Wardipedia – 07. Mentalising

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Mind awareness


We love the concept of ‘mentalising’. OK, not the name itself which is a bit naff but does have the soundest of origins in psychoanalytic and attachment theories. Mentalising simply means being aware of what’s going on in our own minds and in other people’s minds. Mainly thoughts and feelings, but of course these branch out into intentions, desires, beliefs etc. So mentalising is similar to ‘emotional intelligence’ but focuses more specifically on accurately understanding our own and others’ feelings and also thoughts.

 Some people are great about being self-aware but a bit clueless about other’s states of mind. And vice versa. For all of us, there’s an unfortunate paradox that the more we need to mentalise, the harder it can be to do so, especially if we’re feeling very fraught. On wards, this happens very, very frequently – a patient is highly agitated, certainly not able to mentalise and this requires staff to throw all their energy into remaining calm so that at least they are continuing to mentalise. Prof Anthony Bateman elaborates on this below in the ‘snippets’ section.

Definition from Jeremy Holmes:

Mentalisation: ‘mind-mindedness’, the ability to see ourselves as others see us, and others as they see themselves; to appreciate that all human experience is filtered through the mind and therefore that all perceptions, desires and theories are necessarily provisional.

Ward examples


  •  One person on multi-disciplinary team has done 3 day introductory mentalising course and introduced techniques to ward.
  • Mentalising is a core part of our TalkWell training

Mentalising on inpatient wards
Prof Anthony Bateman wrote in the Jan 2012 Star Wards newsletter:

Disordered mental processes affect the capacity to think and to represent states of mind in ourselves and others; conversely losing our ability to represent states of mind will disorder our mental processes.  Crucially, loss of mentalizing in one person tends to stimulate non-mentalizing in another – if someone makes no attempt to understand things from your perspective you are unlikely to easily try to understand things from their perspective. So disordered mental processes in mental health patients will stimulate non-mentalizing in staff. In the hurly burly of in-patient wards the staff need a star to steer themselves and this star can be mentalizing for just as non-mentalizing begets non-mentalizing so mentalizing begets mentalizing. So a primary task of staff on mental health wards is to develop and maintain a mentalizing milieu, to make things ‘mental’.

Only then can they help a person with a disordered mind gain some order and coherence. There are a number of ways that this can be done.

First staff on mental health wards have to maintain mentalizing in themselves and each other. Patients will have little chance to regenerate their own mentalizing to help them order their mental processes if the staff act and react in non-mentalizing ways. Second, staff need to organise around a shared understanding of psychological processes. Mentalizing is important as a unifying mental process because it interfaces with a wide range of psychological functions- cognition, affect, non- conscious process, subjective and interpersonal experience and so on. This suggests that whether or not a formal mentalizing approach is adopted in treatment, there is a need for any clinician to see the world from the patient’s perspective, and that whenever that focus on the patient’s internal mental process is dominant there is intrinsic value because of the powerful commitment to the patient’s subjectivity. It is this consistent focus on the subjective reality of the patient that is a hallmark of the mentalizing process and is something that all mental health professionals can sign up to. Third, clinicians need the skills to adopt a mentalizing dialogue between each other and between themselves and their patients. Their training and organisational structures need to support this.

Finally the whole purpose of the mentalizing milieu and interaction with staff is to develop attachment processes between staff and patients that effectively facilitate more robust mental states. We need others to find ourselves and the prototype for this is the attachment relationship. It is in the attachment relationship that mentalizing first develops and may flourish. But we also know that disorganised attachment can undermine mental development and even make people more disordered.

This is particularly so when the attachment system is over-stimulated which leads to mental collapse due to a vulnerable mind being swamped. Excitement and pleasure, for example, become over-excitement and terror; uncertainty about feeling can become panic about survival. A mentalizing ward respects the balance between too much stimulation through intrusion and too little through neglect. A mentalizing member of ward staff appreciates that many patients have complicated feelings of loss when they leave hospital, such is the strength of attachment when a therapeutic alliance has been effective. Recognising these attachment processes informs the interactions between patients and staff and makes the ward a safer place for all.

A rather long note from Marion Janner (founder of Star Wards)

I’ve been having Mentalisation Based Therapy for my very naughty Borderline Personality Disorder for seven years. I’m a fan, indeed slightly evangelically so! MBT (or more specifically my MBT therapist) has kept me alive and functioning through very rough times and part of its fabness is that psychologically-oriented and talented staff can be taught the basic techniques in just three days.
The following is a shortened version of a piece I wrote about five years, describing what it’s like to have MBT. And talking of short, I’m an almost invisible without ocular support 4’9”, hence the tiny joke in the heading.
Mentalisation Based Treatment – a short patient’s guide
What is MBT?
So what’s the big deal? Surely we’re all pretty in touch with what we’re thinking and feeling, and have got as good a chance as anyone else of guessing what others are doing? Er, no. Unfortunately those of us with BPD are unlikely to be top scorers in the Minds’ Awareness League. Not great at accurately identifying what’s happening in our own minds and even less likely to correctly work out what’s in other people’s minds. Especially if we’re feeling stressed out.And there’s an even more fundamental problem here. When we’re feeling crap, we’re likely to shut down (or at best tone down) our ability to ‘mentalise’. Thinking becomes a real effort, and reasoned thinking about thinking nearly impossible. Certainly for me, when things are tough I often self-harm specifically to avoid thinking, as that’s too painful.
Self-harming gives us something very concrete to focus on, which links with another aspect of BPD. Apparently, if we’ve got BPD we tend to find it easier to believe things that we can see rather than imagining what might have led to a particular situation. (No money under the pillow, definitely no tooth fairy.)MBT is intended both to help us sharpen up our ability to mentalise and to be willing to use it, especially when we’re feeling intense emotions. For example, in a session the therapist might ask us to consider what the other person in a difficult situation might have been thinking, and help us move past our initial assumption, especially if it’s a really negative one.
What’s the difference between ‘mentalising’ and thinking and why can mentalising sometimes be better?
Thinking is thinking. Mentalising is thinking about thinking and feeling, our own and other people’s. Obviously it’s often best just to get on and have thoughts. About whether Borat is the funniest film ever made or a shocking and trashy piece of sexist and racist rubbish. About whether there’s something we can do as a non-punitive alternative to self-harming.
I’ve found it helpful looking at mentalising from the perspective of people with autism. Perhaps it’s because I’ve struggled to understand quite what mentalisation is about that it’s been useful to me to consider a group of people with a totally different disability to mine. People with autism live very much in the here and now. They have been described as having no ‘theory of mind’, as most are unaware of their own thinking processes and have even less recognition that other people think or have feelings. Clearly people with autism think. (An inordinate amount of the time, it seems, about Thomas the Tank Engine, at least when they’re kids.) But it’s a very automatic experience, and reflecting on their own thoughts just doesn’t arise. And the way they see the world is such that although they may notice the manifestation of others’ thoughts and feelings, for example they can see that someone is smiling or hear them shouting, they don’t connect that with the emotions that produce those observable responses. People with autism find it almost impossible to imagine themselves ‘in someone else’s shoes’.
For those of us with BPD rather than autism, mentalising is an acquirable skill, and one which can give us valuable extra perspective on a situation. For example, if I’m planning to take an overdose, just thinking about it tends to take me along a route which lets me confirm this is the ‘right’ thing to do. But if I have to mentalise, I have to look at my thinking. It’s hard for me to do this without concluding that I’m not thinking straight. That my thoughts and feelings about the overdose are caused by feeling seriously crap and that I should at least try to hold off any decision til I’m feeling more settled.And if I then move on to thinking about others’ thoughts and feelings, it takes me to the painful place of knowing how traumatised my friends are if they find out that I’ve taken an overdose. Let alone the impact on them if the next overdose turns out to be fatal.

None of this mentalising necessarily stops me from taking self-damaging action but it at least gives my self-protective side a decent shot at introducing some logic to the situation.

What’s it like having MBT?
You might expect that a therapy with mentalisation at its heart would involve the therapist endlessly asking “And what was in your mind? And what was in their mind?” But, luckily, this hasn’t happened. It’s all much more nuanced than that. Similarly, although the approach is very non-directive, when I ask for advice or need help in practical problem-solving with something I’m wrestling with, my psychiatrist will often respond in a ‘normal’ way and help me out.

I had cognitive behavioural therapy with a psychologist before I ended up being sectioned. At that stage, I was taken on by a personality disorder unit as an outpatient and have had MBT weekly with a psychiatrist for about 18 months. Both types of therapy feel very similar, despite the psychologist and psychiatrist being very different types of people. Both approaches have felt supportive, non-judgmental and focused on what I’m thinking. I’ve been able to see issues, especially painful ones, from a different perspective and to understand what might be fuelling the tough stuff. Both have made me feel like I’m setting the agenda about what we talk about and that I can say anything, however embarrassing or ridiculous I feel it is. And I know that the self-protective part of me, which tries to resist my self-destructive tendencies, gets crucial reinforcement.

The most noticeable difference in style is that my psychiatrist has very ‘high boundaries’, so I know almost nothing about him and his life, other than what I can pick up from clues around his office. (He either rides a motorbike or is excessively worried about getting a head injury when driving his car.)

Perhaps the most tangible difference I experience is that I’ve only once self-harmed after a session with the psychiatrist whereas I used to do so regularly after my previous sessions. This really puzzled me til I read a couple of books about MBT. These made me realise that while the MBT sessions feel quite normal and ‘spontaneous’, they’re carefully designed to be at a level of intensity, or intrusiveness, that I can comfortably cope with. (This relates back to the business about us closing off if things become too painful.) This doesn’t mean that I’m never moved outside my comfort zone – most sessions we cover things which make me cry. But somehow, overall I don’t end up feeling completely jangled or bursting with feelings I don’t know how to or don’t want to deal with.

Does it work?
Well, I’ve been able to survive 18 months of pretty consistent suicidal feelings and still be around to write this. And studies have shown that it certainly works for a lot of, but not all, patients. One very reassuring thing is that it’s been designed as a result of careful research into both the causes of BPD and the impact of MBT. I don’t really understand all the stuff about how BPD develops, but it goes something like this.

If mothers have problems connecting well with their babies, they respond differently to other mothers. One thing that the research shows is that when the babies are really upset, these mothers don’t calm the babies in a way that helps the babies to ‘understand’ or learn what’s their own distress and what’s the mother’s. It’s a bit like the baby’s distress is magnified and bounced back at the little thing rather than being soothed and dissolved by the mother. As well as emotional mishaps like this, it’s been found that many people who develop BPD often have early experiences of abuse or neglect by parents. These things lead to many of us being unable to soothe ourselves in ways that are conventional, or not self-destructive, again reinforcing our tendencies to self-harm.

Another central proposition of MBT is that when we’re babies and our mothers aren’t able to comfort us in an effective way, we sort of bung onto our mother the parts of ourselves we can’t cope with. This results later on in life with us coping particularly badly with the loss of someone close to us, partly because we might have ‘assigned over’ to them the painful parts of ourselves. This contributes in a rather complicated way to our tendencies to self-harm and be suicidal, apparently to feel re-connected to the outsourced part of ourselves.
The quality of ‘attachment’ in our earliest years continues to affect how we feel and think right through our lives, and if they’ve got off to a bad start we’ll have difficulties with other close relationships. Including potentially the one with our therapist.

The MBT therapist, then, will be very aware of this and will be careful that we don’t just slot back into a pattern of feeling overwhelmed by intensely painful feelings which make us close off thinking, especially about our own and the therapist’s thoughts. Feeling understood by someone we trust (the therapist), is a sound place to be able to move into a calmer, safer way of coping with difficult stuff.


Categories: Imagination, Wardipedia