Mentalizing and Group Psychotherapy: A Novel Treatment for Antisocial Personality Disorder

Mentalizing facilitates effective responses to life challenges by generating a psychological understanding of an individual’s own actions and those of others in terms of underlying thoughts and feelings. It involves a blend of cognitive and emotional responses to a challenge, awareness of one’s own current experience alongside the experiences of others, and attention to both externally observable and internally subjective aspects of interpersonal interaction (10). Mentalizing involves both the process of arriving at this psychological knowledge and the process of responding to such knowledge by designating it as “just thoughts or feelings” not requiring further consideration or, by contrast, something worthy of serious reflection and purposeful action. Thus, mentalizing operates as an interpersonally contextualized meta-reflective process that includes cognitive appraisal and emotional identification, experiencing, and regulation. This mental process is out of balance and easily disrupted at all levels of abstraction among people with ASPD, who show evidence of a range of mentalizing problems, especially in social interactions.

Mentalizing is a multifaceted process (11), where psychopathology arises from an over- or under-use or imbalance of the poles of the four main dimensions of mentalizing: self and other, cognitive and affective, automatic and controlled, and external and internal. In ASPD, antisocial behavior and violence occur through a number of imbalances. First, this behavior may be triggered when understanding of others’ mental states is compromised and self-states are given priority. Such imbalance occurs rapidly if the attachment system is activated by perceived threats to self-esteem, such as interpersonal rejection or disrespect (12). Second, the behavior may occur when increasing affect overwhelms cognitive appraisal and situations are interpreted according to affective rather than cognitive or rational processing (e.g., “I think you are against me, so you are”). Balanced cognitive-affective mentalizing and discrete recognition of self-states that are well-differentiated from the experience of others’ mental states (e.g., envisioning the subjective state of the victim) prevent interpersonal violence (13). Third, such behavior may occur when excessive external focus and hypervigilance with constant monitoring of the environment for threat (e.g., “the look in the eye”) are used to understand mental states without considering the internal state of the other. This external focus can lead to excessive use of automatic mentalizing (e.g., “He looked at me, and I knew he thought I was a piece of rubbish. I am not having that.”). Fourth, such behavior may occur in the context of reliance on automatic, reflexive processing without stopping and thinking with controlled mentalizing (e.g., “Am I right here? Let me think about it. What is it that is causing me such annoyance?”).

These imbalances may become fixed, forming persistent mental modes of function known as psychic equivalence, teleological mode, and pretend mode. In psychic equivalence, thoughts are seen as facts, thinking is concrete, and experience is intense. In teleological mode, interpretations about others’ motivations and mind states are based on what the other people do (e.g., “actions speak louder than words.”). In pretend mode, the mind is isolated from the external world. The person becomes detached and may show dissociation, or depersonalization in extreme cases.

Mentalizing interfaces developmentally with attachment, and the two are loosely interacting psychological and biological systems. The development of effective, robust, and balanced mentalizing requires a secure attachment environment. In an insecure, dismissive, or disorganized attachment environment, commonly generated in the context of adverse early experiences, mentalizing becomes distorted, unstable, and oversensitive to emotional and interactional stressors. Dismissing attachment styles are overrepresented among people with ASPD and among violent offenders. The early life of individuals who later develop ASPD is characterized by adverse environmental threats to the developing attachment system in terms of loss, separation, neglect, and physical and sexual abuse (14). Many of these children develop preadolescent conduct problems that carry a high risk of subsequent development of adult antisocial behavior and violent offending (15). From this perspective, ASPD can be understood as a disorder of mentalizing and attachment in which genetic precursors interacting with early environmental adversity result in abnormal personality development, particularly in areas of affect regulation, impulse control, and ability to mentalize. In summary, the mentalizing model of antisocial behavior suggests that the behavior arises out of a dysfunction of the attachment system, which, when activated, temporarily inhibits affect regulation and mentalizing abilities (16).

Given the attachment sensitivities and mentalizing problems associated with ASPD, helping these patients to develop and maintain mentalizing capacities to consider other’s perspectives, identify others’ emotions, be compassionate toward others within relationships, accurately read other’s intentions, and differentiate their own experiences of others motives from others’ actual motives (i.e., self-other mentalizing) may not only assist in social functioning but also may reduce the risk of antisocial behavior. Indeed, mentalizing has been shown to be a protective factor against aggression among people with violent traits (17), and encouraging mentalizing has been shown to reduce school violence (18). Most importantly, people with ASPD need to be supported to develop a capacity to relate with others in “we mode,” in which sharing and understanding of the mind states of the self and others result in prosocial behavior.

Loss of integrated and balanced mentalizing results in a reduction in joint intentionality and togetherness, which leaves people with ASPD isolated from others and unable to engage in and feel part of everyday social interactions through which personal learning and change can occur. Joint intentionality is a specific mentalizing mindset proposed to account for the human capacity to participate in shared collaborative activity between two or more people. The key to constructive prosocial interaction is the capacity to coordinate perspectives and thus appreciate the distinction between the subjective (one’s own view) and the objective (actual physical reality “out there”), and then to coordinate these with knowledge of another individual’s mental state (19). The joining of minds is the crucial ingredient of social mentalizing. Joint attention defines a common object at the same time, acknowledging that people have different perspectives on it. This shared process leading to collaboration with others requires a high level of mentalizing and is singularly absent in the daily lives of people with ASPD.

Two central group processes, the development of shared values by the group and a focus on relational mentalizing, are harnessed at the start of an MBT-ASPD group to reduce a sense of isolation, signify the importance of “we-ness,” and generate self-other compassion and sensitivity; both are at the core of mentalizing and prosocial behaviors and attitudes. The implementation of these processes will be discussed by using a clinical illustration. MBT clinicians lay the foundations of individual and joint intentionality at the beginning of the treatment. First, the patient and clinician work on an individual-level formulation of problems, using the patient’s history and experiences to agree upon the patient’s aims of treatment. Second, patients present their formulation to others in their group to see what aspects of their own problems overlap with those of others. Third, the patients create a shared area of problems in a new joint synthesis. Fourth, a group formulation is generated, including group values, to facilitate an experience of being part of something that is beyond the sum of its parts (the individual patients).

MBT-ASPD is organized as a group psychotherapy to promote an experience of working together with a common aim. Every group develops its own “microculture,” which is based on agreed upon customs or traditions. In MBT-ASPD, the group has to agree on its own values from the start. This is the first step toward building an experience of we-ness.

In this case illustration, John wanted to talk in the therapy group about an incident that led to his arrest. He gave a brief summary of having insulted and threatened someone, which led to an argument and to the police being called.

Peter [challenging, referring to the insult]: You should not have said that.

John [immediately reactive]: Come over here and say that. I can say what I want when I want. [suggestive of teleological thinking]

Peter: No. You come over here, and I will say it again.

John: Don’t talk to me like that. You will regret it. Show some respect.

Peter: Don’t say “respect” to me. You don’t know what it is. You have to show some to get some.

Clinician: Hang on. Can we just pause for a moment. I am not sure what happened. John and Peter, can you hold it a moment? Can we go back to what we were talking about before this. Because, John, you were saying that you had ended up insulting someone, but you had wanted to buy some clothes, but unfortunately it did not work out.

John: Well, I wanted to get some cheap sale clothes. I thought that they might have some jeans and stuff. The first assistant told me that there was 20% off the price on the tags, but his friend would help me as he had to leave. He gestured to someone else to come over, and I could see immediately that he was trouble. I could tell as he was walking toward me. When he said that the price included the 20% off, I knew he was tricking me. So, I said “No, no, no. Your partner there said it was 20% off this price.” He insisted this was not true, so I called him a dirty shitbag and spat at him. When he told me to get out, I threatened him and got hold of his neck and pushed him away and he ran off. He deserved it. I told you—I know trouble when it walks toward me. [psychic equivalence]

Peter [challenging]: That is what I said—you shouldn’t have spoken to him like that and certainly not spat at him and got hold of him.

Clinician [concerned about escalating tension in a low-mentalizing dialogue and now trying to empathize with John, who is in danger of experiencing being misunderstood and excluded]: Hang on. I was thinking about how it might have been quite a disappointment not to get the clothes you had gone for. Now we seem to be against you and telling you that you did something wrong.

[siding with John to some extent] We have a value that we keep away from judgments of each other and there is a strong “should” in there, Peter. John, can you describe a little bit about what sort of state of mind you were in and what sort of clothes you were looking for and what you like?

The clinician is trying to deescalate and to change the focus temporarily by engaging in an “MBT loop”—a temporary detour from the affective content creating low mentalizing, with a graded return to exploration when mentalizing is stable—by asking John to consider his self-states when he was on his way to the clothing sale in more detail, rather than focus on the tension of the here and now. The clinician also partially sides with John, because the group response has so far been negative and invalidating. The aim is to reduce interpersonal tension and to create conditions in which mentalizing is more likely to occur. Only once these conditions are established can the current interaction in the group be explored. John’s description of his state of mind at the time of the incident suggests low mentalizing, and his and Peter’s current mental states show hallmarks of psychic equivalence, imposing their own perspective with a threat of impending action.

The next step is to ask patients other than Peter to join the conversation, a process known as triangulation of perspective. On this occasion, another patient joined in:

Mark: John, you don’t like being tricked, do you? You are sensitive to it. Are you sure it was a trick?

John: Yes. I know a con man when I see one.

Clinician: Mark, get us to where you are about John and his sensitivity.

The clinician continues the triangulation and attempts to bring in another viewpoint while avoiding discussion about whether John’s judgment of the assistant as a trickster was accurate, thereby keeping the group in an MBT loop away from the current tension between John and Peter.

Mark: Well, I have thought for a few weeks that you, John, are too worried that people are always trying to trick you. You are too suspicious. You said that your problem was that you did not like people. I have one question for you really—do you think that I am against you and have been all along in this group?

John: I don’t know. Peter is, though, and he shouldn’t talk like that and tell me what to do. I am not coming back here unless Peter apologizes.

Peter: No. I won’t.

Clinician: I am getting anxious again. Peter, when you say it like that, I worry that this might get out of control. It makes it difficult for me to think. Can we have a few minutes to get back to our other values of tolerance and respect?

Peter [to clinician]: It is your problem if you are getting anxious. I am not going to be violent. Look, mate. Did I get off my chair?

Clinician [uncertain about reason for question]: No.

Peter: Then there you are.

Clinician: Where am I?

Peter: If I get off my chair, you need to worry. [This is teleological mode thinking—only physical change indicates the validity of a mental state.]

Clinician: OK. So please don’t get off your chair. But it is important to me that I was anxious. Can we discuss that a bit?

Here, the clinician presents his experience of the interaction and asks the participants to take it into account with the aim of stimulating balance in self-other mentalizing. This intervention contrasts with psychodynamic therapy, in which openly presenting the clinician’s mental states through disclosure of counter-responsiveness is generally not recommended. But the embryonic capacities for affective empathy found in clients with ASPD can be nurtured only if they explicitly learn about the effects they have on others’ minds in the context of trusting relationships. Here, Peter shows a low level of emotional empathy for others by saying, “It is your problem if you get anxious.” This callous disregard of the clinician’s state of mind, a dismissal of the other, cannot go unaddressed. Prosocial relationships require recognition of and sensitivity to the effects of one’s actions on others. Self-disclosure of clinician mind states, including countertransference experience, is therefore used in MBT-ASPD to establish a platform on which to explore these issues.

Peter: What do you want to say about it?

Clinician: Well, when I am anxious like that, I cannot really think about what we are doing and what is the best way to sort things out. So, I cannot think about how to help. It is one of the aspects to this group that we want to consider each other and how we affect each other. This is why we need to look at what just happened between us all, so we can learn from it. If we get angry and then threaten each other, we will get nowhere. It seems things are a little calmer, so can we rewind now and work out what has happened?Peter, tell us about your concern about what John had reacted to and what he had said.

John [to Peter]: When you tell me I shouldn’t have done something, I think you are judging me, and you should not do that. You know I hate it.

Peter: Well, I think you are so jumpy that you do things without thinking and it gets you into trouble all the time.

Having reduced the tension and rekindled a mentalizing atmosphere, the clinician can return from the MBT loop to the starting point and ask the protagonists in this argument to revisit their interaction further and to rework their understanding of what was being said and what they were reacting to. In addition, the incident itself can be explored to identify and empathize with John’s experience at the time and to explore his distrust in others:

Clinician: So, how might we have done something differently here. Peter—did you understand what John was reacting to when he said, “Come over here and say that”?

The detailed exploration of a nonmentalizing interaction occurring within the group, with a focus on self-other affective mentalizing, reduces the toxicity of the process and allows learning from the present to occur in future social interactions.

Participating in mentalizing interactions within a values-based system that encourages we-ness in a group environment that is more regulated and protected than the patient’s natural social environment is important for patient learning and change (see Box 1 for recommendations for conducting MBT-ASPD). As the group develops, there will be other, more complex and subtle, disruptions of the group’s interactions, emotionally and relationally, in the atmosphere of the group, in the position of authority figures, and in attitudes of deference or antagonism toward the group leader. The experience of being a part of, being challenged by, and contributing to the culture of the group is a fundamental aspect of MBT. The therapy introduces and regulates the experience of making a cultural contribution that enables the patients to begin to experience their agency within a group. Experiencing recognition of one’s subjectivity within a group setting is a powerful social experience that can create a virtuous circle, as mentalizing of self and other becomes cooperatively reinforced and supported. Violence then becomes less and less tenable as a way of interacting with others and the world.