Contents

MBT-Introduction....................................................................................................... 3
Role of Group leader ............................................................................................. 3
1. Session One: What is Mentalization and a mentalizing stance? ......................... 5
2. Session Two: What does it mean to have problems with mentalizing? ............. 11
3. Session Three: Why do we have emotions and what are the basic types? ....... 16
4. Session Four: How do we register and regulate emotions? Mentalising ..............
emotions. ......................................................................................................... 19
5. Session Five: The significance of attachment relationships? ............................ 22
6. Session Six: Attachment and mentalization ...................................................... 25
7. Session Seven: What is a personality disorder? What is borderline personality
disorder? ................................................................................................................. 27
8. Session Eight: On mentalization-based treatment. Part 1................................. 31
9. Session Nine: On mentalization-based treatment. Part 2 ................................. 34
10. Session Ten: Anxiety, attachment and mentalizing ....................................... 36
11. Session Eleven: Depression, attachment and mentalizing ............................ 39
12. Session Twelve: Summary and conclusion ................................................... 42

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MBT-Introduction

This file gives an outline of MBT-I as it is currently organised by Sigmund Karterud

and Anthony Bateman in London. If you wish to use it please register your interest
with Davina Metters at the Anna Freud Centre. You will be asked to collect some
baseline/mid-point/end point data.

The introductory course is precursor of the MBT programme and has a number of
aims:

a) Inform/educate patients about mentalizing and BPD and associated areas of

knowledge
b) Prepare patients for long term treatment
c) Elicit more detail about mentalizing capacities
d) Confirm initial assessment and diagnosis.

All patients have a meeting with a senior member of the team to review their
experience of MBT-I at the end of the 12 sessions and to plan further treatment.
The sessions have been run by some practitioners as a continuous programme with
patients joining at any time. In Oslo patients attend the course in parallel to the MBT
programme itself.

Role of Group leader

The group leader remains ‘in charge’ of the group throughout each group and over
the 12 sessions. ‘In charge’ is not used here to suggest that the group leader is
autocratic but to imply that the group leader manages the group carefully to ensure
that each topic is covered adequately and discussed in enough detail to ensure that
patients are aware of the relevance of the topic. Crucially, the group leader models a
mentalizing stance throughout any discussion, whilst maintaining an expert stance in
terms of knowledge about mentalizing and personality disorder. This balance is
important. A mentalizing or “not-knowing” stance can become confused with being
without knowledge or understanding. Nothing could be further from the truth. The
application of our knowledge to inform our own mental states and to stimulate
thought in others is the very essence of mentalizing. The group leader models the
stance by demonstrating that his knowledge, whilst being that of an expert, can be
extended, clarified, and enriched by the contributions of group members. Critically,
his mind can be changed by the minds of others; the patient’s understanding of and
ideas about the topic in question feed back to the question itself. Hence the
emphasis we recommend on the group leader stimulating discussion. Maintaining
equilibrium between providing information on the one hand and learning from the
perspectives of the patients on the other is a key skill for group leaders. The group
leader should be careful not to be too lecturing in his/her style, as this tends to
encourage passivity in the group members. On the other hand, he/she should not
give too much detail when giving personal examples, as this can dominate the
process.

The group leader should use a flip chart and play an active role in structuring the
group. There is a certain amount of material that must be covered in each session.
He/she should therefore follow the manual closely. Experience has shown that it is
easy to digress and get lost which impede the completion of the programme. It is
also important that the learning takes place through the participants’ own activities.
The group leader must, all the time, maintain a psychoeducational perspective.

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He/she shall comment on the degree to which personal examples illustrate
theoretical points, and make sure that participants understand the theory properly
through their own examples. When the group leader stops further personal
exploration, the patients should be encouraged to pursue the topic in their individual
or group therapy.

The patients should work actively with the material on their worksheets. The
worksheet for patients can be downloaded at the webpage XXXXX. The worksheets
contain brief summaries of content, key words and space to make notes in
connection with the group exercises and homework.

The group leader should follow the manual and the themes indicated herein and not
stray beyond these. The manual’s topics are comprehensive enough and it is
important to get through all the topics each time since there is a logic that builds up
under the given homework assignment. Most of the other themes that will pop up will
be covered in later group sessions, and this can be mentioned when the leader
“parks” digressions and questions.

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1. Session One: What is Mentalization and a mentalizing
stance?

The group leader welcomes the participants to the session and presents himself/
herself.

If the group is part of an on-going MBT program, the leader explains that all group
members are attending the MBT program in different groups, and asks each of them
to present themselves briefly by saying their first name and describing why they were
referred to the programme.

Alternatively, the group leader explains that the group is a refresher group for old
members and an introductory group for the new members. The old members are
asked to take a lead in the work in the group to help the new participants engage in
the process and to explain some of the topics that have been covered. The new
members are asked to introduce themselves and to describe why they were referred
to the programme.

The group leader describes the purpose of the groups, which is that the members
shall learn about mentalization, emotions, attachment, interpersonal interaction and
mental health. The aim of this session is to better understand what the treatment
programme is about, to appreciate what mentalizing is, and to participate as actively
as possible.

The group leader hands out worksheets and encourages the participants to make
good use of them.

The group leader briefly describes the structure of the group –

 there are a total of twelve groups,
 the group leader will give a short introduction each time
 examples based on the participants’ own experiences will be
discussed
 some texts will be used
 some role playing will be undertaken.

The group leader emphasizes that the group is educational, and that each
participant will not be asked to into depth about their personal problems, but that
they will all have an opportunity to do this in individual and group therapy sessions
later in treatment if it appropriate after completion of the group. In Oslo the patients
are already in individual and group sessions and so the patients are encouraged to
explore their problems in more detail in these contexts. The group leader states that
he will continuously summarize what can be learned from the examples discussed.

The group leader then explains that it is important that everyone attends every
session. It is important for group cohesion that everyone is present at every session,
and it will allow everyone to gradually become more comfortable with each other.
Participants are advised that they will also get to know each other better through the
exercises and discussions, and the hope is that everyone can participate actively
with their own stories.

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Group activity: The group leader writes up “What is mentalizing?’ on the board and
gives his own explanation, writing key points down as he does so. Alternatively, the
group leader writes up “What is mentalizing?’ on the board and asks the old
members of the group to outline their understanding of it for the new members.

The group leader then moves on to take what the participants have understood from
this and expands his explanation of what mentalization is using examples and
comments from the group. He/she can now use a flip chart to emphasise key points.
He/she can say that there is nothing mysterious about mentalization, that it is
essentially a very simple concept and that it is something that we all do much of the
time.

It is important that the group leader covers specific aspects of mentalizing in a way
that is comprehensible to the participants. Mentalization is when we attribute
intentions to each other, when we understand each other and ourselves as driven by
underlying motives and recognise that these take the form of thoughts, wishes and
various emotions, etc. A precondition for good interpersonal relations is that we
understand each other, ourselves included, reasonably accurately.

When we interact with others in a spontaneous and natural manner, mentalization

takes place automatically. We do not need to exert ourselves and do not even notice
that we are mentalizing (i.e. that we are interpreting other people’s intentions and
feelings). We simply respond to people reciprocally by making reasonable
assumptions about their motives. It is only when they depart from an expected
response that we are surprised. At this point there is an interruption in the
spontaneous interaction. We stop and wonder: “What happened now? Did he really
understand what I meant? That’s not what I meant. Let me try one more time.” Or:
“Shit, the same thing is happening again, he won’t listen. Fine, if he wants to be like
that…, I’ve had enough of explaining things to him.” Then we resort to controlled or
explicit mentalizing.

In the review of automatic versus explicit mentalizing, it is not uncommon to discover

that someone is overly concerned about what others are thinking and feeling. This
tendency can be described as hypermentalizing, and most patients will understand
that hypermentalizing is counterproductive and consumes large amounts of energy.

Group activity: What would you think if in your home town you saw a foreign-looking
man standing at the corner of an intersection studying a map, looking up and down
the various streets with a questioning expression on his face? Make some notes.

This simple exercise is suitable for demonstrating:

1) That people interpret the same event in different ways;

2) That some interpretations are more plausible than others;
3) That some statements about the object is mentalizing (e.g. “I believe that he is
confused”), while others are not (e.g. “he comes from a foreign country”).

The group leader proceeds by saying that mentalizing is both advantageous and
important. It is beneficial to mentalize for example when …

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You are going to console a friend who is sad.
You are going to straighten up misunderstandings with a friend.
You are going to quieten down a child who is angry.
You feel like getting blind drunk or smashed on drugs
You wish to convince your boss to give you a higher salary.
You are going out on your first date.
… and the participants can add their own examples.

In summary, mentalization is important for the following reasons:

To understand what is taking place between people.

To understand yourself, who you are, your preferences, your own values, etc.
To communicate well with your close friends.
To regulate your own feelings.
To regulate other people’s feelings.
To avoid misunderstandings.
To see the connection between emotions and actions more easily, so that you can
escape destructive patterns of thoughts and feelings more easily.

It may help to clarify things if you say something about situations in which one does
not mentalize a lot, or that do not require much mentalizing skill, in order to
emphasise that we are focusing on one’s own and others’ minds. When you are, for
example, performing math tasks or exercising, or resting or eating, you are not
necessarily mentalizing as the focus is not on the mind but on the task itself. This
distinction is illustrated in the exercise given above and it is helpful if the group leader
uses aspects of the group activity just undertaken to illustrate the difference between
mentalizing as a skill of the mind about minds and descriptive narrative for example.
The group leader agrees that the man could be a tourist, and it is important to
register this thought and think about it; this is not necessarily mentalizing, rather it is
a descriptive statement about him. If it does involve mentalizing, it only involves a
small component, as you are not thinking about his mind.

At this point it is helpful to draw out the other different poles of mentalizing to place
them alongside the discussion about explicit/controlled and automatic mentalizing as
it provides a preview of later groups. The additional poles of mentalizing that are
discussed are:

 emotional/thoughts
 self/other
 external/internal.

The group leader offers examples of each of these to illustrate the points and asks
the participants if they can think about when they feel that other people have relied
heavily on any one of these. Mentalizing is a balance of these aspects of mental
function and using one excessively results in poor quality mentalizing such as
hypermentalizing mentioned earlier. Relying too heavily on emotional cues may also
be unreliable; conversely relying on cognitive understanding without attention to
subjective feelings may also cause trouble – someone may be convincing about what
they are selling you and yet, if your feeling is one of distrust, it is probably best not to
purchase from that individual.

At the end of the discussion the flip chart should contain all four mentalizing poles
with some examples identified to illustrate them, preferably provided by the patients.

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These can be added to as the discussion develops further using the other group
activities.

As this introduction suggests, mentalizing has a lot to do with misunderstandings.

Group leader: Let’s discuss why we so often misunderstand others and ourselves?
Any suggestions?
Group activity: Suggestions about why we so often misunderstand each other.

The group leader notes down all the suggestions and comments on them. The point
here is to encourage a discussion about the characteristics of the mind, how
individuals’ have different values and different life experiences and how people use
different strategies to hide aspects of themselves.

Suggestions are commonly related to one of the following issues:

The mind’s non-transparency. This is a key point: how can we know what is going on
in another person’s mind?

Our tendency to attribute thoughts to others (e.g. think that others are thinking the
same way as we do). This is also known as Projection which refers to the possibility
that we may project our own unacknowledged feelings or thoughts onto other people.

Experience that others understand without you having to say it yourself. The group
leader also mentions here about the importance of not succumbing to this wish or
assumption in individual and group therapy. Therapists aren’t able to read other
people’s minds either.

Layers of the mind. This refers to the fact that it is also impossible to fully understand
what is going on in our own minds. It is easy to misunderstand oneself; you may
have access to some thoughts and feelings, but underneath these lie unclear
thoughts and emotions that can be difficult to understand.

Differences in interpretations and actions. Individuals vary with respect to how they
interpret things, how they arrive at judgments and their ability to deal with situations;
in short, individuals have different perspectives on the world. To acknowledge this
difference involves acknowledging that wishes and interpretations depend on
perspectives, and that, by wishing and believing differently, an individual can behave
differently even in similar situations. An individual’s wish and interpretation of a
situation is not only influenced by the here and now, but it is also influenced by the
person’s interpretation of the situation in light of his or her views about the future and
understanding of the past. Wishes and interpretations about specific situations also
influence memories, preferences, hopes and other mental experiences. The
significant effect that cultural differences can have on our perspectives, wishes and
beliefs also needs to be emphasized, not least because group members may have
different ethnic backgrounds.

Defensiveness. When another person adopts a defensive attitude or position and

holds back feelings and/or thoughts because he or she is afraid of something (e.g. of
being embarrassed or judged) then this will inevitably affect one’s ability to
understand what is going on in their mind.

Having difficulty finding words to express inner thoughts and feelings.

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Deliberate concealment or ‘playing mind games’. If the other person is hiding his or
her intentions, playing a game or being dishonest it adds to the difficulty of
interpreting their mental states. It is the minds non-transparency which makes it
possible for people to hide things in this way.

This is then followed up by a new group activity.

Group activity: The group leader asks for examples involving someone
misunderstanding himself or herself.

This exercise emphasises the ‘self’ component of mentalizing and the strong feelings
that can result from misunderstanding oneself. Two to three examples should be
sufficient. The group leader helps to clarify possible reasons for the
misunderstandings. The group leader may bring up own examples from everyday life
and even personal experiences, in order to convey that mentalization problems and
misunderstandings are not just something that apply to patients. It could be a
misunderstanding in a shop, a meeting, etc.

Group activity: The group leader asks for examples in which the person
himself/herself has misunderstood others.

This exercise focuses on the opposite pole, namely the ‘other’ and how
misunderstanding others can cause problems. Again, a few examples will suffice.
The group leader assists by relating the points to key words on the flip chart and by
discussing possible explanations for the misunderstandings.

Mentalizing stance. With reference to what has been discussed, the group leader
suggests discussing some typical examples of poor mentalising skills. For example:
arrogant claims about other people’s motives; black-white thinking (i.e. without
nuances and uncertainty); thinking without taking account of emotions and
overlooking the fact that people influence each other.

Group activity: The group leader asks about more examples of poor mentalizing
abilities.

The group leader then defines a mentalizing stance as markedly different from these
examples. Instead, it is characterised by a curiosity about the other person’s
experiences, thoughts and feelings; it is a not-knowing, exploratory stance.

Group activity: Two patients are invited to role-play. The one will be interviewing the
other. The task is to find out how the other person was yesterday afternoon, using a
mentalising stance.

Patients, especially new patients, may sometimes be reluctant to participate

in role playing at this stage. If nobody is willing to be the interviewer, the group leader
can take this role; often other patients will feel more able to take over once the role
playing has started. The experiences are then discussed. How was it to apply a
curious and not-knowing stance about another person’s state of mind? How was it to
encounter this type of attitude? Does it help to mentalize, i.e. becoming more aware
of your own state of mind?

9
 The group leader explains that the individual therapist tries to meet the patient
with this type of attitude and each person in the group therapy is encouraged to strive
to do the same.

Homework: Practice using a mentalising stance. Those who are able to, are
encouraged to find a friend or someone in their family to interview in the same way,
i.e. about how the other person was earlier in the day or yesterday.. Patients are
encouraged to ask questions in a curious, non-knowing and non-judgmental way and
to try to bring out as many moods, thoughts and emotions as possible. They should
note how it makes them feel and also ask their interviewees how it makes them feel.

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2. Session Two: What does it mean to have problems with
mentalizing?

The group leader starts by briefly summarizing the last meeting. The main points to
re-iterate are:

 Mentalizing is an ability that everyone has and that it makes us

meaningful to each other
 We interpret each other automatically and do so more explicitly at
times, particularly when we are muddled or uncertain. Even then we
can easily misunderstand others and ourselves because of the mind’s
complexity and lack opacity

 We react differently to the same situations, our minds are multi-

layered and these layers can be in conflict with each other. We often
do not recognise or appreciate that others misunderstand, we can
have difficulties expressing unclear thoughts and feelings, we may
become defensive, and we deliberately hide aspects of ourselves.

 Provide some examples of poor mentalizing ability, such as a

arrogant and stubborn attitude and black-and-white thinking; use of
certain words such as ‘just’ ‘clearly’ ‘always’.

 End on what typifies a mentalizing stance, i.e. curious exploration and

a non-knowing attitude.

The group leader asks if the group members were able to do their homework and, if
so, how they found it.
The group leader asks if anything that has been discussed thus far is unclear, and
whether there is anything that they have thought about since the last time, that they
wish to discuss in the group.

If patients give examples from their homework, these are discussed briefly and
positive aspects of the work are identified. Similarly, if patients are unclear about
what has been covered so far, this is pursued only briefly, because group members
often have a tendency to ask about things that will be addressed later in the
programme.

Since the last meeting, the group leader will have noticed who was active and who
was reticent, and should address those members who have been quiet so far, with
the intention of getting them more involved.

The group leader explains that in today’s meeting they will go further with respect to
good and poor mentalizing abilities and the consequences of each. First, however,
they will tackle some mentalizing exercises. The following task is written on the
worksheet:

Group activity: It is Sarah’s birthday. She is planning to celebrate with Mike, her
boyfriend, and has invited him home for dinner. She has purchased wine to go with
the food, and is looking forward to him coming after work. When Mike arrives, he
does not have a gift with him, and he says to her “wow, what a dinner you have

11
made, and on a Tuesday”. During dinner Sarah is quiet and drinks most of the wine
herself.
What happened? Why do you think Sarah behaves the way she does?1

The group leader makes a note of all the suggestions on the board. At the end he or
she summarizes that there are several possible motives that could underlie Sarah’s
behaviour and that they are not mutually exclusive but rather can complement each
other. Still, some motives are perhaps more important than others and there are
some interpretations that are less likely than others. Answers like “Sarah usually
drinks on Tuesdays”, or “Sarah usually turns silent when she drinks” are examples of
low mentalization. An interpretation such as “Sarah likes the wine better than Mike”
also represents a low mentalization level. An interpretation that Sarah is upset and is
trying to manage her feelings represents good mentalizing, not simply because it is
likely to be more accurate, but also because it tries to establish Sarah’s mental state
in relation to her behaviour. Some patients may think that Sarah should have said
something; if this is the case, the group leader should ask the patients to consider
why Sarah did not express what was going on in her mind. The raising of this issue is
very positive, not because the patients seem to ‘know’ how someone ‘should’ behave
(this would be a non-mentalizing position because it included knowing and
absolutes), but because discussion of this issue can stimulate further mentalizing
about Sarah’s state of mind.

The example serves as a “warm up” exercise and an introduction to the theme of the
consequences of poor mentalizing skills. The group leader summarises again what
was discussed the last time with respect to what typifies poor mentalizing:

 Feeling certain about other people’s motives

 Thinking in black-white terms (i.e. without nuances)
 Poor acknowledgement of accompanying feelings (reduced empathy)
 Overlooking the fact that people influence each other
 Interpretation of others without careful consideration may be
irrelevant, be off the point, or even be very concrete (i.e. that first this
happened then that happened, etc.)
 Little curiosity about mental states
 Lots of words are spoken with poor content
 Speech is filled with clichés and fancy words that do not seem to have
been digested and that tend to alienate the discussion partner
 External factors are emphasised at the expense of mental states, for
example that it rained, or that one had a headache, or the situation is
described as being “just how it was”, without any more explanation.

Group activity: The group leader asks about possible consequences of poor
mentalizing:
1) in relation to others, and
2) in relation to oneself

The group leader writes suggestions on the flip chart. Typical answers are that

 It is easy to misunderstand each other and that this can have negative
consequences (e.g. others feel overlooked, not heard or wrongly
interpreted and become upset about this, etc.)
1
This exercise was provided by Randi Kristine Abrahamsen, Clinical Psychologist,
Bergen Clinics, Norway.

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  One’s actually behaviour may differ from the other person’s expectations,
which can confuse the other person
 One may react in a very emotional way, based on misunderstandings and
become afraid, angry, disappointed, etc.

 Poor mentalizing of one’s own thoughts and emotions means that one
does not always understand one’s own reasons for acting the way one
does. and may second guess oneself

 Feeling insecure or needing constant confirmation from others

 Becoming overwhelmed by emotions or acting without reflection (i.e. letting

the surroundings or one’s own impulses govern ones actions, etc.)

Some patients may give other responses such as “I can always understand other
people” or “I find that no one understands me”. The group leader has to take such
suggestions sensitively and empathise initially with such experiences, but should
only do this for a short time and may close the conversation by suggesting that it is
something that can be explored further in the forthcoming or continuing therapy. The
emphasis should be on using such statements as examples of early warning signs of
compromised mentalizing – the use of the words ‘always’ and ‘no one’ are the key.
The group therapist suggests that being alert to such words might help to prevent a
collapse into non-mentalizing by making the individual ‘think twice’ about what he is
saying and experiencing. Could there be other possibilities? Is it likely that someone
will always be right?

The group leader summarises that poor mentalizing leads to:

1) Recurrent problems in relationships with other people
2) Insecurity, an unstable sense of self, poor emotional control, impulsivity, and more

The group leader says that he/she now is getting a bit ahead of the programme since
this is a topic for the next session, but that it is important in this context to emphasize
that the most important cause of poor mentalizing is strong emotional activation.
When emotions are intense, a person’s mentalizing ability is undermined, and may
even be shut down completely, exemplified by expressions such as “everything
turned black”, “I just froze up”, “I couldn’t say a thing”, “I wasn’t able to think”, with
additional phrases formulated by the group participants.

Group activity: the participants are asked to think through their own experiences
and make some notes about what a typical reaction pattern is for themselves as they
become emotional.

The group leader asks if anyone would like to share their own experiences. These
are then discussed.

The group leader draws up a curve to illustrate the connection between mentalizing
and emotional activation and the transition to fight/flight response:

13
The group leader emphasises three important points:

1) Feelings are activated faster and more strongly in some people

than others
2) The fight/flight response can kick in at different times for different
people, depending on the individual’s personal threshold
3) The time it takes to return to a normal state after intense emotional
activation varies among people

Group task: Participants are asked to reflect and make notes on the worksheet
about what they think about themselves with respect to emotional activation, the
threshold of their fight/flight response and time to regain their normal state of mind
after intense activation.

The group leader asks if anyone wishes to share their reflections. These are
discussed.

The group leader emphasises that these three points are important themes for the
treatment, that emotional intensity can be controlled, that the threshold can be raised
and that the time it takes before one gets back to one’s normal state can be reduced.
We will return to this later.

14
Homework: Make a note of a situation during the week in which you have noticed
that your ability to mentalize was undermined.

15
3. Session Three: Why do we have emotions and what are the
basic types?

The group leader summarizes the topic from the last session. The session addressed
problems with mentalizing that typically lead to problems in interaction with others.
Some key points were:

 one’s own insecurity

 unstable sense of self
 problems regulating emotions and impulsivity.

The most important reasons for poor mentalizing are:

 emotional activation which can make a person unable to function;

 the intensity of emotions which varies between individuals;
 the threshold for fight/flight response varies
 the variable time it takes to regain one’s composure after activation

.
The group leader reminds the group about the homework assignment and asks if
anyone was able to make a note of anything that they wished to share.

The group leader introduces the day’s topic and invites everyone to brainstorm the
topic and writes down points on the flip chart:

Group activity: What types of emotions are there? Any suggestions …

When the activity starts to ebb, the group leader adds some emotions if the ones
written down are insufficient. The group leader suggests there is a difference
between basic emotions and newer (social) emotions. Basic emotions are emotions
that exist in all mammals, while newer emotions exist in more developed primates
and humans. Basic emotions are localized in the same area in the brain, evoke the
same physical reactions and each of them are linked to a set reaction pattern. The
group leader explains that there is some disagreement about which emotions are
basic, and that we have chosen to present one version (Panksepp, 1998). The group
leader asks the members to suggest which emotions are basic emotions.

The group leader summarises the seven basic emotions as follows:

1) Interest and curiosity, exploratory behaviour
2) Fear
3) Anger
4) Sexual lust
5) Separation anxiety/sadness
6) Love/caring
7) Play/joy

The group leader asks if anyone has any comments and if anyone is surprised that
other emotions are not found on the list. The group leader reminds everyone that
there is a certain degree of disagreement about this list. And the list is not meant to
diminish the importance of emotions like envy, jealousy, greed, gratitude, guilt,
shame, etc.

16
The group leader asks rhetorically, why would these basic emotions be important for
us? He/she confirms any suggestions that are related to evolution (e.g. that these
feelings have been shown to be important with respect to survival and reproduction)
and that they represent an innate reactional preparedness. We do not need to learn
these emotions or reaction patterns because they are determined by nature (but we
can still distance ourselves from them, a topic that will be discussed later). They
supply us with automatic responses that have been important for human survival
over the course of 100 millions of years. The group leader then describes the
purpose of the emotions.

The main purpose of the seven fundamental emotions are as follows:

1) Interest and curiosity/exploratory behaviour: This motivates us to

find out useful information about our surroundings (e.g. what
resources are available, where food and water can be obtained,
whether there is a safe place to hide, whether there are any sexual
partners around etc.).
2) Fear: This stimulates us to ask ourselves questions such as: is
what I am facing dangerous; can it injure me; could it kill me; Is he/
she a rival who is stronger than I am; is he or she an enemy?
When the fear becomes intense enough and the source seems
stronger than oneself, it prompts our decision to flee or submit.
Fear can also prompt us to freeze/play dead if the threat is
overwhelming and we are in mortal danger.
3) Anger: If we identify someone or something that is standing in our
way, we may show anger and see if he/she submits. If the person
resists, the intensity of anger will increase and possibly lead us to
attack.
4) Sexual lust: This encourages reproduction and the continuation of
one’s genes.
5) Love/caring: This motivates us to care for our offspring, family,
partner and friends.
6) Separation anxiety/sadness: These emotions function as an
appeal for others to take care of oneself. They signal to potential
caregivers that one is in danger/in need of protection or that one
has become isolated from the group/family, or that one has lost
someone close who one depends on.,
7) Play/joy: This stimulates interaction with others so that one
remains a ‘pack animal’ rather than a hermit, increases our skills of
interacting with others, introduces the limits to one’s own
excitement, and enables the development of strategies for dealing
with anger through rough and tumble play.

The group leader discusses reactions to this exposition. As the descriptions suggest,
emotions are basically different action programmes.

17
The group leader explains that humans, unlike other animals have the ability to
suppress the feelings of emotional reactions. That is why the relationship between
emotions and feelings sometimes seems obscure.

The group leader emphasises the difference between:

1) Emotions that are the organism’s bodily reaction, as action

programmes, to specific stimuli.
2) 2) Feelings, which are the conscious experience of the body state
during emotional activation.

The group leader explains that because of their upbringing and socialization, people
can be distanced from their natural, emotional reactions. This means that people can
react emotionally, but that they do not necessarily feel their emotions. Emotions can
be suppressed. You can therefore be emotionally activated, but at the same time be
unaware of the specific nature of the emotions involved. One can for example, feel
heart palpitations or bodily unease without knowing why. The group leader explains
that the reason for this will be addressed and discussed later.

Group activity: The group are encouraged to discuss the emotions listed above in
relation to themselves and their individual differences. Questions to be addressed
include whether everyone in the group feels these emotions and whether each
person experiences them with equal frequency and intensity?

The participants’ different reactions and experiences are discussed. The group
leader reminds them about a mentalizing attitude (i.e. an openness and curiosity in
relation to people’s differences).

Homework: What emotions have been the most prominent the past week? Or has
the emotional activation been diffuse, i.e. more of a physical unease?

18
4. Session Four: How do we register and regulate emotions?
Mentalising emotions.

The group leader summarises what they learned in the last meeting:

That everyone has a wide range of emotions, but that some are more fundamental
than others. All mammals experience these emotions, and they are as follows:

1) Interest and curiosity,

2) Fear,
3) Anger,
4) Sexual desire,
5) Love and caring,
6) Separation anxiety and sadness, and
7) Play and joy.

The emotions are triggered by specific stimuli and consist of physiological reactions.
Feelings are conscious awareness of these bodily reactions. In humans, it is possible
to become emotionally activated without having a conscious awareness of the
feelings.

The group leader then asks if anyone has made any notes about emotions and/or
feelings they have experienced in the past week that they wish to share with the
group.

The topic this time is how to deal with emotions and feelings. As we have discussed
earlier, this is a very important mental health topic. First of all, the question of how we
register emotions needs to be addressed.

Group activity: How do we register emotions:

1) In others?
2) In ourselves?

The group leader encourages discussion and has an overall aim of identifying two
primary ways in which emotions are registered. The ensuing discussion commonly
gradually identifies the first of these, namely we register others’ emotions by
interpreting others' facial expressions (the soul’s mirror); this is consistent across all
cultures and, to some extent, across animal species. We also interpret others body
language, what they do and say. This is external mentalizing that was discussed in
session 1. The second pathway by which we understand others emotions is via
identification. There are nerve cells called mirror neurons in the brain that enable us
to experience what someone else is experiencing when they do or feel something.
For example, when we see another person feeling sad, we can become sad
ourselves. This is part of the basis of empathy.

The discussion can then move onto the ways in which we register bodily reactions
(examples of these should be given) and feeling states (which may be referred to as
affect consciousness) in ourselves. . The group leader can remind members that
they touched upon this in their last session, when they discussed how people differ
with respect to their feelings and how they register their emotions – some people do
so more easily than others.

19
Most often the group participants are better at giving examples of how feelings are
expressed in others than how they feel themselves. The group leader can offer some
examples, such as “lump in one’s throat”, “pressure behind the eyes”, “weak at the
knees,” “hairs standing on end”, etc.

The group leader then introduces a group exercise that stimulates thinking about
emotional awareness. Some improvement can be made simply by being more aware
and “being more present in one’s own body”.

Group activity: The group leader asks the members to close their eyes and forget
the surroundings and focus on themselves. He/she directs their attention inwards,
asking such questions as:
 Is there any place in your body that attracts your attention?
 What do you feel?
 Try to feel if there is any trace of emotional activation? Perhaps not, but there
often are.
 What types of feelings are you experiencing? (If it’s very uncomfortable, leave
it alone but if it’s positive, try to stay with it).
This should not last long and the leader should be clear that the most important
thing is that each group member is turning his/her attention towards his/her inner
experience.

Participants’ experiences are discussed. For some, this exercise may evoke feelings
of anxiety and this should be acknowledged by the group leader Occasionally, a
patient may unable to do the exercise at all and may even have a paranoid reaction
(one patient said that he thought that the group therapist was trying to control him).
Redefine this as fear which ensures that it is on the list of basic emotions, and
emphasise that the person can retain control after all. Some people will report that
their physical experiences blocked feelings during the exercise (e.g. that they were
too busy breathing to pay attention to what they were feeling), while others may
report different emotional states.

The group leader then turns to the subject of emotional regulation through others.
He/she briefly introduces the topic and says that they are going to take an emotional
regulation exercise that everyone is familiar with: namely, consoling another person.

Group activity: Role-play about emotional regulation through others. The group
leader asks one of the participants to act being emotionally upset, perhaps a mixture
of disappointment and anger. If none of the participants feel comfortable taking the
role, the group leader himself or herself can play the role. Another group member is
given the following assignment: 1) to find out what feelings the person has; 2) to find
out why he/she feels this way; 3) to try to console the person.

The participants’ experiences are discussed with a focus on the issue of the patients’
willingness or unwillingness to let someone else console them. The group can then
discuss, based on other experiences, what behaviour/actions from other they have
found most consoling (e.g. empathic understanding, emotional resonance, physical
contact etc.) with an acknowledgement that each person will be different.

The group leader brings up the topic of impaired emotional regulation. Impairment
means that one is stuck in a painful, uncomfortable and often unclear emotional state
and resorts to dramatic means (such as getting high or self-harm) to escape it.

Group activity: The group leader asks the group members to suggest names for

20
such unpleasant emotional states and writes these on a flip chart.
The group leader asks for examples of what the participants have done to get out of
such emotional states.

The group leader then labels such emotional states unmentalised feelings and
emphasises the importance of talking about such experiences in therapy. While in
such a state, you can do very dumb things. It is important to try to reduce the time
spent in such a state, and therapy can help with this.

Anthony: Here I have added 10 lines on self-harm

Homework: Make a note of at least one occasion during the last week, on which you
managed to effectively regulate an upsetting emotional state.

21
 5. Session Five: The significance of attachment
relationships?

The group leader summarizes, briefly goes over what they learned in the last
session, including: how we register feelings in ourselves and others; interpreting
inner emotional signals in ourselves and emotional expressions in others; self-
regulation of feelings and how others can help regulate our feelings; unmentalised
feelings that are very uncomfortable and how we attempt to get out of such emotional
states.

The group leader asks if anyone would like to share an experience of positive
emotional regulation from the previous week.

The group leader then introduces the day’s main topic: attachment. He/she links this
immediately to feelings and emotional regulation and defines it as follows:

Attachment is a positive feeling and emotional bond towards another human being.

The first attachment relationships are with your parents/caregivers and other family
members. These attachment relationships will later influence your relationships and
interaction patterns with others, for good and for bad. Attachment is a phenomenon
we find in all mammals and its purpose is to protect the immature organism against
dangers and promote affectionate bonds between relatives. When the child
experiences something uncomfortable, (for example, hunger, thirst, frustration or
fear) he/she instinctively turns toward the attachment person with an expectation of
being comforted. The attachment person has an equally instinctive reaction to the
signals of unease on the part of the child (for example, whimpering, and crying)
which is a signal that the caregiver needs to attend to the child in some way. To
become emotionally regulated in this way –to be given food or something to drink, to
become less fearful, smiled to, etc.– leads to an establishment of an inner image of
the attachment person that is associated with wellbeing (reward), so just the thought
of the attachment person can be enough to calm oneself. This is the standard path to
emotional self-regulation. But before one has achieved an ability to self-regulate,
being separated from one’s attachment person may involve feelings of unease and
fear (separation anxiety and sadness). The group leader summarises that this
process means we learn to understand and regulate our emotions ‘through’ someone
else, and this process continues throughout life even though we begin to regulate
ourselves.

Humans can have different attachment patterns. In children, this is tested by

observing how the child reacts when it is separated from the attachment person,
which is most often the mother. In the test situation, the mother leaves the room after
a while and leaves the child alone; then an unfamiliar person (observer) enters the
room. The situation of being both abandoned and in the same room with a complete
stranger triggers separation anxiety and fear in most children. An observation is
made about how the child deals with this situation and how he/she reacts when the
mother enters the room again after some time. Children with so-called secure
attachment, react with unease and protest when the mother is about to leave, but
relax after a while and start to play with some of the toys in the room. When the
mother returns, the child goes to the mother and will often whine a bit, but will quickly
calm down, possibly by sitting on her lap. After a short period of time the child will
usually resume playing.

22
Some children, however, have what is called an insecure attachment pattern. There
are two types of insecure attachment patterns: an ambivalent or overinvolved type
and a distanced type. In the ambivalent/overinvolved pattern, the child is insecure
about his or her attachment person – in all likelihood with good reason, because the
person has behaved unpredictably (i.e. has been erratic in response and presence).
In order to attract the attachment person’s attention, the child has therefore learned
to exaggerate his or her emotional expressions (e.g. they express an excessive
amount of unease and crying). When such a child is abandoned in the test situation,
he or she cries loudly and clings to the mother when she is about to leave the room.
The child then has difficulty quietening down and playing while the mother is away.
And when the mother returns, the child is ambivalent in relation to her, cries and
protests when she wants to pick the child up, but quietens down gradually. It takes a
longer time for the insecurely attached child to start playing again after this
experience. It is as if the child needs to hold onto mother for fear that she will leave
again.

The other insecure pattern is called distanced. It is in many ways the opposite of the
ambivalent type. While the ambivalently attached children have exaggerated
emotional reactions, the distanced children exhibit little response. They are
detached. They do not react at all on being abandoned in the test situation. It is as if
they do not care whether the mother leaves or returns. When these children’s
physical responses are measured, they have been shown to be stressed in the
situation, but they express this stress to a very little degree. The have learned to
overregulate their feelings. They may have experienced that their feelings are
commonly overlooked, consistently misunderstood and thought to be something else,
or they may have been ridiculed or tormented for what they were feeling, or
experienced other negative consequences.

Attachment patterns are thus dependent on how the interaction with one’s early
attachment persons and the ensuing patterns develop. Since this has much to do
with how the child attracts attention, one can also call these attachment strategies on
the part of the child. This is not to be confused with the idea of attention seeking
behaviour. Some patients and their helpers see certain symptoms of BPD as ways of
deliberately trying to get attention, for example taking an overdose. Nothing could be
further from the truth and it is important that the group leader emphasises that the
idea of attention seeking behaviour is not part of the mentalizing framework of
understanding.

It is also possible to mix the insecure attachment strategies, e.g. sometimes acting
ambivalently, while at other times acting distanced.

The attachment pattern influences humans from childhood. However, it is not fixed, it
can change during childhood. It exerts an influence on one’s relationship patterns as
an adult. It determines to a large extent how one deals with close relationships and
particularly in situations that cause pain or when there is a danger or fear of being
abandoned. Is the other person a source of security and enjoyable experiences, or is
the relationship characterized by insecurity and drama or is it distanced and
emotionally flat? The way a person regulates his/ her attachment relationship is of
major significance for his/her life.

Group activity: Tom and his girlfriend, Sara, meet again after the university
holidays. During the holidays, Tom has not called Sara and when she called or sent
an sms he did not answer. Sara did very little during her holidays, but when Tom
asked her about it she answered: “I had a fantastic holiday with plenty to do. I wish

23
the holiday had lasted longer.”
Discuss this episode in light of attachment strategies for Tom and Sara. And finally:
Why does Sara answer as she does?

This exercise serves as a kind of run-up to the next exercise, in order to activate the
participants in thinking about attachment and so that the group leader can correct
any misunderstandings.

Group activity: Think about a relationship with an important person in your life
(girlfriend, boyfriend, family member, friend) and think about whether it is secure,
ambivalent or distanced.

This discussion occupies the main part of the session. The group leader clarifies
question about attachment trough the examples of the participants.

Homework: Make notes on what is typical for you in your attachment relationships.

24
 6. Session Six: Attachment and mentalization

The group leader summarises the last session:

Attachment refers to a positive emotional bond with another person

One’s typical attachment strategies as an adult are influenced by the attachment
pattern that was established in childhood.
Typical attachment strategies are secure and insecure attachment patterns,
ambivalent/overinvolved and distanced/detached attachment patterns.
Each of the participants was encouraged to explore a relationship to an important
person in light of what characterizes different attachment strategies.
The home assignment involved thinking more about what has been typical of one’s
attachment relationships.

The group leader asks if anyone wishes to share the homework. This is discussed.

The main theme this time is attachment and mentalization:

Growing up in a mentalizing culture promotes a secure attachment which facilitates a

person’s mentalizing abilities.

A mentalizing culture implies a culture with frequent discussions about people and
why they behave the way they do, including why people do what they do within the
family, for example. A mentalizing culture is necessary to manage any significant
events that affect anyone in the family. Discussion about experiences need to be
done with a reasonable degree of open-mindedness, minimal certainty and without
triggering any oppressive family taboos.

The group are informed that the treatment programme strives toward a mentalizing
culture, – in the group s and individual sessions; for example, there is a constant
effort to find out about one’s own and others’ minds and their transactions. This is re-
emphasised in Sessions 8 and 9.

Group activity: What characterises the family culture of each individual participant
with respect to mentalization?

The group leader leads the discussion on this topic and there will be examples of
oppressive silence, heavy family get-togethers, taboo areas, chaotic family
discussions, etc. The group leader must be prepared for the possibility that the topic
in this session may activate painful memories and strong emotions. Again, the group
leader must emphasise that this is a topic one should explore further in the other
parts of the treatment, and that the key point in this context is the consequences for
each individual in the group. More specifically, it relates to what consequences it has
for the person’s mentalizing abilities when the relationship to an attachment person is
problematic or simply bad. There may be many reasons for such a situation. The
attachment person may not have been available physically or mentally, the person
may not have had the ability to listen, to understand or be empathic. There may have
been, and indeed still be, someone else in the way (sibling, other parent); the person
may not have had good caregiving skills or there was an environment of mental or
physical abuse or substance abuse. The end result is often attachment conflict.

25
Attachment conflict means that one inhibits or exaggerates signals about one’s
emotional state because one fears or is insecure about what will happen if one calls
for the attachment person.
Attachment conflict means that an impulse to get closer is inhibited by something
else (e.g. fear of punishment, or own wish to punish)

Group activity: Make a note of your own examples of attachment conflicts.

The group leader leads the discussion about attachment conflicts that have been
noted and brings the conversation onto the subject of the likely consequences that
this may have for a person’s mentalizing abilities. He/she brings up the idea that
attachment relationships are important, in order for the child to become aware of their
own emotional states, to be able to put words on these states, find out the reasons
for them, and use emotions to orient themselves in a mental landscape. There will be
negative consequences for a person’s mentalizing abilities if the relationship to the
attachment person(s) is poor, if the child cannot use the attachment person to
understand feelings and relationships between people and that this means that one
is very much left alone. In addition, it becomes difficult to think around the attachment
relationship itself because the individual lacks reference anchors. This becomes
easier over time as one grows up and gains other references and can see things
from the outside and compare them with other experiences. It becomes particularly
difficult to think about the relationship if it is characterized by violence and sexual
abuse – how can one begin to understand why a person, who should be treating one
with care and love, is behaving with complete disregard for one’s well-being?

Attachment conflicts inhibit a child’s mentalising abilities right from the start, and
leave behind emotional scars and confusion.

They undermine the child’s ability to deal with attachment conflicts later in adult life.

Group activity: Make a note of something you find difficult to talk about in a close
relationship and what the reason(s) for this may be.

The group leader takes notes and leads the discussion on this topic.

Homework: Make a note of something that has been difficult to talk about in a close
relationship the past week.

26
 7. Session Seven: What is a personality disorder? What is
borderline personality disorder?

The group leader briefly summarizes the topic and discussion from the last session:

 growing up in a mentalizing culture promotes the ability to mentalize

 major attachment conflicts in childhood impair this ability
 Impaired mentalizing ability makes it difficult to deal with conflicts in close
relationships (e.g. thinking often becomes black-white, and emotions will tend
to overwhelm the ability to think, etc.).

The group leader asks if anyone wants to share experiences from their homework
assignment relating to difficulties speaking about something in close relationships.

The group leader then turns attention to the topic of the day which is personality
disorders. At this point the group leader takes a didactic approach outlining current
understanding of personality disorder. Key areas to cover at this point are:

1. A person has a personality disorder when the person’s personality features a

certain number of maladaptive personality traits, which are typical ways of thinking,
feeling, regulating impulses and relating to other persons. The traits need to have
been characteristic of the person since at least late adolescence or early adulthood
and have been relatively consistent since that time.

2. Personality traits typically affect self-image and self-esteem, but also influence
ways of thinking about others, and will usually cause problems in schooling, work
and/or family life (e.g. being shy, not self-assertive, extremely suspicious, dependent
on others, uncontrolled temper, always avoiding conflicts, etc.).

3. A personality disorder does not affect the entire personality. One can have many
good and positive personality traits and many talents in addition to those that are
problematic. For example, Edvard Munch clearly suffered from a personality
disorder. He was an extremely skilful and innovative painter, but a difficult person in
the sense that he had problems interacting with other people.

Group activity: Ask each group member to make a note of: 1) his/her own
problematic personality traits, and 2) his/her good and positive personality traits and
any talents.
Or alternatively, ask each member to write down what ‘makes me me’ (i.e. what are
his/her/what are my individual characteristics).

The group leader asks if anyone wishes to share their notes, makes a list of key
words on the flip chart and leads the discussion.

Following this discussion the group leader outlines a positive view of personality
disorders in terms of their changeability. Personality disorders are not necessarily
permanent. Many traits can change with age, which usually results in a person
becoming more relaxed, less intense and learning to deal with situations in a better
way. Problems can pop up again during times of stress, however (for example, in
connection with work problems or problems in close relationships, e.g. separation
and divorce). Personality disorders improve quicker through treatment, for example,

27
through mentalization-based treatment. Personality disorders may also have a better
outcome than depression.

Next the group leader discusses the origins of personality but does not go into detail.
Personality disorders arise as a result of a combination of genetic influences
(temperament and vulnerabilities) and negative environmental influences during
childhood. Depending on the balance of these factors, certain characteristics come
to dominate our ways of relating to others and these, in turn, define the different
personality disorders.

The group leader now outlines the classification of disorders briefly reviewing key
words of the various types:

1) Schizotypal PD: Very shy and suspicious, few friends, bizarre

views.
2) Schizoid PD: Flat affect, little need to be together with others,
prefers doing most things alone.
3) Paranoid PD: Suspicious, uncompromising, and temperamental.
4) Antisocial PD: Repeated criminal acts, ruthless, aggressive, little
capacity for caregiving.
5) Borderline PD: Unstable relationships, unstable emotions,
fluctuating self-image.
6) Narcissistic PD: Grandiose sense of self, arrogant, lacking in
empathy.
7) Histrionic PD: Theatricality, exaggerated expression of emotions,
plays on sexuality, constantly draws attention to self.
8) Avoidant PD: Anxious, inhibited in new interpersonal situations,
reluctant to take personal risks, excessively fearful of criticism or
ridicule.
9) Dependent PD: lack of self-confidence, goes to excessive lengths
to obtain nurturance from others, constantly needs advice and
reassurance from others.
10) Obsessive-Compulsive PD: Rigid and stubborn, preoccupied with
order and schedules, difficulty delegating tasks to others,
perfectionist.
11) Personality Disorder Not Otherwise Specified: Insufficient traits to
meet the threshold for any one of the above personality disorders,
but has several traits from many personality disorders.

The group leader leads the discussion about the different personality disorders.

The group leader goes through the criteria for borderline personality disorder with
reference to mentalization, with the reasoning that these are the traits that are most
often found in persons in the MBT programme, while emphasising that many
participants may have other personality traits that they have problems with as well:

Criteria for borderline personality disorder:

1) Intense and unstable relationships, alternating between extremes

of idealization and devaluation. Quickly enters into new romantic

28
 relationship, idealizes the person, and allows himself or herself to
be seduced or infatuated, which reduces his or her social
judgement; does the opposite when disappointment arrives, seeing
only the negative where before they could only see the positive.

2) Has difficulties with being alone and strong feelings associated

with being abandoned. Therefore he/she carries out desperate
efforts to avoid being abandoned, e.g. allowing himself /herself to
be treated poorly, acting submissively, carrying out dramatic acts
such as injuring himself /herself or threatening to commit suicide

3) Identity problems: Fluctuating self-esteem, unstable self-image,

constant changes in life-goals, difficulties in holding on to one’s
inner core self

4) Impulsivity that can be self-destructive (i.e. impulsive risk-taking):

e.g. purchasing things one can’t afford, driving and recklessly
and/or above the speed limit, acting on poorly considered
decisions, promiscuity, abuse/misuse of alcohol and narcotics, etc.

.
5) Self-destructive acts such as self-mutilation and suicide attempts
(to regulate painful emotional states).

6) Recurrent feelings of inner emptiness and meaninglessness,

7) Constant mood swings: e.g. fluctuating between intense dysphoria

and euphoria in a single day, or between positive moodiness and
sadness, bitterness or anger.

8) Intense anger that is difficult to control (e.g. that may result in

throwing things, swearing or physical fighting)

.
9) Reacting with suspiciousness or a feeling of being outside of
oneself when stressed.

The group leader clarifies and discusses the traits as they are presented. It is
important that the group leader maintains a mentalizing perspective during the review
and discussion.

Homework assignment: Make a note of the personality traits that have been most
problematic for you the past week.

A leaflet is given summarising aspects of BPD (see appendix).

29
30
 8. Session Eight: On mentalization-based treatment. Part 1

The group leader summarizes the topic and discussion from the previous session:

 definition of personality disorders

 what are maladaptive and adaptive personality traits
 how the course of the disorders fluctuate, that most improve with age
and that treatment increases the chances of improvement
 various different personality types
 Criteria for borderline PD.

The group leader asks if anyone would like to share notes about what they have
experienced as problematic personality traits over the past week or if they have
further questions about the diagnosis.

The group leader then addresses the theme for the session and starts with a
definition of the aim of mentalization-based treatment.

The aim of MBT is to improve a person’s mentalizing ability in close relationships.

Improved mentalizing ability means that the person experiences having a more
stable inner core self, that the person is less likely to let emotions get the better of
himself/herself, and when this happens, that he/she is more quickly able to regain
his/her composure, i.e. the person is more robust emotionally, less vulnerable to
interpersonal conflicts and better able to deal with arising conflicts.

How does psychotherapy enable people to achieve this?

Psychotherapy means that one talks about one’s innermost problems with another
person and/or several other people. In this way, one becomes more aware about
oneself and one’s feelings and how one relates to others. This is a benefit in and of
itself, because in general the person has been left on his or her own to figure this out
and may have gone astray in these thoughts and feelings. But psychotherapy
involves even more. It also deals with getting closer to other people, about letting
others into one’s life, i.e. daring to trust others and make bonds to others, letting
others become significant in one’s life. As has been discussed earlier, particularly in
the sessions dealing with attachment, this is not an easy process. It requires careful
attention to what is happening in one’s own mind and in others’. What is happening
in other people? Are they ready to accept me and my mind? Do they understand,
accept and support me?

The patients are reminded of the session on attachment and mentalizing.

Psychotherapy will automatically stimulate attachment feelings and the pattern of
attachment that a patient identified in Session 5 is likely to become apparent in
therapy. The group leaded explains that this is a natural development and that it will
be important to focus on how the relationship between patient and therapist can
interfere with taking an interest in what is going on in one’s own mind and the mind of
others. The group are told that this topic will be discussed in more detail in the next
session.

How the treatment is structured:

After agreeing a treatment contract, each receives the following:

31
 1) Mentalization-based problem formulation
2) Crisis plans
3) Appointment(s) with psychiatrist for relevant prescriptions if needed
4) Individual therapy once a week for around 18 months.
5) Psychoeducational group therapy of 12 sessions (in parallel in Oslo; in
series in Halliwick)
6) Group therapy 1.5 hours weekly for around 18 months and in some
programmes for up to three years
7) Collaboration with other agencies on work-related rehabilitation

The therapists meet regularly and exchange information about how the therapy is
progressing. The therapists treating a patient are granted permission to discuss the
patient’s progress among themselves, but the group therapist does not ordinarily
mention anything about the patient in the group. It is up to the patient to decide what
he/she wants to talk about and when he or she wants to talk about it. In some
circumstances, the group therapist can address specific issues directly, when they
relate to violence or threats, serious contract breaches or suicide attempts that the
patient does not want to talk about. When it comes to the other group members, the
participants are encouraged not to have contact among themselves in person, by
telephone/sms or via social media such as Facebook and twitter, outside of the
therapy sessions. If they nevertheless chose to meet outside group, then they are
encouraged to talk about these encounters in the therapy sessions. Intimate
relationships between patients attending the MBT-programme are not permitted, and
if such a relationship should develop then at least one of the parties will have to
leave and seek therapy elsewhere.

MBT involves practicing mentalizing skills in close relationships

MBT therapists provide little direct advice.. They try to engage the patients in a
mentalizing stance and, in doing so, help the patient gradually develop their own
solutions having reflected on their problems in increasing detail. As mentioned
earlier, the mentalizing stance means being curious about the other’s mind, about
experiences, thoughts and feelings– a not-knowing attitude in which one attempts to
find out by trying many different alternatives. MBT is a collaborative effort in which
the therapists seek to get the patients to come along on the same mentalizing
journey. In short, mentalization-based treatment is based on practicing mentalizing
skills together with the therapist and other group members. To be good at something,
you need to practice it. In this treatment programme, the participants have the
opportunity to practice mentalizing skills.

The mentalizing group therapy can be described as a training arena for mentalization
and requires the following from each individual participant:

1. That they regularly bring in (tell about) events from their own lives, preferably
recent events, resulting in poor mentalizing (strong or confusing feelings,
impulsive actions poor conflict resolution, etc.), or in which the person has
been subjected to stress. (Particularly in relation to others) that put high
demands on mentalizing ability.
2. That they try to understand more about these events using a mentalizing
stance (exploratory, curious, open for alternative understandings, etc.).
3. That other group members participate in this process by exploring their own
problems and those of others through a mentalizing stance.

32
 4. That everyone together tries to find out about events in the group in the same
way.
5. That they try to bond to the group, its members and the therapists.

Group activity: Discuss whether you have problems with, 1) bringing in events from
your own life, 2) focussing on events in the group, and 3) assuming a mentalizing
stance.

Use the rest of the time on the discussion of these issues.

Home work: Did you encounter any problems during your last group meeting talking
about a relevant event(s) from your own life?

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 9. Session Nine: On mentalization-based treatment. Part 2

The group leader summarizes the topics of the last session:

 Aims of MBT to enhance the mentalizing ability in close relationships;

 The structure of the treatment programme;
 Training in mentalizing in the group...

The group leader asks for the home work of the week and discusses this with the
participants.

The main topic for this session is the attachment aspect of MBT.

Group activity: Discuss the difficulties you think you may run up against when you
form a therapy relationship with 1) the individual therapist, 2) the group therapist, and
3) the other group members.

Common objections to forming affiliate relationships include the contention that it is

both painful and meaningless when one knows that one soon will be separated, that
they inevitably go wrong, and concerns about the fact that attachment involves
caring about another person. Some will feel that they might care too much about the
therapist, but worry excessively that the therapist does not care about them (i.e. that
the therapist regards the relationship as ‘just part of his/her job). Others may
question whether it is possible to bond with all the individuals listed: after all, one
needs to like the people one bonds with and one may not like the therapists or other
group members. Still others may raise the issue that attachment can lead to wanting
more, such as a wish to contact the therapist whenever things are difficult. The
question of how you can bond with someone who doesn’t say anything about himself
or herself may also be raised, As well as the issue of why one cannot have contact
with other group members outside of the therapy session, if you become friends.,?
Etc…

As indicated above, this group activity activates a wide range of themes, and it can
easily turn chaotic. The group leader may, after a while, assist by structuring the
discussion. One way to do this is to discuss the relationship with the individual
therapist, the group therapist and the other group members separately. Some
patients may experience a conflict of loyalties here, similar to that of one own’s
family. It is hard to say something negative in front of others, in public. This may be
vented in the group. Other themes that can be highlighted are the apparent diversity
among the participants’ concerns regarding attachments to therapists and other
group members. How come? How is this transmitted intersubjectively?

To those who have participated in group therapy earlier, it should be explained that
the MBT group will use more time investigating what takes place in the here and
now. When there are 8-9 persons present, it is natural that things can become quite
chaotic at times. One might experience that the therapist has to stop further
discussion and try to find out what is going on beyond the spoken words, that things
are going too fast, that one has to rewind, etc. It is important to listen to the therapist
in such situations.

The group leader changes the theme to common reasons for not opening up or
telling others about what is difficult. These are feelings of being let down, not

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understood, overlooked or misunderstood by the therapist or one of the other group
members.

Group activity: Discuss what your typical reaction is when you feel let down,
misunderstood, overlooked or something similar by a therapist, by another group
member or by someone who is close to you.

Group discussion of this topic takes the rest of the time. The group leader
emphasises that this is a particularly important topic to address in therapy; as such
reactions often have a tendency “to go underground”. Clarifying misunderstandings
and sensitive interpersonal feelings is a central element in mentalization-based
treatment.

Homework assignment: Make a note of how you reacted when you experienced
being let down, misunderstood, overlooked or something similar the past week, by
someone in the therapy group or by someone close to you.

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 10. Session Ten: Anxiety, attachment and mentalizing

The group leader summarizes the last session:

 on the significance of bonding

 establishing attachment to the therapists and the other group members,
 how attachment to others activates difficult emotions and represents a
challenge to one’s mentalizing endeavours,
 how one might experience disappointments in the treatment
 How one’s reactions to feeling upset by others might “go underground”
instead of being spoken about.

The homework about any interpersonal events that led the individual to feel let down
or misunderstood is shared. The theme of experiences of one’s needs and wishes
not being met (what self psychologists label experiences of self-object failures) –is a
very important and a rich pedagogic area to expand understanding of therapy so the
group leader may spend some time on this.

The group leader introduces the topic of the day by saying that almost everybody
that applies for treatment for an unstable sense of self, unstable emotions and
problematic relationships with others, will also have disturbing symptoms in a more
narrow sense, and that it is often these symptoms that motivate the individual to seek
treatment. The most common symptoms are anxiety and depression. In this session
we will deal with anxiety.

Anxiety is intimately connected to one of the basic emotions that was addressed in
the third session – fear. Fear is indispensable for survival in a dangerous world; it
signals danger and turns on an animals ‘alarm button’, schematically activating a
preparedness for fight or flight.

The group leader explains that the threshold at which fear stimulates a flight and
flight reaction and the intensity of the response varies between individuals. To a large
extent this is a matter of temperament. Some individuals are more intrinsically fearful
than others. This become apparent when we consider simple phobias. The word
phobia is derived from the Greek word “phobos” and means simply fear. Simple
phobias are fear of specific things, animals or situations. It might be spiders, snakes,
knives, lifts, tunnels, etc. Most people will experience fear in an encounter with a
snake. Reacting emotionally when encountering a snake is not evidence of an
illness; it is a natural and purposeful reaction that is grounded in evolution. If the
mere sight, or thought of a snake elicits panic, however, or if one harbours a constant
fear of encountering a snake in European countries, it approximates a phobia. The
fear reaction is stronger than normal and will lead to troublesome consequences for
the individual.

Group activity: Make notes on your own possible phobias

The group leader asks each member in the group what they have written down and
discusses the kind of simple phobias being reported by the participants. He/she sets
aside agoraphobia and social phobia for later discussion.

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Then the group leader mentions that there are anxieties that are not confined to
special objects or situations. One may experience unspecified anxiety where the
source of the emotion is unknown. In such cases we assume that the source is
forgotten and that it is buried in unconscious layers of the mind.

The intensity of fear can be so strong that the physical and mental processes may
not handle it properly. The autonomic nervous system can become overloaded
causing the individual to experience a panic attack: increased heart rate, difficulties
breathing, dizziness, fear of fainting, dying, or going mad, or simply losing control,
etc.

Group activity: Have you had any panic attacks? Note how it felt

The group leader asks all group members about any experiences of panic attacks.

Thereafter he/she proceeds with the theme of panic attacks leading to a focus on
how to avoid the sources of possible triggers. Most often these will be situations
packed with people and perceived difficulties with the escape route, such as buses,
trains, shops, restaurants, cinemas, theatres, concerts, etc. If one avoids such
situations to the extent that this avoidance has significant negative consequences,
we would describe the individual as suffering from agoraphobia (agora being the
Greek word for marked place).

Group activity: Make notes on any kind of agoraphobia.

The group leader asks all group members about experiences of agoraphobia. He/she
continues by saying that there are other kinds of anxiety disorders that also are
common, but which will not be commented on in detail here. There are social
phobias, which concern the fear of exposure and embarrassment in the presence of
others; social phobias are closely connected to excessive performance anxiety,
which may prompt the individual to avoid social gatherings such as parties,
restaurants, group seminars or situations where the individual feels a burdensome
obligation to perform in some way. Then we have generalized anxiety, in which the
individual is tense and worried about problems with daily living. There is also
obsessive-compulsive anxiety with its obsessions and rituals, and post traumatic
anxiety, in which the individual is exposed to painful re-experiences of traumatic
memories.

Treatment of anxiety disorders involves controlled exposure. Exposure to the anxiety

triggering situation in itself is usually not enough. It is necessary for it to be done in a
manner that implies an experience of mastery and control, not defeat. At this point
the group leader reminds the participants about what they have learned in previous
sessions about emotions and attachment. By default, children’s natural reaction
when experiencing fear is to turn to their attachment figure or another secure person
who they trust. The natural reaction of this person is generally to take care of the
child and calm him/her down. Multiple experiences of this kind informs the child that
fear is an emotion that can be handled. However, this interaction will not always be
ideal, for different reasons, and this can leave the child continuing to feel frightened
or feeling that it is useless or worse than useless to approach others, leading to the
conclusion that fear has to be handled by oneself alone, or even that one has to hide
one’s experience of fear. The fact remains, however, that the best remedy for anxiety
is a calming other person. Everybody that has experienced anxiety must have
realized that it helps to be with another trustworthy person in an anxiety provoking
situation. This is a principle which is used in the treatment of anxiety. In exposure

37
therapy, for instance, a therapist treating someone with anxiety about travelling on a
bus might accompany the patient on his/her initial travels on buses; travelling with
someone who makes you feel secure, helps one to travel without anxiety. This gives
an experience of mastery and control when it is accomplished. Thereafter one may
experience the same while travelling alone, especially when the other person is
waiting at the bus stop, for example.

Group activity: Make notes on how other people have had a calming effect on your
anxieties

The group leader asks all group members about this issue and underlines that the
very act of approaching another person when experiencing anxiety is significant
because it is the attitude that patients are encouraged to develop towards the
therapists and the group members in the MBT programme. As will be remembered,
we have emphasised the importance of trying to bond with the therapists and the
group members. This requires that one “brings in”, talks about in the sessions, things
that one fears, including things that happen within the sessions that activate fear.
This is easily said, but may be difficult to do. When trying to be open with respect to
one’s anxieties, one will often experience a kind of resistance within oneself. It may
be related to the fact that fear is often connected with shame, or that one gets an
uneasy feeling of being childish and helpless, or that one does not trust that the other
has the capacity to be helpful, etc.

Group activity: Make notes on themes or experiences that one is reluctant to talk
about to the individual therapist or to the group

The group leader discusses this with the whole group.

Home work: Note if you managed to approach another person (therapist, the group,
family or friends) during last week with something that made you anxious, if it did or
did not help, what are your thoughts about the reasons why it succeeded or failed.

38
 11. Session Eleven: Depression, attachment and
mentalizing

The group leader briefly summarizes the discussion in the previous session: a

The close association between anxiety and fear.

Fear can be an appropriate response in some situations but that, if it becomes
excessive, it can get out of hand (e.g. causing panic attacks) and can develop into a
maladaptive response if it begins to be triggered by benign or non-threatening
stimuli.
Anxiety can easily generalize to other areas if not addressed
There are effective treatments for anxiety conditions.
Treatments for anxiety disorders typically involve controlled exposure.
Studies have shown that one is able to manage anxiety better when one approaches
the triggering situation in the company of someone one trusts.
It is important not to respond to anxiety by avoiding the source of the anxiety, but
bravely by involving others in your exposure to it instead.
It is important in therapy that one is daring enough to bring up the issues that are
really bothersome to oneself.

The group leader goes through the week’s homework assignment discussing the
examples brought about approaching others to help with anxiety.

The group leader then turns to the current session’s topic: depression.

Like anxiety, depression is also associated with a basic emotion –separation anxiety
and sadness. This is also a natural reaction related to a break in what we call the
attachment system. All children who have established an attachment relationship will
respond with separation anxiety when they are abandoned and with sadness when
the person they miss does not return when expected. We believe that separation
anxiety is a natural part of a type of protest phase and that it is connected to crying
and screaming which are used to attract the parent’s attention. Sadness belongs to a
later phase in which the protest has not had the desired result. When this is because
of the death of the caregiver or a close person, then we refer to it as a grief reaction.
An intense grief reaction is quite similar to depression, although qualitatively
different.

Individuals vary with regard to what they react to in terms of sorrow, how strong their
grief reaction is and how long it lasts. In most people, the emotion passes after a
time and the individual is able to adapt to his/her new life circumstances relatively
quickly; but when the emotion remains intense for a longer time, we refer to it as a
depression. Some may describe it as a pathological grief reaction. In depression the
person is sad and low in mood, tired and with low self-esteem and has ruminative
thoughts, feels profoundly negative about life and often guilty. The person has
difficulties concentrating, life seems meaningless and there seems to be little hope
for the future. The thought of giving up on life may not be far away.

The relationship between depression and grief reaction is therefore quite close. This
hypothesis is supported by research on large population studies. The loss of
someone dear is the most common trigger for depression. It does not need to be a
death. It could be that someone travels away for a long period of time, that you
yourself are sent away, that the attachment person is ill and unavailable, that one’s

39
parents divorce or that one moves away and loses close friends. It may also involve
the loss of social standing and social position, or being disgraced in public in some
way.

If a person has first experienced a serious loss at a young age that has led to a
poorly processed grief reaction, one will be more disposed to reacting with
depression after a loss in adult age. And the more depressive episodes one has had,
the easier it is to experience it again. It is as if one establishes an automatic
response pattern to stress and discomfort. The response pattern, a depressive
reaction, may also be triggered by things other than loss, but we think that it is in
relation to the loss of an attachment person that the reaction pattern is established as
part of evolution. Other things that can trigger depression are general stress and
physical illness, as well as factors of which we are still unaware.

Group activity: Make a note of what may have triggered a depressive response in
you.

This is a sensitive topic. The group leader must spend considerable time reviewing
the examples that are given, not because it is important to hear everyone’s
depressive episodes in detail, but because everyone should have an opportunity to
say something on this topic. It is NOT a good idea to ask everyone to think about
what may have triggered their own depressions, and then listen empathically to the
stories of 2-3 group members, not leaving adequate time for all participants. The
group leader must say openly to the group that it is important that everyone is given
a chance to talk about their experiences and the available time should be divided
equally. If five minutes are set aside for each person and there are eight people in
the group, then this would take 40 minutes.

The group leader then turns to the topic of course and treatment. Most depressive
episodes resolve themselves, while some are never completely resolved. The person
can continue in a chronic state, which is not as serious in terms of risk as when the
depression was at its worst, but is characterized by constant low spirits in which the
person has difficulty feeling happy about anything. The individual has low self-
esteem and is pessimistic in all aspects of life, including about the future and.
Depressive episodes pass quicker with treatment and many chronic depressions can
be normalized with treatment. Serious depressions should be treated with
medication, with so-called antidepressants.

Antidepressants can also be effective for panic attacks and they can also reduce
strong mood swings that are due to general emotional instability. Many people with
BPD have taken antidepressants in the past and may still be on medication. When
someone takes part in a comprehensive treatment programme such as the MBT,
they should take advantage of the situation by reducing or ending the antidepressant
treatment if possible. This should be done after the treatment is well underway, and
the person feels more in control of his/her life. The reason for this is not only that one
should learn to deal with life’s difficulties without medication, but also because
antidepressants have a tendency to blunt emotions. This is particularly true for
sexual desire. Accessibility to one’s emotions is important in order to get the most out
of this treatment programme.

Group activity: Make a note of the experiences you have had with antidepressant
medication.

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The group leader brings up and discusses the participants’ experiences with
antidepressants.

The final main topic is depressive thinking. The term “depressive thinking” refers to a
set of automated thought patterns that tend to accompany a depressed mood and
which can establish themselves as part of “normal thinking” after repeated
depressive phases or when a depressive state lasts for a long period of time. It refers
to thoughts that quickly pop up with content such as “everything is hopeless”,
“nothing helps”, “it’s impossible for me”, “I am hopeless” etc. Depressive thoughts
such as these, which are often the result of adverse life experience, may in
themselves sustain a depression or a depressive tendency. The group leader
explains that the mentalizing approach to understanding the difficulties of individuals
with depression is to view these cognitive distortions as acquiring overwhelming
potency because of mentalizing failure. The low mood acts directly on mentalizing
capacities, thereby shutting down the mental processes that are needed to recover
from the depression. Being able to question fixed negative thoughts is an important
part of mentalizing and to recover from depression patients need to begin to
mentalize.

Group activity: Make a note of your own tendency towards depressive thoughts,
which you have either experienced in the past or are experiencing now.

The group leader reviews the participants’ notes about depressive thinking and
underlines that awareness of the nature of one’s own thoughts is an important aspect
of mentalizing. In addition the leader notes when patients thinking is rigid, fixed,
certain, and unquestioned because these qualities suggest non-mentalizing is
playing a part in maintaining the depression.

Homework: Make a note if you had depressive thoughts this past week and how you
dealt with them. Were you able to stimulate some doubt about them?

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 12. Session Twelve: Summary and conclusion

The group leader briefly summarizes the last session on depression:

Depression is closely connected to the basic emotions of separation anxiety and

sadness
Nature has developed this response system through evolution because it turns out to
be beneficial for the relationships between children and their attachment figures.
Loss of attachment figures leads to grief
Strong grief reactions are almost similar to a depressive state.
Other events may trigger grief/depressive reactions, like loss of social esteem or
social position, stress or somatic illnesses.
After suffering a first depressive episode, another one becomes more likely. If one
has suffered recurrent depressive episodes, or a milder chronic type, often referred
to as dysthymia, depressive thinking may have evolved and that in itself may sustain
the depression.
Depressive thought patterns indicate a loss of mentalizing.

The group leader then asks if there is anyone who wishes to share their notes from
the homework assignment the previous week, and leads the ensuing discussion.
This is the last meeting and the group leader makes a decision about how much time
he/she can use on the homework. It depends a bit on the group’s activity level. It may
also be the case that the group leader has put aside a few topics that he/she has not
had time to address earlier and that could now be reviewed. The group leader must
simply improvise a bit more this last session.

At the appropriate time, the group leader says that they will now spend some time
clarifying things that have been discussed during the entire course, but that still may
be somewhat unclear to some of the participants. He/she asks if there is anything
anyone has on their mind at the moment – something they wish to learn more about,
comment on, or discuss further. If nobody brings anything up, the group leader
summarizes the subjects that they have been through in the group. He/she starts
with the first meeting, about mentalizing, and brings up the main points, including the
group exercises. Through this type of reminder, the group members usually get quite
involved, both reflecting on what they have been through and wondering about things
they may not have fully understood.

Approximately twenty minutes before the end the group leader asks the participants
for their feedback:

Group activity: Jot down a few key words about what you think has been
particularly educational for you (a topic, a discussion, a homework assignment, an
event) in the group.
Make a note of any suggestions you may have for improvements in the programme.

The group leader brings up particularly educational experiences and makes a note of
any suggestions for improvements. At the end he/she thanks the members for their
active participation and wishes everyone the best of luck on the continuation of their
treatment programme.

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