Comorbid Antisocial and Borderline Personality

Disorders: Mentalization-Based Treatment

m

Anthony Bateman
St. Ann’s Hospital, London
m

Peter Fonagy
University College London

Mentalization is the process by which we implicitly and explicitly

interpret the actions of ourselves and others as meaningful based on
intentional mental states (e.g., desires, needs, feelings, beliefs, and
reasons). This process is disrupted in individuals with comorbid
antisocial (ASPD) and borderline personality disorder (BPD), who tend
to misinterpret others’ motives. Antisocial characteristics stabilize
mentalizing by rigidifying relationships within prementalistic ways of
functioning. However, loss of flexibility makes the person vulnerable
to sudden collapse when the schematic representation is challenged.
This exposes feelings of humiliation, which can only be avoided by
violence and control of the other person. The common path to
violence is via a momentary inhibition of the capacity for mentaliza-
tion. In this article, the authors outline their current understanding of
mentalizing and its relation to antisocial characteristics and violence.
This is illustrated by a clinical account of mentalization-based
treatment adapted for antisocial personality disorder. Treatment
combines group and individual therapy. The focus is on helping
patients maintain mentalizing about their own mental states when
their personal integrity is challenged. A patient with ASPD does not
have mental pain associated with another’s state of mind; thus, to
generate conflict in ASPD by thinking about the victim will typically be
ineffective in inducing behavior change. & 2008 Wiley Periodicals, Inc.
J Clin Psychol: In Session 64: 181–194, 2008.

Keywords: mentalization; mentalization-based treatment; antisocial

personality disorder; borderline personality disorder; self; violence

Correspondence concerning this article should be addressed to: Anthony Bateman, Halliwick Unit, St.
Ann’s Hospital, St. Ann’s Road, London N15 3TH, UK; e-mail: anthony@abate.org.uk

JOURNAL OF CLINICAL PSYCHOLOGY: IN SESSION, Vol. 64(2), 181--194 (2008) & 2008 Wiley Periodicals, Inc.
Published online 9 January 2008 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/jclp.20451
182 Journal of Clinical Psychology: In Session, February 2008

Most personality disorders (PDs) do not present to clinicians in a pure form.

Comorbidity is the rule rather that the exception.
Our focus here is on patients diagnosed with antisocial personality disorder
(ASPD) comorbid with borderline personality disorder (BPD) who have committed
acts of violence. This admixture of personality features complicates the clinical
picture that is presented to the clinician, who has to take into account the
phenomena of ASPD and the possibility of violence to others in treatment, as well as
the danger of self-harm and suicide common in BPD. There is limited evidence
available about how to treat such individuals and, if we were to start from first
principles, an understanding of the processes underpinning this complex psycho-
pathology would inform treatment innovation, which, in turn, would then be subject
to empirical investigation.
Kazdin (2004) has outlined a sequential program for the development of
psychotherapy based on these principles. The first stage follows from the proposition
that treatment should reflect what we know about the processes that directly bear on
the onset and course of a clinical problem. In violent patients with ASPD/BPD, we
need to understand the interrelationship of the phenomena and if possible,
demonstrate that a specific process or lack of process is present in a sizable
proportion of individuals with this comorbid presentation.
We believe that the process of mentalization is linked to the phenomena of personality
disorder, and in this article we suggest that a focus on mentalizing is relevant to the
treatment of violent patients with complex personality pathology. A clinical vignette
from a group session followed by an associated individual session during treatment of
patients comorbid for ASPD/BPD will illustrate some of our points.

Mentalizing and Personality Disorders

Mentalizing simply implies a focus on mental states in oneself or in others,
particularly in explanations of behavior (Fonagy, Gergely, Jurist, & Target, 2002).
That mental states influence behavior is beyond question. Beliefs, wishes, feelings,
and thoughts, whether inside or outside our awareness, determine what we do.
Explanations of behavior in terms of others’ mental states (mentalizing) are
relatively vulnerable compared with explanations that refer to aspects of the physical
environment (nonmentalizing). The latter are far less ambiguous because the
physical world is less readily changeable. When taking a mentalizing stance the mere
contemplation of alternative possibilities may lead to a change in beliefs. Thus, a
focus on mind leads to far more uncertain conclusions than a focus on physical
circumstance because it concerns a mere representation of reality rather than reality
itself. We may act according to wrong beliefs about others’ mental states and
underlying motivations in a particular situation, sometimes with tragic conse-
quences. For example, we may believe that people mean us harm as they run towards
us and react accordingly, when, in fact, they are concerned for our welfare and wish
to push us out of the way of a car we have not seen.
Normal people will, at times, move from understanding themselves and others
according to what is in the mind to explanations based on the physical
environment—‘‘I must have wanted to because I did it.’’ However, we have
suggested that rapid and frequent shifts from mentalizing to nonmentalizing modes
of experience is characteristic of borderline personality disorder (Bateman &
Fonagy, 2004). In this article, we suggest that abnormalities in mentalizing are also a
significant problem in ASPD.
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 Mentalization-Based Treatment of Comorbid PDs 183

The phenomena of ASPD/BPD are a consequence of a shift from mentalistic

modes of function to prementalistic ways of perceiving the world. The prementalistic
modes of organizing subjectivity, which emerge have the power to disorganize
relationships and destroy the coherence of self-experience that the narrative provided
by normal mentalization generates. This move most frequently occurs when the
attachment or affiliative system is activated. As soon as emotional states are aroused
in the context of an interpersonal interaction, ASPD/BPD patients become
vulnerable to loss of mentalizing because stimulation of the attachment system
actually inhibits mentalizing itself (Fonagy & Bateman, 2006). The consequence of
the inhibition of mentalizing itself is a reemergence of modes of experiencing internal
reality that antedate the developmental emergence of mentalization, namely psychic
equivalence, pretend mode, and teleological thinking. Nevertheless, in addition,
there is a constant pressure for projective identification—the reexternalization of the
self-destructive alien self (Fonagy & Bateman, 2007).

Psychic Equivalence
Mentalization gives way to psychic equivalence, which clinicians normally consider
under the heading of concreteness of thought. No alternative perspectives are
possible. There is a suspension of the experience of ‘‘as if’’ and everything appears to
be ‘‘for real.’’ This can add drama as well as risk to interpersonal experience, and the
exaggerated reaction of patients is justified by the seriousness with which they
suddenly experience their own and others’ thoughts and feelings. A patient had a
dream about a giant wave destroying thousands of people. When she woke up in the
morning, she heard that there had been a huge tsunami. She became terrified and
believed that she had caused the disaster and eventually took an overdose of
paracetamol because she could not cope with her emotional state.
A patient who had been sexually abused by her grandfather had flashbacks of him
coming in to her bedroom. She barricaded her door at night. Even though he had
died a number of years ago, her image of him entering her room was experienced as
current rather than a memory from the past and she reacted accordingly.

Pretend Mode
Conversely, thoughts and feelings can come to be almost dissociated to the point of
near meaninglessness. This is pretend mode. In these states, patients can discuss
experiences without contextualizing them in any kind of physical or material reality.
Attempting psychotherapy with patients who are in this mode can lead the therapist
to lengthy, but inconsequential discussions of internal experience that have no link to
their genuine experience. A patient talked about her childhood explaining how it
linked to her suicidal behavior. It seemed logical and understandable, but ‘‘knowing
it’’ did not alter her level of risk or improve her self-destructive patterns. It simply
justified her behavior.

Teleological Mode
Early modes of conceptualizing action in terms of that which is apparent can come
to dominate motivation. This is teleological mode. Within this mode, there is a
primacy of the physical and experience is only felt to be valid when its consequences
are apparent to all. Affection, for example, is only true when accompanied by
physical expression. A patient believed that her new boyfriend did not want to see
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her anymore because he did not meet her at the agreed time. In teleological mode,
she believed that if he wanted to see her he would have been there. When he
contacted her an hour later to let her know that he had been stuck on an
underground train that had broken down, she swore at him and told him that she
never wanted to see him again. Later she cut her wrists.

Alien Self
Finally, with the dissolution of the self, aspects of oneself that are experienced as
alien are projected and seen as belonging to others. Relationships become rigid and
fixed and the other has to be controlled forcibly to keep hold of alien parts of the self.
The alternative is complete collapse of the self and destruction of the self becomes
preferable. In a teleological mode this is dangerous, i.e., physically, by self-harm and
suicide. The need for the other as a vehicle for the alien self can become
overwhelming as the patient experiences it as a matter of survival and an adhesive,
addictive pseudo-attachment to this individual may develop. We assume, as
suggested by Winnicott (1956), that when a child cannot develop a representation
of his own experience through mirroring (the self), he internalizes the image of the
caregiver as part of his self-representation. We have called this discontinuity within
the self the alien self. We understand the controlling behavior of children with a
history of disorganized attachment as persistence of a pattern analogous to
projective identification where the experience of incoherence within the self is
reduced through externalization. The intense need for the caregiver characteristic of
separation anxiety in middle childhood that is associated with disorganized
attachment, reflects the need for the caregiver as a vehicle for externalization of
the alien part of the self rather than simply an insecure attachment relationship. This
method of stabilizing the mind and the self is carried through to adulthood. The
experience of fragmentation within the self-structure is reduced by this process of
externalization. Loss of mentalizing destabilizes the self provoking an uncertainty—
Who am I? Who are they? What do they want? Who am I in relation to them? No
answers are available to the individual and panic ensues. As it does so, the individual
attempts to recapture a sense of self by schematic representation—‘‘I understand this
if he does not like me—he is victimizing me and I am a victim.’’ To manage this state
of mind, individuals’ project aspects of themselves that are destabilizing and see them
in the other. The alien aspects of the self are most dangerous to the individual’s
integrity and narrative structure.

The Self and Violence

A rapid, attachment-dependent movement between these different modes of
experiencing the self and the world is characteristic of BPD, but is modified by the
co-occurrence of violent ASPD. In comorbid ASPD1BPD, the mental processes are
more stable in contrast to the rapidly fluctuating states found in BPD itself. Yet the
patient’s hold on understanding the mental states of others is tenuous and can be
suddenly and catastrophically lost as the attachment system is stimulated. Stability is
maintained by interpreting the world according to teleological understanding much
of the time, but in many instances, we suggest that stabilization of mental processes
arises from the rigidity of the externalization of the alien self. This presents serious
problems for the treating clinician. The rigidity of the system has to be challenged
and yet the challenge might induce violence.
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 Mentalization-Based Treatment of Comorbid PDs 185

In ASPD/BPD, the alien self is firmly and rigidly located outside—a partner may
be seen as mindless and needing to be told what to do; a system portrayed as
authoritarian and dangerously attempting to subjugate. This stabilizes the mind of
the patient. Threats to these schematic representational structures, which could be a
system being overly nice or pleasant or a partner demanding an unacceptable level of
independence, lead to arousal within the attachment system, which triggers an
inhibition of mentalizing, which, in turn, leads to fears of inability to control internal
states and the threat of the return of the alien self.
It has been suggested that threats to self-esteem trigger violence in individuals
whose self-appraisal is on shaky ground because they exaggerate their self-worth
(narcissism). Patients with ASPD/BPD inflate their self-esteem by demanding respect
from others, controlling the people around them, and creating an atmosphere of
fear. This maintains pride, prestige, and status, and ensures the experience of the
external location of the alien self. Loss of status is devastating as the alien self is
returned and reveals internal states that threaten to overwhelm them. Experience
becomes more firmly rooted in psychic equivalence. Such patients are momentarily
unable to mentalize, to see behind the threats to what is in the mind of the person
threatening them, and so they have no way of keeping out a rapidly lowering self-
esteem and loss of position.
Emotional capacities such as guilt and love towards others and fear for the self
may protect from engaging in violent behavior, but the loss of mentalizing and the
embryonic ability of these patients to experience such feelings prevent mobilization
of these inhibitory mechanisms. Fear for the self is absent and the dangers associated
with violence become secondary. The onset of pretend mode means the risk of being
caught is unreal and an illusory sense of safety and lack of reality is manifest. The
internal state no longer links with external reality—‘‘It happened like in the movies;’’
‘‘it didn’t seem real’’.
Gilligan (2000) creatively and persuasively focused our attention on the regulation
of shame as a key factor in the pathology of ASPD. The shame associated with loss
of self-esteem is also experienced in psychic equivalence mode and is so devastatingly
destructive that the patient has to do something immediate and urgent if he is to
survive. He cannot accept the return of the alien self, which will induce
overwhelming feelings of shame, and so he inevitably attempts to control the
source, which is seen as out there. Aggression towards the source of danger cannot
be limited to nonphysical aggression such as shouting. This can only occur if
mentalizing is retained and awareness of the mental state of the other remains, at
least partially. Recognition of the other person as having a separate mind inhibits
violence; the loss of mentalizing allows a bodily attack as the other person becomes
no more than a body or threatening presence. So it is to violence that we now turn to
understand in more detail this final element to the complex picture.
The common path to violence is via a momentary inhibition of the capacity for
mentalization. Mentalization protects against violence. Some individuals, constitu-
tionally poor at recognizing mental states in others through facial expressions or
vocal tones, may not fully acquire the ability to ‘‘mentalize’’ and thus inhibit their
natural violence. These individuals are callous and unemotional. They remain
unencumbered by the recognition of others mental states and are unaware of the
effects of their actions or expressed desires on others. As a result, they remain
unaffected by negative responses and in line with the terrible threat that such
individuals represent, we dismiss them as ‘‘psychopaths.’’ We are not concerned with
this group here.
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186 Journal of Clinical Psychology: In Session, February 2008

Others never had the opportunity to learn about mental states in the context of
appropriate attachment relationships. Or, alternatively, their attachment experiences
may have been cruelly or consistently disrupted. For yet others, a nascent capacity
for mentalization has been destroyed by an attachment figure, who created sufficient
anxiety about his thoughts and feelings towards the child for the child to wish to
avoid thinking about the subjective experience of others. It is important to retain an
awareness of the possibility that violence may be rooted in the disorganization of the
attachment system. A child may manifest an apparent callousness that is actually
rooted in anxiety about attachment relationships. Yet, in fact, they are not callous
and unemotional, but terrified and potentially striving for a more reliable
attachment. It is this group that we are more concerned with here as a harsh early
childhood could signal greater future need for interpersonal violence as a means of
expression of underlying mental states. In support of this model are studies (Jaffe
et al., 2004; Shonk & Cicchetti, 2001) that demonstrate that the association between
childhood maltreatment and externalizing problems is probably mediated by
inadequate interpersonal understanding (social competences) and limited behavioral
flexibility in response to environmental demands (ego resiliency).
We argue that the group whose aggression is high in early childhood and
continues into adolescence and early adulthood is likely to have had attachment
experiences that failed to establish a sense of the other as a psychological entity. We
propose a synergy between psychological defenses, neurobiological development,
and shifts in brain activity during posttraumatic states such that mentalizing activity
is compromised. The shift in the balance of cortical control locks the person with
maltreatment history into a mode of mental functioning associated with an inability
to employ alternate representations of the situation (i.e., functioning at the level of
primary rather than secondary representations), an inability to explicate the state of
mind (metarepresentation) of the person they face, and a predisposition to enter a
mode of mental functioning associated with states of dissociative detachment, where
their own actions are experienced as unreal or as having no realistic implications.
Treatment has to address all of these facets.

Mentalization-Based Treatment
Mentalization-based treatment (MBT) has been developed for the treatment of BPD
and is fully operationalized for that disorder (Bateman & Fonagy, 2006). It has been
shown to be effective in randomized controlled trials in a partial hospital program
(Bateman & Fonagy, 1999) and is currently being investigated in an intensive
outpatient format. It is now being adapted for patients with ASPD. The primary
aims of MBT are to create a therapeutic environment in which mental states of self
and others become the focus of concern. To this extent, it may be especially suited to
the abnormal processes associated with ASPD/BPD patients who need to extend
their ability to maintain mentalizing when self-esteem is threatened by developing
some mental functioning at a secondary level of representation.

Clinical Modes of Mentalization-Based Treatment

Mentalization-based treatment is offered to patients in the form of combined group
and individual treatment. Patients are seen every 2 weeks, but sessions alternate
between individual and group modes. Group therapy is an excellent context in which
to address the difficulties presented by patients who disregard normal social
processes and fail to take into account common interpersonal sensitivities.
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 Mentalization-Based Treatment of Comorbid PDs 187

It provides the possibility for them to develop a better understanding of their role in
social processes, and how their interactions with others can provoke distortion in
social understanding and interpersonal interaction. As we have already suggested,
if a person feels angry with someone or feels misunderstood or treated unfairly, he or
she has to manage his or her mind rather than rid themselves violently of the physical
cause of the discomfort. The dangers of mentalizing group psychotherapy with
ASPD/BPD become obvious when we consider the aim is to promote serious and
detailed consideration of the motives of self and other when emotions are aroused
and to find ways of managing the alien self without resorting to control through
violence. Once rigidly held schematic representations are challenged or even
questioned, violence will not be far off.
Patients with both ASPD and BPD find group therapy problematic partly because
of their compromised ability to understand the motives of others, but our current
experience is that they can attend regularly for a prolonged period of time if the
sessions are interspersed with individual sessions in which they review their role and
behavior in the group as well as addressing other personal concerns. In the following
illustrative clinical vignette, we report a group session in which the patients form an
agreed understanding of a violent event. Their understanding is temporarily accepted
without question by the cotherapists. This clinical material will be discussed in
relation to our earlier outline suggesting that it is the loss of mentalizing processes
that lead to violence in patients with ASPD/BPD. Although this is not addressed
fully in the group, it is considered further in the subsequent individual session with
the patient who again reported the episode of violence.

Case Illustration
Group Session
The group is formed by 6 patients, all of whom have a diagnosis of comorbid ASPD
and BPD. They are aware of their diagnosis and have been attending the group and
individual sessions for 6 months. One patient, Kieren aged 28 years, is absent. The
group members are aged between 25 and 36. All have been in prison in the past for
violent offences. Steve and Patrick are currently on probation having been released
from prison early for good behavior. John is 32 years old and was brought up in a
rough part of Northern England. He presented with depression and indicated that he
wanted to change himself so that he could have a better relationship. He had been
violent to his partner on a number of occasions and was currently living separately
from her. Steve is 28 years old and has spent most of his life dealing in stolen goods
and sometimes in drugs. He also has a number of offences for fraud. He presented
for help because he was drinking too much and it was getting him into too many
fights. He had also been involved recently in extortion and blackmail. He lives with
his mother and father who themselves have a criminal history. Patrick is 36 years old
and has a number of children by different partners. He asked for help because he and
his current partner had recently had a baby boy. He stated that he wanted to be a
‘‘better person’’ for his son. Michael is 25 years old and is the only member of the
group to work. He works in a warehouse and his employer suggested he seek help for
his anger. Following an anger management course, he was referred for further
treatment because he had many problems related to his childhood including sexual
abuse and physical violence while in care homes. His parents had abandoned him
when he was 4 years old. Peter, who is 31 years old, had similar problems, but was
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more depressed at presentation to the services. The group began with John talking
about an incident that had occurred a few days ago.

John (J): I stabbed someone the other night. He was causing me a lot of problems
and so he had it coming to him.
Steve (S): What did he do?
J: He was in my flat. I had let a number of the young people on the estate come
into my flat to use it as a cooch (drug den). They know that I let them do it
sometimes and I quite like it. Anyway, I told them it was late and so they had
to leave. Then one of them said that I had pinched his cigarettes. I said ‘‘What
did you say?’’ He repeated himself and so I told him that I had not and he had
better leave. He then started swearing at me and told me that I was a thief. I
warned him that he should shut up and get out.
Patrick (P): You warned him then?
J: Yes.
P: That was good. You had done what you should. After that, it is up to him.
J: I warned him again actually. Because he continued to accuse me of stealing his
cigarettes so I said again that if he didn’t shut up and get out he was getting
what was coming to him.
P: Then he deserves everything that was coming to him if he carried on.
J: He then started to go, but as he was still talking when he packed his things I
picked up the kitchen knife and went for him. His mates got hold of me and
held me back so I couldn’t reach him. They thought that he was out of the
flat, and so let me go but when he got outside he started to shout back at me
that I was a thief and cheat. So at that point, I ran out and stabbed him.
Couldn’t help it. He had crossed a line.
Therapist (TA): What line are you referring to?
Michael (M): That’s obvious, isn’t it? He had warned the guy and he carried on. You
can’t allow that to go on.
TA: Can you say more about what ‘‘that’’ is?
M: Well, he had warned him and he just carried on. That’s disrespectful.
Steve (S): Yes, you need to understand that these people were in his flat and you
can’t be disrespectful like that. If you let that go, there would be real trouble.
Peter (P): Yes. Big trouble.
TA: I am beginning to understand that there is something about this that you all
understand, but I am not quite there yet.
J: Look, they were in my flat with my permission, but that does not allow them to
do what they want, does it?
TA: I understand that, but in this situation it leads to someone being stabbed and
my concern is how circumstances can lead you to do that—you suggested that
you could not help yourself so something pretty important had happened in you.
S: It’s obvious to me. If you let someone get away with that you never know what
will happen next time. They will assume that they can do anything. He gave
him his chance to get out gracefully, but he did not take it. John followed the
rules, but the other guy broke them and you can’t allow that.
TA: Can you help me with a bit more about the rules?
J: Well, if you disrespect someone and they warn you, you should get out or
expect a fight. I don’t care when someone warns me, although I know that they
have given me a chance, but I stay and go for it. If I lose, I accept that but I
don’t care what happens to me, so I usually win. Most other people worry a bit
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 Mentalization-Based Treatment of Comorbid PDs 189

about what happens to them and so they don’t go quite as far as I do. But the
rules are the rules.
Therapist (TB) to J: As I understand it, then this man disrespected you and then
behaved a bit like you do and stayed to challenge you, which
you couldn’t allow. Can you say what the challenge to you is?
J: If I let him get away with what he was saying and his accusations, the other people
would have told everyone around the estate and then people would think that I
was weak. I wouldn’t have any respect from anyone then.
P (interrupting): Yes, you have to understand the sort of place we live in. If you
didn’t deal with situations like this, people would laugh at you
and that would be you finished as a person.
TA: Can anyone say what Patrick means by being finished as a person?
M: I know what he means. If you don’t stand up for yourself then you are nothing.
TB: Nothing?
M: Yeah, nothing. You would be nobody and people might even start to take
advantage of you. People are frightened of me and so keep away. I am
someone. Everyone knows that they cannot mess with me and I want to be
left alone. If I am not left alone then something happens. The other day
someone didn’t move out of the way when I was walking along. At first, I left
it and stepped aside, but as he passed I just felt that I couldn’t let that
happen. He was challenging me, and so I ran back and smacked him in the
face. He won’t do it again. But he was treating me like I was nothing and that
is not on.
TB: Can you just say what it is like to suddenly feel in danger of being nothing?
(silence)
S: You don’t wait to feel it, you just sort out what you have to sort out.
TA: What if someone doesn’t know the rules or if their mind is elsewhere—for
example, that this person you hit for not standing aside when you were
walking along. Maybe his mind was elsewhere. (silence)
TA: I realize that none of us have mentioned the person who was stabbed. It seems
that we have forgotten about him. Was he OK?
M: He’s not important. He had it coming to him. I don’t think about people after
something has happened unless I have a score to settle. Then I keep it and plot
to get my own back later. I don’t do remorse stuff. It does your head in.
S: It’s no good being guilty about it all. Anyway, both these guys deserved what
they got.
TA: Being punched in the head for not moving aside?
S: Depends on the circumstances. This guy was probably giving him that look that
says he is defying you and so he shouldn’t do that. (The group continued with
some discussion about the ‘‘look,’’ what it was and what it meant.)

John describes a context in which he has invited young people into his flat to use
drugs. Here he is in charge, they are in his debt, and he has their gratitude. He can
feel safe in the knowledge that all those around him accept his superior status in a
hierarchy. The moment that an individual challenges him by accusing him of theft,
his anxieties are aroused and he feels threatened. The therapists attempt initially to
explore this challenge and what feelings it induces in him (a common mentalizing
technique), but the other patients quickly start to ask him if he kept to an accepted
code of conduct, in this case a warning that something will happen unless the
challenge is withdrawn. The revelation that two warnings were given is reason
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enough to suggest that the act of violence is probably justified. The underlying
feeling state is initially avoided; the discussion focuses on the importance of respect.
All members of the group consider respect as necessary for survival. A return to the
theme is indicated by their unease about ‘‘the look’’ which, in essence, is one of
disrespect. However, it is just before the return to the theme of disrespect that there is
an indication of what is of most alarm to John and to the rest of the group—
becoming nothing.
John expresses concern about ‘‘losing respect,’’ Patrick about being ‘‘finished as a
person,’’ and Michael as being ‘‘nothing.’’ It is clear to them all that loss of face is
not an option, and they have to rid themselves of the cause of the threat to maintain
their sense of pride, dignity, honor, and, in the end, their own self. Indeed, they ask
the therapists to understand the world in which they live—which is unforgiving,
talionic, and where it is a daily struggle for survival. This seems to be accepted by the
therapists who gradually become bystanders in the discussion of the violent act,
seemingly agreeing with the patients about the responsibility of the victim for
what happened. The perpetrator is seen as being within his normal mind when
stabbing him.
To this extent, we believe that the mentalizing capacity of the therapists is
temporarily switched off by patients who present horrifying material without
concern. The therapists become identified with the aggressor rather than placing
themselves in identification with the victim. To do so would leave the therapists
themselves concerned about being the recipients of violence and yet at the same time,
they cannot completely identify with the violent patient as that too is dangerous.
The patients seek to control the alien self, in this case, a torturing and humiliating
self, by developing a nonmentalizing explanation. The victim ‘‘deserved’’ it because
he was warned and you have to do this sort of thing otherwise you do not get
the respect you should. He cannot countenance any such feeling of humiliation
in himself.
At the same time, the group disrupts the mentalizing of the therapists using a
‘‘power dynamic’’ that fuels the victim–victimizer–therapist interaction, through the
impact of conscious and unconscious coercion. The roles of John, the victim, and the
therapists can be seen from this perspective as representing a dissociating process;
the victim is dissociated from the group as ‘‘not us’’—‘‘He was warned and he knows
the rules. It is his choice if he ignores them’’— by John and the group. The therapists
are warned that they have to understand the culture that is inherent in the way they
live. The therapists then abdicate their role for a brief time by colluding with the idea
that the problem lies with the victim. The task of the therapists as observers of the
process is to maintain mentalizing as much as possible and to avoid this risk as well
as the risk of schematically representing the perpetrator as a demon and the victim as
a helpless innocent. This is equally nonmentalizing.
The therapists in this vignette attempt to maintain a mentalizing stance and ask
for clarification and understanding from members of the group to identify the
meaning of words which are implicitly accepted as having an agreed definition—‘‘the
rules,’’ ‘‘disrespect,’’ ‘‘finished as a person,’’ ‘‘being nothing.’’ To explore these areas,
the therapists recruit other patients to expand on the relatively underdeveloped
statements that are made. This is characteristic of mentalizing groups in which
therapists try to stimulate a process of understanding between members of the group
about what they understand is going on in the minds of each other. The therapists
also participate actively: in this vignette by expressing their uncertainty about the
explanation of events. Finally, they briefly indicate that something intolerable had
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 Mentalization-Based Treatment of Comorbid PDs 191

taken place in John, but he does not explore it further. As a matter of principle, we
ask therapists to explore more explicitly such affective change in more detail.
Although this group session allowed the patients to identify the role of respect, the
importance of hierarchy, their recognition of avoiding ‘‘becoming nothing,’’ it did
not address the underlying dynamics involved in the violence. In part, this was
related to the problems the therapists had in actively maintaining their mentalizing
stance, but it was also related to recognition that to insist on too much exploration in
the group might have been experienced as forcibly returning the humiliating alien
self. The group protected John from this perhaps because they were unconsciously
aware that not to do so could lead to further violence. In MBT, it is commonly in the
individual session that some of these serious actions can be explored in more detail,
and this was done in this case.

Individual Session
The individual therapist was aware of the content of the group and so at the
beginning of the session, in line with our normal practice, he told John what he knew
about what had been discussed.

Therapist: I understand from Dr A that you reported stabbing someone since I last
saw you. It might help if we can talk about that a bit more, although I
understand that you talked quite a bit about it in the group.
J: Yes, well, I told the group that he deserved it. I warned him and he took no notice
so he had it coming to him. Rules are rules.
T: You have mentioned the ‘‘rules’’ to me before. It sounds like you feel he broke the
rules.
J: He did. He knows the rules. He was in my place as well, so he should have been
more careful about it. I don’t know what happened anyway.
T: Tell me a bit more about what it is that you didn’t know.
J: I keep trying not to do these things. If I keep doing them, I won’t be allowed to see
my kids. The f______ social worker will just see me as dangerous. I am not
dangerous. These things just happen.
T: From my perspective that seems to be what is dangerous—these things just
happen. Can you help a bit to see what it is that does happen? (John then
reiterates some features of the events already discussed in the group.)
T: What is it about all that which you feel is the most significant bit?
J: Don’t know.
T: Can you push it a bit?
J: Well, I think it is something to do with worrying about how people will see me. If I
let people call me names and tell me what I am, then I won’t be treated as I
should be.
T: I can see that you felt that not to respond would be seen as weak and it might give
you more trouble in the future as far as you could see. What is that like to feel
weak?
J: I can’t live like that. I have to have people respect me. Otherwise, I don’t know
that I could live there. You don’t know what it is like to live in these places. I
wouldn’t be able to go out and some of my mates would avoid me. I am not a
troublemaker, but other people do stuff and then trouble happens.
T: I can see that you try to avoid trouble most of the time, but you find it difficult
at these times when you don’t know what happens. I am still curious about
what changes at these points.
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192 Journal of Clinical Psychology: In Session, February 2008

J: I just see them looking at me and that starts it.

T: There’s that look again (referring to earlier discussion of a look). It really does
something to you.
J: They think that they have got one over you (colloquial for winning a personal
competitive interaction) so you have to show them that they have not.
T: One over what?
J: (sighs) I don’t know. (silence)
T: What is it like in you when someone seems to be getting one over you?
J: It is not good. My mind goes at that point, and I know I have to do something
about it. It all just happens. (pretend mode)
T: Yes, it seems that it is at those times that you struggle. What happens to your
mind?
J: It goes blank and that is it.
T: To my way of understanding, you see a look which is a challenge, and it is that
challenge that you have to win. If the other person doesn’t respond in the way
you want, you start feeling that they might win something and then your mind
goes blank.
J: It is not always like that. Sometimes I can ignore it, but this time it was in my
house and so it was more of me that he was going for. I think that the group
therapists thought that I was a troublemaker and that I shouldn’t have done it.
Do you?
T: I am not sure how your mind moved on to that. Where did the group therapists
suddenly come into it?
J: They seemed to think that I was causing some of it and being the trouble and
shouldn’t have done it. Do you?
T: I don’t think you should have done it, but you have helped me begin to
understand that you felt you had no choice. But I think that the most important
part is seeing if we can help you manage whatever happens when the look
happens without having to attack someone. That leads you into trouble when
you are trying to avoid it. It occurred to me to ask if you had ever felt that I was
giving you the look.
J: Oh, no. You are my doctor. It is here that I am trying to sort it out.
T: Perhaps if it happens though, you can let me know.
J: Hmm. Anyway, I wasn’t sure that I wanted to go back to the group really. The
others were quite helpful, but I thought that the therapists didn’t really
understand.
T: Tell me more about that.
J: Being in the group just made me feel that it was my fault that this thing happened.
I don’t want to feel like that. It is wrong anyway. So the best thing is not to go
back to the group.
T: It sounds like you are wondering if I am going to make you go back to the group.
J: You can’t, but do you think I should?
T: Yes, I do. You see, I guess that by staying away (teleological response to a feeling)
you want to make sure that you don’t have to feel anything more about what
has happened, but if you can work out what is going on it might help another
time so that your mind does not just go blank (encouraging mentalizing).

This clinical dialogue is a transcript from a tape recording made as a part of an

ongoing pilot project into treatment for ASPD and so is highly accurate. It illustrates
a number of points about mentalization-based treatment. First, the therapist is active
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 Mentalization-Based Treatment of Comorbid PDs 193

about his investigations of the events related to a violent episode. It is not left to the
patient to bring up the topic. We explore violent acts in the same way as we explore
acts of suicide and self-harm in our treatment for BPD.
Second, the therapist clarifies that he is aware that the topic has been discussed in
the group therapy, indicating that the confidentiality is between members of the
treatment team rather than held with any one therapist. This policy is known by the
patients prior to treatment and should not be a surprise to them. Patients with ASPD
seem to have little concern about it, which is in contrast to patients with BPD who
have complained on a number of occasions about the lack of confidentiality in
individual sessions.
Third, the therapist tries to maintain the focus on the action and is not easily
deflected from his task. The patient is helpful in this regard, as he does not really
attempt to move away from the topic. Should he do so, the mentalizing therapist will
try to ‘‘stop and stand’’ and maintain the focus for as long as possible.
Fourth, the therapist tries to move to a consideration of the detail of mental states
and internal feelings of the patient. However, this is hard for the patient who finds it
difficult to identity his feeling states.
Fifth, many of the therapist statements are inquisitive, but always balanced
with some supportive and validating component. In MBT, we commonly try
to see things from the patients’ point of view while asking them to stretch their
minds to other perspectives Gradually, we hope to be able to move to more detailed
work within the treatment session itself. This therapist attempts to do this
towards the end of the vignette by referring again to ‘‘the look,’’ but the patient
moves away quickly. In doing so, he illustrates a nonmentalizing response to the
extent that he gives a specious explanation about why the look could not occur
within the session.
The patient’s rapid move away from any consideration of the therapist to a
discussion about the group therapists exemplifies the difficulty these patients have
with transferential experience, which is in marked contrast to patients with BPD who
rapidly invoke the patient–therapist relationship in discussing their problems.
Patients with ASPD tend to avoid the intensity of the relationship itself and
therapists have to respect this while not avoiding it completely.
Finally, the therapist also states his point of view when asked a direct question by
the patient rather than placing it back to him to explore. Patients who operate in
psychic-equivalent mode find exploring other people minds in fantasy provocative
and thoughts can rapidly become facts, leaving the therapist vulnerable to
accusation. It is better to inform the patient what is on your mind in a way that
encourages further dialogue about the focus of discussion.

Clinical Issues and Summary

Although we have increasing evidence for positive outcomes using MBT with
patients with BPD, we have little information on outcome for those with concurrent
ASPD and BPD. In this pilot project, the overall aim was to reduce violent episodes
by helping patients maintain mentalizing at the point at which is it likely to be lost.
Certainly, a focus on mentalizing engages the patients in treatment who have
attended regularly over a year. Therapists can expect a reduction in violence if the
group and individual therapy facilitate greater flexibility in the patient’s rigid
mentalizing. This cannot be done in the short term and so treatment is for 1 year, but
even that might be overoptimistic and a longer period may be required.
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194 Journal of Clinical Psychology: In Session, February 2008

We have always emphasized that the application of MBT for personality disorders
requires not only a focus on techniques that facilitate the development of mentalizing,
but also an avoidance of those that decrease it. In patients with concurrent ASPD and
BPD, therapists have to focus on the more stable aspects of the mind found in ASPD
rather than concern themselves with the rapidly fluctuating states of mind of BPD,
which are hidden within the stability of the ASPD. Patients with ASPD do not have
mental pain associated with the others state of mind; thus, to generate conflict in ASPD
by thinking about the victim will typically be ineffective in inducing behavior change.
It would only be of help if that type of conflict was aversive to them.
In the act of violence described in this article, there was no consideration of the
victim’s state of mind, and not a single patient expressed any concern about what
happened to him or what was going on in his mind that made him behave in the way
he did. The inability of the patient with characteristics of ASPD not to experience
psychic pain in this way suggests that they will not respond to aversive interventions,
such as time out, contracts, or punishment, but might begin to respond to
withdrawal of positive reinforcement of their self-regard. Most mentalizing
interventions contain within them some aspect that helps patients feel that the
therapist is trying to understand what is happening in their mind rather than
attempting to make them to conform to some predetermined way of living. The
overall aim is to engender a mentalizing process about events that ‘‘just happen’’ and
about inner experiences that are perplexing.

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Journal of Clinical Psychology: In Session DOI 10.1002/jclp