner’s mind in DBT), combined with efforts to manage the attachment in an attuned but modulated way, so that the patient can do the work of DBT (or any therapy approach). While this effort to “bring the mind online” when mentalization has been deactivated overlaps considerably with inquiry and acceptance strategies in DBT, the rich descriptions and examples of doing so in MBT can augment DBT’s behaviorally oriented method.

Throughout the course of treatment with patients who have BPD, interpersonal problems within the therapy relationship are to be expected. Mentalization-based treatment brings a flexible and nuanced set of techniques that are flexible and empathic to address misunderstandings or relational problems between the therapist and patient. The DBT package of interpersonal effectiveness skills provides a guide to enhancing a relationship through being gentle, acting interested, validating, and maintaining an easy manner. Based as it is in attachment theory and psychoanalysis, MBT provides a broad technique that engages and stabilizes the patient’s ability to understand how he reacts to others and how others experience him in the relationship.

Mentalization-based treatment techniques can complement DBT techniques to stabilize identity problems inherent in BPD. Dialectical behavior therapy helps the patient with BPD by supporting efforts to build a life that enhances self-respect, while decreasing behavioral tendencies that destroy self-respect. Dialectical behavior therapy also addresses identity issues through the core skills of mindfulness, which increases self-awareness. The DBT therapist can incorporate MBT into treatment to allow the patient to integrate the observations he makes of his experiences by stabilizing the reflective capacity to be more coherent to oneself and others in that self-awareness. Mentalizing allows the patient and therapist to incorporate meaning and individuality into their lives to facilitate a unique and vibrant sense of self.

In summary it occurs to us that the DBT therapist’s study of mentalizing may bring some attachment-based perspectives and techniques that will strengthen the attachment relationship. Just as hockey players can benefit from some training in figure skating, DBT therapists might find mentalizing to provide some new and effective moves in an attachment-oriented direction.