E113 - What were they Thinking? Mentalisation Based Therapy (w/ Peter Fonagy & Anthony Batemen)

Mentalisation-Based Therapy (MBT) is a structured, evidence-based psychotherapy designed to enhance a person’s ability to mentalise, especially in emotionally intense situations. It was developed by today's guests Prof. Peter Fonagy and Prof. Anthony Bateman for treating borderline personality difficulties (BPD) but has since been adapted for other mental health conditions, including anti-social and narcissistic personality difficulties, eating disorders and more. 

Today we discuss:

 - What does it mean to mentalise? 

- Do we have a problem with mentalising in our society?

- Useful definitions of Personality & Personality Disorder.

- How early attachment relationships influence our psychological health.

- What an MBT session looks like.

- Some of the research that has been done and that is planned on the effectiveness of MBT. 

- The potential utility of combining MBT with psychedelics. 

Interviewed by Dr. Alex Curmi. Dr. Alex is a consultant psychiatrist and a UKCP registered psychotherapist in-training.

If you would like to invite Alex to speak at your organisation please email alexcurmitherapy@gmail.com with "Speaking Enquiry" in the subject line.

Alex is not currently taking on new psychotherapy clients, if you are interested in working with Alex for focused behaviour change coaching , you can email - alexcurmitherapy@gmail.com with "Coaching" in the subject line.

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Transcript

Welcome back. There's a few skills which are essential to live a psychologically healthy life. And I would argue that one of those skills is mentalization. Mentalization is the ability to understand and interpret one's own mental world. One's thoughts, feelings, intentions, but also importantly the mental states of other people, their thoughts, feelings, intentions.

It involves recognizing that people's behaviors are influenced by all sorts of things, their inner experience, their environment, their circumstances, and that can importantly differ from one's own. Mentalization is crucial for having healthy social relationships, regulating one's emotions,

and living a high quality life.

It's been recognized in recent decades that some individuals have more problems with mentalizing than other people.

and these might be the same individuals which end up with diagnoses like that of borderline personality disorder or antisocial personality disorder. As a result in the nineties, two [00:10:00] clinicians, Anthony Bateman, a psychiatrist and Peter Gie, a researcher and psychoanalyst, came to, came together to develop a therapy all around mentalization.

And this was called mentalization based therapy. It's a structured, evidence-based psychotherapy designed to enhance a per designed to enhance a person's ability to mentalize, especially in emotionally intense situations.

It's been studied and shown to be effective for conditions like borderline personality disorder, particularly when it comes to emotional regulation, forming better relationships, reducing the incidence of self harm. 

And the research is expanding to look at the use of MBT for all sorts of other conditions as well, like antisocial personality disorder, eating disorders, potentially neurodiversity, 

Today, I'm very pleased to be in conversation with Peter and Anthony. And in this conversation, we discuss if we indeed have a problem with mentalizing, not just as individuals, but as a society and a culture. The common problems people run into with mentalizing. Terms like personality and personality disorder and how we can define them usefully in this context.

How our early attachment relationships influence our psychological health and our ability to mentalize. We discuss in some detail what an MBT session looks like. Some of the research around its effectiveness.

Potential future research to look into the use of MBT. Potential future research to look at the use of MBT in other conditions like eating disorders. The potential crossover between MBT and psychedelics. As tools to help people to mentalize.[00:12:00] 

Plans to research the use of MBT for other disorders like eating disorders. And the potential crossover between MBT and psychedelics and potentially how they could be combined in order to help people to mentalize better.

This is the Thinking Mind Podcast. It was great to have a conversation like this with Peter and Anthony. I got a lot from it and I hope you will too. This is the Thinking Mind podcast, a podcast all about psychiatry, psychotherapy, self development and related topics. If you'd like to support the podcast, check out some of the links in the description.

And as always, thank you for listening.[00:13:00] 

Welcome back, everyone. Today, I'm so

pleased to be here with Peter Fonagy and Anthony Bateman. Peter, Anthony, thank you so much for joining me. Thank you. And thank you from Peter as well. There's a lot I want to talk about today concepts around [00:14:00] personality, personality disorder, attachment, mentalization, and of course, mentalization based therapy.

But first, I'd like to talk a little bit about some of the sociocultural trends. Recently, I've noticed a trend that a lot of our political debates, our societal debates, seem to be extremely tribalistic, extremely emotionally charged. And it seems like emotions are often getting in the way of our perceptions of reality.

So I'll direct the first question to you, Peter. Do you worry about how in the main we, we're handling our emotional lives in the political landscape and the social landscape? Enormously. But I think I'd be a very strange person if I wasn't concerned about it. There are many layers to this, but from our point of view, today's topic, The absence of mentalizing in debates and considering the thoughts, feeling, wishes, beliefs, and [00:15:00] desires of those that we are addressing, those we are talking to, those who we are talking about, as well as really seriously considering our own thoughts, feelings in a mentalizing sort of way, I think makes it more likely that debates It's become more extreme, tribalistic what we like to call theological, action oriented as opposed to discussing ideas or discussing beliefs.

And as soon as beliefs are experienced as if they were real, as if they were reality, what we call psychic equivalence, they become dangerous because we stop questioning them as if they were thoughts or feelings. But of course, we can react to that. By what, again, we call hyper mentalizing or pretend mode by talking about thoughts and feelings in a non realistic way that they [00:16:00] don't correspond to anything.

And I think the debate, the mindless debate that you talk about is often could be characterized as a non mentalizing or an ineffectively mentalized debate between people. And what do you think is the reason for this trend? And if I knew the reason for that, I wouldn't be here talking to you. I would be in a very different place, so I don't really know.

There are lots of people that have made lots of suggestions about that. I couldn't particularly wish to endorse any, but it certainly is the case that things have become worse over the last 20 years with the increase of loneliness, the increase of social media or host of things. That have undermined discourse as it used to be my personal feeling and I don't want to Introduce this as it was fact because I can [00:17:00] still distinguish between belief and fact but my personal feeling is that Social media is a little bit of a virus because views Had up till now been moderated by printing media.

That is, you couldn't just express a view and for that to be thought through without checking because printing was simply expensive. So, you know, there was a quality check. There were gatekeepers. Exactly, a gatekeeper. But as soon as social media and digital media came in, it became very cheap. And that.

led to a situation where we are much less willing to really properly look at other people's thoughts and feelings and views and get into little echo chambers where we just want to have our own thoughts and feelings [00:18:00] repeated. So, you know, these are obviously my ideas and I wouldn't want to impose them on anyone else.

Well, fair enough. I appreciate that. Thinking more about individuals, today we're going to talk a bit about MBT, and of course among other things MBT is a recommended treatment for personality disorder. Anthony, how can we define terms like personality and personality disorder? Of course, these terms are used a lot colloquially and they have certain definitions that people understand them by.

But, what are definitions that we might use to, to better understand these terms? Now, just linking back to what Peter was saying, in a way, to answer that question about personality and personality disorder, it's quite intriguing, really, because in a sense, I've become much more aware, particularly with clients, patients, and so on, about social disconnect and the absence of resilience to manage sort of everyday stressors and so on.

And that links through to personality and [00:19:00] personality disorder. So, So, in a way, we originally began with mentalizing actually looking at the capacities of individuals in a sense about their mentalizing capacities. As Peter was outlining, that's the ability in a sense to actually reflect on your own mind states and reflect on other people's mind states and the interconnection between the two and so on.

And the absence of that, of course, or difficulties in that leads to social dysfunction in various ways. So we began by looking at what was then called borderline personality disorder, which was a sort of. A grouping of people who actually had considerable problems with their relationships, which were often seen to be short lived and unstable.

They had problems with actually experiencing themselves, so they had what was called an unstable self. They didn't know who they were, sort of sense. And that was linked through to emotional, sort [00:20:00] of extremes, experiences. And an expression of those emotions in various ways and impulsivity, so they self harmed or they harmed themselves and actually tried to kill themselves, in fact, more often than other people.

And this is where this sort of idea came of personality and personality dysfunction. But we carved, they were carved up then into these categories, you know, voidant, antisocial, borderline and so on and the tendency now has actually been to one, recognize that many of them are actually the sort of descriptive characteristics that define them are actually really developed through actually trauma and developmental trauma.

And so there's a greater interest in the ideas of complex trauma and presentations into adulthood and that our personality dysfunction overall. I've always found it helpful to define [00:21:00] personality as, you know, obviously a set of traits and I almost think as a set of traits, as a set of tools that you can use to interface with yourself interface with the world, interface with other people.

And I also think it's striking how, of course, as human beings, we don't have one kind of personality, we're all unique. And it strikes me that it's quite, that's quite an adaptable situation, an adaptive situation, I should say, because life throws at you so many complicated, unpredictable situations, that it's actually helpful to have people who have very different personalities working together collaboratively.

Would you agree with that, that basic definition of personality, that it's this interface we can use to interface again with ourselves, with the world, with other people? Do you think that's a useful definition? Yeah, yes, I do. Because it actually moves us towards a much more dynamic, dimensional sort of components of personality functioning.[00:22:00] 

And how that functions and how we function in different contexts and so on. So it's, it's perfectly in line with the sort of mentalizing idea around the abilities of the individual to actually consider themselves and consider their own mental state and actually be aware of their sort of self states and express those to others.

But in the context of actually being empathic with others mind states and so on, so that each can feel understood and interact, so there's a sort of smooth to and fro and so on. And, and where that's disrupted actually then leads to the disorders of self, self experience if you like, and their relational interpersonal problems, which are core really to any definition of personality disorder.

And Peter, maybe you could take us through how do our early attachment experiences affect our ability to [00:23:00] mentalize, first under normal circumstances, and then how do they get disrupted? Well, I think this is a really interesting and very challenging question, about which we have changed our mind over the years.

So, when we started out, we started with that, what I still consider, at core, an appropriate view. That none of us are born with an awareness of mental states. It's not something that emerges somehow as Descartes kind of, I think, therefore I am you know, little phrase would suggest it's really because other people think of us that we start thinking about thinking that is, if I was brought up in the forest on my own I would not develop an understanding of minds.

So, in that sense, the presence of another, an adult, whose interest in a child's mind is [00:24:00] critical. And that, of course, is mainly what attachment relationships bring to children. That is, a caregiver, a caretaker, who is interested in what that particular person is thinking or feeling. And to re present it to them.

By way of mirroring gestures, and there is good evidence that the more secure that relationship is, the more sensitive that relationship is, the more mentalizing will be established in a stable and robust way. And we collected evidence on that. More years ago than I care to remember. So, you know, there was evidence.

And it's it remains true. What we actually lost sight of there is what Anthony was referring to also as well, that that's only part of the picture. The sensitive adult surrounding the [00:25:00] child. Is also a member of a community that supports that adult and that community of course is part of a society which can be more or less mentalizing.

So it's not just to do with the adult, but also we said, why is this mentalizing bit so important? Is it just because it makes communication better? And what we have arrived at more recent years is, yes, it's communication, but an aspect of communication that's unique to human beings. And that's social learning.

That is, we are the only species. on the planet that is capable of passing on knowledge from one generation to another, in terms of knowledge. For that to happen, we have to trust other people. And to trust other people, to trust the knowledge that we [00:26:00] are actually obtaining from others. We have to have some sense of whether that person is trustworthy or not.

Because obviously, from an evolutionary point of view, it's not in everyone's interest to make us more adapted to the social world. It's actually, in fact, from the point of view of their survival, it'd be better if we didn't adapt. So we have to know who is really interested in our survival. And that's perhaps a cue for mentalizing.

Someone who can mentalize me. Someone who can understand me. I can also trust. I can open my mind to and receive this knowledge that is really the unique aspect of being a human being, learning from others. And I just believe that [00:27:00] mentalizing and this sense of trust in knowledge or what we call epistemic trust.

Go together and link to attachment as a really as three overlapping construct. Attachment generates the capacity to mentalize, which in turn enables social learning, which feeds back to attachment, which feeds back to mentalizing and so on and so forth. So I see this now as much more as interlinked, overlapping kind of construct.

Yes, and I suppose what you point out is the importance of society and culture as well as the matrix in which we all live and of course the ability of a parent to mentalize to their child is going to be in some way influenced by the community around them. And I'm also, I was always really fascinated by the idea [00:28:00] that People's attachment styles seem to have an influence on not just their trust in other people, but their trust in the world, or their trust in life in general.

For example, their trust, their faith that they'll be able to get a good job, for example, that sustains them. But then on reflecting on attachment, it makes sense to me, because after all, when you are a young child, your parents are your world in some sense, and you do live and die by your parents. So I, I thought these, these parallels were really interesting.

Do you, do you Anthony, do you also see these, these parallels in terms of trust in the world rather trust in your, the attachment figure being a predictor of trust in the world or trust in life in some sense? Well Peter's better placed to answer that than me, but in a, in a sense, yes because what we find in treatments and so on, the sort of attachment processes do begin to inform you.

about your treatment, particularly in therapy for example, and in MBT. [00:29:00] So we tend to try to appraise the person's level style of attachments really, and to what degree they might generate a level of trust in other people and trusting other people because or clinical practice, of course, engagement of someone in a process of change in therapy is incredibly important.

And if you're actually, first of all, got to generate a sense of trust where there's actually. Systemic distrust. It's your first step and we spend considerable time, for example, recently in mentalizing an MBT with antisocial personality who are at their very core distrustful. And nobody trusts them and they don't trust anyone.

And that's exactly how it applies when they come forward into adulthood and so on with very problematic backgrounds with considerable trauma neglect, coercive parenting, and [00:30:00] so on. And so they don't generate robust mentalizing, and they don't generate A sense that they can rely and trust in others.

And that's what you're presented with. So why would they come forward and think you might be helpful to them and so on. So you have to work very explicitly on that right at the very beginning of treatment to engage them. And this is, I suppose, where those mentalizing modes come in. Those more defensive ways of mentalizing.

Maybe that represents a more early stage of development. Could you comment a bit on what those different modes are? Yeah, well, Peter's already mentioned them really and the first one of sort of not being able to distinguish between what I believe and think and so on and what my experience is and facts.

actually is psychic equivalence. And when I don't differentiate, so actually I know, and actually what's in my mind is reality. This is a very [00:31:00] ineffective way of mentalizing, because I just enforce my own view, and I see my own view out there as being facts, and so on. The problem is That we can apply this even to ourselves.

So I can, for example, think, Oh, look, you know, I'm a rather idle Miserable person. I'm a bad person But if I do that in psychic equivalence, it's not a passing thought or passing experience about myself. I am a bad person And I experience myself as being bad and it's therefore very powerful and indeed very painful for me, for example, if my mentalizing is at that ineffective level, even around myself.

Okay. So that's the psychic equivalence. But I can feed that as well, as Peter pointed out, is what we call he called really teleological. Okay. Which in a sense is actually understanding mental states, motives and people's underlying mental states through action, through what happens [00:32:00] in the world.

So you are actually what you do in essence, you're not exactly what you say, and so on. And of course we can all operate in these relatively ineffective mentalizing modes so called, but they're, they're usually transient or we catch ourselves and we move and so on and we kind of move away from them and then come back to them and so on.

But in fact, our, our patients, our clients and so on can get stuck in them. And once they're stuck in them, it's very hard to get out because you can only get out, in my terminology as it were, if you borrow another mind. If you get a, a sensitive clinician or something like that to actually help you begin to reappraise your own mind and so on.

And that's really a tough call because you don't trust in anyone and so on. And so, Peter, is it fair to say that what a therapist in do, what a therapist is doing in that situation is effectively like a form of re-parenting or a form of active therapeutic [00:33:00] parenting? That's a very loaded question and I wouldn't wish to be bound by an answer on that.

I think there are analogous aspects to therapy and parenting. And is it the therapist's task to support the developing mentalizing of the patient? Yes. Are they doing the same as a parent would do? No. Because what they confront is an adult whose mentalizing is there but is blocked in some way.

So their task is To unblock it. It's you know it. I would use it the analogy of a physiotherapist. So the physiotherapist is not there to teach a person who's just had a hip operation or a knee operation to walk again like a child, but [00:34:00] to recover the muscles that they need in order to talk. So psychotherapists are there to build mentalizing muscles.

In people whose mentalizing had, for whatever reason, atrophy that, you know, when you think about people who have had traumatic backgrounds, if you had been treated truly badly and really cruelly, you know, it's not surprising that you actually don't want to think about how, what people might be thinking or feeling because what on earth might have Made the people around you act the way that they did.

You know, I remember a case of someone I, I, I saw in prison, you know, somebody was there for you know, grievous bodily harm and You know in an interview schedule asking why did you think? Your parents behaved as they did and he said well you tell me you're an [00:35:00] effing psychologist so That wasn't very mentalizing.

But the guy was someone who's at age eight and was Had an alcoholic father who urinated on him when he came back from the pub And when you're age eight and you have a father behaving like that Do you want to think about what could be going on in that person's mind? No, you want to shut your mind off to those kinds of things.

So that's what I mean. In therapy, what we can do is gradually help people open their mind in selective areas by their mind's head shut down to thoughts, feelings, wishes, beliefs and desires. I may be thinking about things in the other direction. I hear obviously MBT is not the same thing as parenting, but.

Many parents struggle and have a lot of dilemmas and quandaries in terms of how to raise their children and how to help them through emotionally difficult experiences. Do you think there are lessons parents can learn from [00:36:00] MBT as to how to help their children through difficult situations? Ghet is absolutely right.

And that is something that Not just parents but teachers and anyone who has frontline contact with children can benefit from massively. So we did an intervention where we helped teachers mentalizing children in their class. So rather than shouting at them and tell them to get out when they were Being naughty, tried to get an idea what was going on in the class at the time, what people were thinking and feeling around this, the kids are fine, reduced aggression in the classroom.

And we are working with foster parents who, by being able to mentalize better the. Very difficult children, young people they have to look after actually appear to be able to stop foster pre placement breakdowns. So, you know, there is a [00:37:00] massive amount that parents, but also those in parental roles can learn.

And we do do. family therapy with some more troubled families, where we actually work to enhance the solidity of a representation of mental states of the family members of each other. And that helps. It helps in a, in a range of ways. So yes it's helping children think about their own minds and helping them think about their parents minds is generally a good thing.

The other aspect, of course, which Peter's alluding to is the parent, as it were, also banishing to hold on to their own mentalizing. And there's nothing like children for breaking down parents mentalizing into ineffective mentalizing mode, I believe you're bad, therefore you're bad, you've always been bad, you take after your father, I've never thought of much of him either, you know, and we fall into these ineffective [00:38:00] mentalizing modes, and actually we have to train ourselves not to get trapped into them.

And parents have to, but clinicians have to. Clinicians can easily get drawn into ineffective mentalizing modes, particularly with people with borderline, antisocial, narcissistic functioning and so on that we've been mostly specializing MBT with. So it is very important. I'm really curious what a MBT session looks like at a granular level.

I have experience with CBT, DBT, humanistic therapy, psychodynamic. But Anthony, if someone comes in for, for their first sessions. And let's say they, they have a lot of emotional volatility, their relationships are constantly breaking down, they have difficulty maintaining employment, say, what, what does an MBT session look like?

What sorts of questions or interventions are commonly used? Well, I mean, they vary to some extent manifestly, but if I'm just saying that the first thing that we would be doing in MBT, not at a [00:39:00] granular level, first off, but would be actually creating an understanding of the patient's client's problems through a mentalizing lens.

So we have to create a framework between us in a way where we can both see what we're looking at and we create that together. And we apply a mentalizing framework to that, because that's our framework, so, so that's what we do. But at the end of that, the, in a way the, you and the patient are trying to see things through that same spectacles, in a sense.

And that's the first bit. Yep. So you're creating a shared understanding. Absolutely. Absolutely. And, and one that in the end you're trying to generate a sense for the patient that actually there's something in this for me, as it were, that there's something here that maybe I can learn from, maybe I can use for me.

And it's about me and it's for me. It's not about Bateman or him [00:40:00] self aggrandizing around mentalizing or something. This has actually got something in it for me. So that's the first thing. But you then brought up, well, this problem that, you know, you're then seeing someone who may be highly emotional, may be highly reactive, very sensitive in many ways particularly to relational misreads and things like that and so, You know in a granular level, we're very keen, first off, that you manage anxiety.

Nobody can learn mentalizing, or actually none of us can mentalize, in a sense, if we're highly anxious or we're highly aroused. So maintaining anxiety within a sort of manageable range is very important. And certainly in any MBT session, you'd be monitoring that and would have to react early on to help managing that.

Secondly, the next thing is that the instructions really for MBT are whatever the client, patient is [00:41:00] bringing, then the first task is to see it from their perspective and be able to show that you're seeing it from their perspective. You don't have to agree with their perspective. It doesn't have to be correct, wrong, or appraised and judged.

Nothing. But it has to be actually recognized. That this is their perspective. And most importantly, They have to see you as recognizing their perspective, okay? So you can't pretend. It has to land. It has to land. And you have to work out, even sometimes, how hard it is to get their perspective. Because it seems so distorted, or so unlikely, or whatever else it is.

You have to get into that position. So we join together. So we, as it were, sit alongside. And that's the first thing. So then Being able to see us as seeing their perspective is the first step. That's when they'll begin to have a sense that somebody's mentalizing them. [00:42:00] Then there's a potential for a connect.

And unless we connect in some way, we can't engage in a process of change. And that this sense of, of trust comes in. Now, once we're there, we can then, of course, begin to play around with actually reflection and questioning things a little bit, looking at them from slightly different perspectives. Or I could put in my own, I said, well, you know, I couldn't even see that at the beginning, so I might place in my perspective for them to consider and so on.

So we start looking at different perspectives, different facets, really. Do you find clinically that there's going to be people who simply, and I imagine this would be the case, people who simply take to it much more easily than other people, people who can grasp the ideas and start to put them into practice much more easily, and maybe for those who find it a bit more [00:43:00] challenging, what can therapists do to try and support them?

Yeah, well, you're quite right, of course, it's like anything that some people take it to it like a duck to water, as it were, they suddenly see something in that they find incredibly useful, and other people are completely perplexed and can't see what the hell this is about, and so on, so you have a whole range of of responses what we try to do though is actually first off, create a sort of a presentation of it all so it's individualized to some degree so that it can be actually, they can relate to it.

We do have actually a sort of beginning of treatment, a psychoeducational program which is tailored to the individual's context, circumstances and so on, to try to get them to see if they can have some sense of where we're coming from and what there is in it that might help them and so on. So it has to become personalized to them.

to a large degree. Now that works to some extent because [00:44:00] we don't have we have a good retention rate in MBT. It's relatively low dropout if you're just looking at studies and that was the case in lots of independent studies in Norway, dropout rates. But their services are very low in MBT, 5, 8 percent reported, you know, from the general population into services.

It's higher in the UK, it's 20 percent or so and things like that. So, you know, it's relatively low, low enough. Mm hmm. And Peter, we've talked about different sort of categories of problems, if you like, borderline process, antisocial process. I'm curious about narcissistic process. Is there any evidence that MBT is more or less efficacious in any of those categories?

The evidence is not yet in on a number of categories, but I would say that the focus of the treatment in MBT. [00:45:00] will determine the success rate in the sense that if for example, with BPD, we are particularly effective, according to some Cochrane reviews, in preventing suicidal ideation and suicidality.

We don't necessarily do as well on some other things as other treatments In antisocial, we do well on aggression that we reduce aggression, we reduce successfully offending rates and things that really matter to people. But my view is that, you know, MBT is actually a very generic treatment initially and that, you know, it has to be really titrated slightly to the particular patient population that you're working with.

So, we are, we talk about MBT for ASPD, MBT for [00:46:00] narcissic personality disorder, MBT for BPD. And that does matter because by providing a focus for a therapist, they're not, they're less like a cork in the ocean. They're just trying to help someone learn to mentalize or learn to mentalize again.

It's a bit like boiling the ocean. It's a big task. When you are thinking about Focusing on acts of impulsive aggression and mentalizing around that issue or focusing on trauma, particular trauma and and mentalizing the experience. Of having been traumatized, you're much more likely to be successful.

So, you know I'm, I'm resisting being drawn into saying MBT is good for this or that intervention. I think MBT needs to be modified to suit the particular intervention. And that really goes with what Anthony was saying [00:47:00] incredibly eloquently, is that we, the essence of MBT, and really is the essence.

is to be there for the person when they've lost mentalizing, where they had problems in mentalizing, and, and to help them recover mentalizing. That's the treatment. It's very simple. Someone has lost mentalizing, we notice that because they stop being curious, they stop being inquisitive, They think that what they think is the truth, or they just talk a lot of nonsense, or they just think that what they do or what someone else does matters.

Thoughts and feelings don't matter at all. And you then intervene and you say, Well, hold on a second. You just, something was disrupted here. Let's just trace back, just as rewind. To when we were actually communicating about something that I understood. And this kind of strategy of [00:48:00] stopping and rewinding gets people back into a mentalizing mode and they can explore what it was around that maybe a mention of trauma or something that hinted that trauma or something, something that made an interpersonal interaction particularly difficult that actually then gets them to mentalize in that context better.

And so it is a structured treatment. It is however, a treatment that I think very importantly is appropriate for a wide range of problems of mental health that involve problems of mentalizing. And that being said, I am curious if narcissism does. present a particular challenge because my understanding would be that in a more narcissistic process the point is that to maintain that intense focus on [00:49:00] self as a kind of a defense, but maybe that's not the case.

In your experience does narcissism present a particular challenge? Yes, it follows from sort of Peter's comments really in a sense that So, there's been development of MBT with a focus on pathological narcissism. So if you're using particular aspects of mentalizing in the service of self in a particular ways that actually leads to major concerns for you and or for others, then actually we target that through targeting those areas of mentalizing that are involved.

So. So you know, in, in essence, you know, we have this sort of person who may have very strong self expectations, you know, because narcissism in a way is a self problem to a large extent, whether in various ways. So, you know, they have very strong expectations of themselves, and they may be quite vulnerable because they don't match their [00:50:00] expectation of themselves and things like that.

But they also use self enhancing techniques as well, in a sense, the way their mind works. So they, they over sort of add eggs to their souffle. So you know, it's a, it's, it's a huge sort of risen souffle, as it were, and and it could be too easily popped, or it's got a very hard surface, and so on.

So self enhancement sort of ways of mentalizing actually tend to be overblown and so on, but we can also use others to get our self enhancement. So the way we then relate with others, we expect them to see us as we want to be seen and we enforce that and only relate to people who see us that way.

And if we don't, we don't like them and we dismiss them and we tend to be dismissive of others and things like that. So there's all these sorts of things. And that's what we would then begin to target. So my colleagues in East Coast America have been particularly working on that, Bob [00:51:00] Trosek and Brandon Unruh have been working on that, and running groups for pathological narcissism and those are people who.

When it interferes with their life, with their relationships, with their work, and so on. And they're pretty successful. And so, in a sense, they wrote with me as well, kindly offered it to me a book about treating people with pathological narcissism. But it goes back. To Peter's point that, you know, we have modifications for antisocial that was used in our current randomized controlled trial that recently published, as Peter said, but it was targeting the aggression and the way of relating to other people and to the world and so on.

But always trying to see the individuals not as naughty, bad people, but as actually people who are troubled and actually trying to work things out. Yes, can you tell, can you tell us more about that study that was recently published? The results on really a very [00:52:00] significant number of individuals with a diagnosis of antisocial personality disorder.

Impropriation was very promising in reducing the likelihood of re offending, reducing aggression with usually an interpersonal context and most importantly, what we found was that The difference between our control group which was probation as usual, and the group that received Mentalization based treatment, in addition to that, was entirely accounted for by improvements in mentalizing.

So, we measured, used a very simple measure, measure reflective function, or uncertainty about mental states, and the extent of improvement on this measure actually accounted for the difference between the two groups. On [00:53:00] top of that, what we also found was that, for example, with offending major offenses not minor, but major offenses those who actually had a higher dose of the intervention that is, they attended more actually benefited more in terms of fewer offenses.

So there was a at least a suggestion, more than a suggestion, a significant dose response relationship. I, I think that's really important because you could say very easily, well, they had more attention the ones that were in, in MBT groups. And I think, I think I should also emphasize about this treatment is that MBT for antisocial disorder is largely a group treatment.

They Had once weekly groups and once monthly individual therapy session for about for over a year now I think [00:54:00] that the group for these individuals Is a very very important social context for recovering mentalizing whereas for another group maybe those with narcissistic personality disorder, maybe those with borderline personality disorder Diagnoses.

The individual therapy may be the driver. I think there is a sense in which less is more for someone who has had an enormously traumatized background and who is threatened, perhaps inadvertently by an over keen focus on their mind. by this therapist who is really wanting to help them and wanting to understand them, but actually is impinging on them, is actually removing their capacity to mentalize by making them anxious.

In a group, engage in when you want to [00:55:00] engage, rather than engaging because you have to engage. is probably the ideal mode of treatment. And so we are learning about these things. We haven't learned everything there is to know, but I dare say there will be better interventions that are focused on the capacity to understand thoughts, feelings, wishes, beliefs, and desires.

and use them that actually have to be adjusted depending on the type of difficulty the individual presents. But that is the hallmark of mentalizing. We want to be there for the person, as Anthony said, as they bring themselves to us for support and help. We don't want to take support and help to them, thrusting it on them willy nilly.

Make it too intrusive. Yes. I think, to be honest, you know, that is [00:56:00] part of the reason why individuals with borderline personality disorder have benefited so little from many experiences of treatments that they had. Because actually, they were too impinged upon engaged in an intense attachment relationship with someone who actually couldn't, didn't have the capacity to kind of move back.

And let them be as they need it to be. Yes, but at the same time, I would also say, from what I've heard many people with a borderline process might say their experience of, say, traditional psychoanalysis or psychodynamic therapy, the therapist can be too withdrawn. And there's not enough contact. So I suppose, as you're saying, it's like, how do we strike the balance between too little and too much contact?

Yeah, absolutely. And that goes along with the idea of managing anxiety. As I said at the beginning of MBT sessions, because attachment, anxiety, or anxiety within the relational realm is much the most sort of [00:57:00] sensitive area for reading minds, reading one's own mind and. context of that being in the same room as someone else and so on and trying to read another mind, thinking about you, getting that wrong, being sensitive to it and so on.

This creates huge anxiety. It has to be managed. Hearing about mentalization makes me really curious about its potential applications for other conditions like. autism eating disorders, things along those lines. Has this been looked at at all? Are there plans to, to study the efficacy of, of MBT in, in other conditions as well?

Yes, certainly there's been a trial on eating disorders with eating disorders with mainly patients who had a sort of bulimic and borderline profile and BMI is above 13 and so on. That, that sort of group of people. with impulse behavior and so on. And and the MBT was compared really to [00:58:00] best treatment as usual, which is still offered to people with eating disorders.

And it did equally well, really. It had some benefits on sort of self experience compared to, I've lost the name of the treatment as usual, which is for Mantra. Yes. Mantra. Yeah, it was. Yeah. And it's also been being looked at in drug addiction as well, and in various guises, not in large trials, but being looked at in that, and also.

In neurodiversity, which you were asking about, which is currently in development really. And again, we are looking and working with people with Neurodiverse versions about actually how treatment might be, mentalizing treatment might be formatted, and what might be the best way to do that.

And we're currently working on that at the moment at UCL. And so yeah, all that's going, going on at the moment. Interesting. And the other thing I [00:59:00] was curious about, there's obviously a lot of research and emerging data and excitement coming from the psychedelics community and how psychedelics could be combined with therapy to improve people's mental health.

And From what I understand, it seems like psychedelics can act as some sort of catalyst for psychological growth, if you'll permit me to use a broad term. I'm wondering, could psychedelics be a catalyst for aiding people to learn mentalization? Do the MBT and psychedelics communities talk to each other?

Are there any plans in this regard? But that's that's a really good question. There are a number of people are very interested in that overlap. There's a trial that's going on at UCL at the moment. That not by us, not by our team, but that's specifically looking at this. But Sunjeev Kamboj is the PI on the project.

But and we are supporting it from from the [01:00:00] wings, as it were. The, the important thing is that mentalizing is a very generic capacity that is, has a massive role to play in most aspects of human social cognitive function. There is no social experience that will not necessarily have an impact on mentalizing.

If you have a psychedelic experience, that will raise all kinds of questions in your mind about what is happening in your mind. That process, that mere process of you stopping to question what is happening in my mind makes you reflect and makes you develop. Those second order representations of mental states that we call mentalizing, you know, so so we'll do psychedelics relate to mentalizing the [01:01:00] absolutely they do, but, you know, does this interview relate to mentalizing if it's emotionally intensive enough, it will be.

Because I'll stop and I'll reflect on it and I'll think, oh my God, I made an absolute trash of that answer. What was he thinking at the time? What did I think? You know, and you usefully or less usefully you enhance mentalizing. The critical thing though, the critical thing is, is that mentalizing leading to increased social trust, increased epistemic trust.

an increased capacity to relate to social relationships in a way that enables me to learn. That's I'm not sure of. So I can, will it impact mentalizing? Psychedelics will. Will it impact in a way that I'm now able to learn better from others? to become a more flexible, more open [01:02:00] mind to be influenced by social experience that I'm less sure.

I think so useful for you to hone in on to that point of trust, that trust is crucial, because how can you build a life for yourself if you have no trust in your future or trust in society or trust in other people as we've talked about before. As we run out of time here, just going on this theme of trust, I'd like to talk a little bit about the state of, let's call it, biological psychiatry or biomedical psychiatry.

And we've had a lot of conversations about this on the podcast recently. Obviously, both of you are heavily invested in the psychotherapy world, which may bias your view to some degree. But how have you seen the state of biological psychiatry change over the course of your career and, and where, where do you see things going in the next few years?

Well, if that's partly to me to begin I'll just give a little bit [01:03:00] of personal history of my trajectory along with biological psychiatry in a sense. When I started out in psychiatry, I, my interest was sort of taken in by really social psychiatry, you know, the idea that there was sort of social systems would affect mental health and could be used for the benefit of mental resilience, mental health and so on.

All these sorts of things for depression, you know, and so on. And I thought this was a fascinating area and the same applied for trauma, you know, this sort of idea of social connectedness in relation to managing trauma and trauma in groups of people and so on. And, but suddenly I found that actually what became dominant was actually the idea that most of these things were all down to our brain amine problems and so on.

And in various guises, in various ways, and so on. And so I was persuaded as a psychiatrist to continue to, well, to prescribe [01:04:00] really more and more and seem to get poorer and poorer outcomes overall as far as I could I don't know if you can tell just in many ways, but that could have been me, but, but, you know, in a way, social psychiatry went down psychotherapy went down and was threatened and seen as a sort of also ran system and for the worried well a little bit, not for people who are really ill and sorts of things.

in biological psychiatry, and the idea that we were medicalized and actually we were scientifically now being treated and medications would be the answer for common mental health problems, and so on, was a surge, really, and I think it peaked, and I think it's on its way back down, because I think people have begun to realize that actually, Mind and the brain are a much more complicated area than that ever suspected.

And so we would have to modify more. Yeah. And, and I would say I trained in Slam at the Mosley Hospital and when I was training, which was 2016 to two 2024 approximately, [01:05:00] that feeling was very much still high. And, and there was a sense in my training cohort. That psychotherapy was a more antiquated way of doing things and actually the answer would be somehow in neurotransmitters, which was an idea that I never really felt was concordant with my clinical experience.

This might be a factor of where I trained, but Peter, would you like to comment on this? My developmental experience is somewhat opposite to Anthony's because I started out. In neuroscience my PhD was in the use of low signal to noise ratio for highlighting functional differences between the two cerebral hemispheres.

And you get a PhD just for a title like that. And then, you know, I, I, I moved away and moved into much more kind of psychotherapeutic and attachment theory end of things. What I see, though, in, in, in my reading and my writing. Is that, you know, the default mode network in the [01:06:00] brain? Which is ultimately what happens when we are not doing anything is more or less overlapping with the mentalizing network in the brain.

So when we are, when our brain is in neutral, as it were, it's actually not in neutral, it is thinking about mental states in ourselves and in others. The Modern neuroscience, by and large, I would say quite confidently, confirmed many of the assertions that we had made about mentalizing early on.

Completely in the dark. So, you know, we are now writing a book that tries to summarize that evidence. But you know, I would say, look the mind and the brain the brain is the mind's organ, you know, It's, it's, these things, unless you're a dualist, you know, these things are the same. Some things are more approachable from the point of view of the brain.

Some things are more [01:07:00] approachable from the point of view of the mind. To persuade someone to take any medication involves the mind you know, you're not going to, you don't have a medication that encourages people to take medication because you can't get them to take it, if you see what I mean so you know, you, you, you know, you have to relate to people and I think, are there going to be are there going to be physical interventions that enhance an individual's capacity to relate to other human beings, probably there are is at the core of human misery or human dissatisfaction, a, an inability to adequately adjust.

One's own self to that of those of others around one. Absolutely so, you know, he or you we are really from singing from the same hymn sheet biological psychiatrists [01:08:00] and and social psychiatrists And I, I think that the sooner we start seeing the problem as not going to be solved by either of us but by going to be solved by a concerted effort and probably by artificial intelligence in a completely different discipline the better.

Well, that would be very humbling when that happens, certainly. We're out of time, but Peter, Anthony, thank you so much for joining me today. It's been wonderful to speak to you both.