Personality and Mental Health
5: 85–90 (2011)
Published online 3 January 2011 in Wiley Online Library
(wileyonlinelibrary.com) DOI: 10.1002/pmh.156
Commentary
Commentary on ‘Minding the difficult patient’:
Mentalizing and the use of formulation in
patients with borderline personality disorder
comorbid with antisocial personality disorder
ANTHONY W. BATEMAN, FRCPsych Barnet, Enfield and Haringey Mental Health NHS Trust,
Halliwick Unit, St Ann’s Hospital, St Ann’s Road, London, UK
Sebastian Simonsen and colleagues raise some
interesting points about the use of formulation in
a mentalization-based treatment. In the initial
manuals (Bateman & Fonagy, 2004, 2006), we
described the formulation as a process by which
the therapist organizes his or her understanding of
the patient, eventually sharing it with the patient
in written form. The aim of the formulation is not
only to organize the mind of the therapist but also
to model the mentalizing process. The written
form has a number of characteristics which, impor-
tantly, include brevity, simplicity and clarity
without use of jargon. The content of the formula-
tion is less important than the process of develop-
ing it. The intention is to engage in a collaborative
process in which the patient considers the mind of
the therapist just as the therapist considers the
mind of the patient. It is a fundamental principle
of mentalization-based therapy (MBT) that we ask
patients to juxtapose their own mind alongside
their representation of the therapists’ mind, and
that it is equally essential for the therapist to con-
sider his/her own mental state in relation to his/
her representation of the patient’s mind. It is the
continual focus on, and the reworking of, the sub-
jective reality of the patient that forms the core of
Copyright © 2011 John Wiley & Sons, Ltd
mentalizing approaches (Fonagy & Bateman,
2007).
Simonsen et al. express some concern that the
formulation is primarily orientated around the
thinking of the therapist, and that some patients
may not have the capacity to work on the formula-
tion at this level. This is an important point,
although, it was never our intention that the for-
mulation would be solely the work of the therapist,
more that it should be a joint effort. The formula-
tion does not come without warning but is some-
thing that is worked on during the assessment
process. In addition, they suggest that the formula-
tion is relatively inflexible. Again, this was not the
intention. It is changeable, a work in progress and
can be revisited at any point in therapy, although
in practice it tends to disappear as therapy pro-
gresses. Currently, we increasingly emphasize the
crisis plan and consider it of greater importance
than the formulation at the beginning of therapy
and during therapy itself, constantly revisiting
and revising it throughout therapy if crises occur
(Bateman & Fonagy, in press).
This author repeatedly emphasizes that thera-
pist interventions must be in keeping with the
mentalizing capacity of the patient, and going too
5: 85–90 (2011)
DOI: 10.1002/pmh
86 Bateman
far beyond the patient’s capacity will undermine
rather than stimulate mentalizing which is the
very aim of the therapy. It is in this context that
Simonsen and colleagues ask two cogent ques-
tions: Is there value in a mentalization-based case
formulation when treating patients with low reflec-
tive capacity; and secondly, how can the formula-
tion be modified if the answer to the first question
is ‘yes’? In short, my answer to the first question is
‘yes’, and to the second, ‘without too much problem’.
Within their questions, they suggest that perhaps
we need to develop better understanding about the
form the formulation takes using the example of a
patient who has borderline personality disorder
(BPD), comorbid with antisocial personality dis-
order (ASPD).
Simonsen and colleagues consider abandoning
the formulation process altogether in patients with
comorbid BPD and ASPD while recognizing its
beneficial effect on the therapeutic alliance and
the organizing stimulus to the therapist’s mind. We
know that mentalizing begets mentalizing and
non-mentalizing begets non-mentalizing, so any-
thing that maintains the therapists’ mentalizing
capacities is to be welcomed. Surely, this in itself
is adequate reason to keep the formulation. Cer-
tainly, a major aspect of the formulation is to help
the therapist continue mentalizing when it would
otherwise be lost and, if it is to achieve this aim,
it must be mentally retrievable ‘under fire’. This
patient cannot retrieve her capacities easily, par-
ticularly when she is in the groups of the intensive
day hospital programme, which makes it even
more important for the therapist to be able to do
so.
Returning to the formulation, it has to have the
characteristics I have already mentioned, namely
simplicity, clarity and brevity. So let us consider
this in relation to some aspects of a mentalizing
understanding of BPD comorbid with ASPD.
Mentalizing and ASPD
Starting with an aside, I have some concerns about
the intensity of the treatment offered to this
Copyright © 2011 John Wiley & Sons, Ltd
patient. Recommendations about intensity of ther-
apeutic intervention, fundamentally, the level of
interpersonal interaction required in treatment, in
MBT are informed not by levels of risk and type
of behaviour but by the assessment of the sensitiv-
ity of the attachment system. In principle, the
greater the sensitivity, the less intensive the inter-
vention. This is especially important to consider
in the process of developing the formulation par-
ticularly in relation to the level of her mentalizing
abilities with which the authors are concerned.
More recently, mentalizing has been considered as
an amalgam of polarities—self and other, internal
and external, automatic and controlled, cognitive
and affective. Patients may overuse one aspect of
mentalizing at one end of a pole or be under-
focused on another, becoming over-reliant on the
opposite mental process. For example, being unable
to rely on affective representation leads a person
to rely solely on cognitive understanding. Taking
the internal–external pole as an example, relevant
to this patient—internally focused mentalization
refers to mental processes that focus on one’s own
or another’s mental interior (e.g. thoughts, feelings,
experiences) while externally focused mentalizing
focuses on mental processes that rely on physical
and visible features and/or actions of one’s own or
someone else. This distinction differs from the
self–other polarity because both internally and
externally focused mentalizations may be either
self- or other-focused.
From an assessment and formulation perspec-
tive, the internal–external distinction is particu-
larly relevant in helping us to understand the
paradoxical situation that some patients appear to
be severely impaired in their capacity to ‘read the
mind’ of others based on consideration of more
internal features (e.g. desires, wishes) while showing
hypersensitivity to emotions based on their obser-
vations of facial expressions or bodily posture. For
instance, whereas BPD patients find it very diffi-
cult to understand the intentions of others—an
internally based task (King-Casas et al, 2008), they
are often hypersensitive to facial emotion expres-
sions—an externally based task (Domes, Schulze,
5: 85–90 (2011)
DOI: 10.1002/pmh

& Herpetz, 2009; Lynch et al, 2006). By contrast,
ASPD patients may lack the ability to read fearful
emotions from facial expressions, an externally
based task (Marsh & Blair, 2008), but they are
often experts in reading the inner states of others,
and coercing or manipulating them based on this
ability (Bateman & Fonagy, 2008). The result of
all this for patients who are comorbid for BPD and
ASPD is instability and confusion in contexts of
interpersonal stimulation and both self-harm and
violence can result. Careful delineation of the
context of this patient’s history of violence alerts
the assessor to be careful about offering an inten-
sive treatment. In cases in which the attachment
system is hypersensitive in relation to both inter-
nal and external foci, less may be more.
Individuals with ASPD maintain the stability
of their subjective sense of self, not only by inter-
preting the world according to teleological under-
standing but also through the rigidity of the
externalization of the alien self. This rigidity pres-
ents serious problems for treatment. The rigidity of
the interpersonal constellation has to be chal-
lenged, and yet the challenge, even through the
formulation might induce emotional decompensa-
tion of even violence because, in ASPD, change
in personal relationships threatens to unleash vio-
lence as a survival mechanism (Bateman & Fonagy,
2008). The authors give an excellent description
of the clinical presentation of the patient and
consider the importance of externalization of the
alien self in these patients. It is proposed that in
some individuals, perhaps those who experienced
attachment-related trauma such as severe parental
maltreatment or exposure to domestic violence
like this patient, the activation of the attachment
system inhibits aspects of mentalization. When
this occurs, modes of experiencing internal reality
that antedate the developmental emergence of
mentalization reappear. This shift in subjectivity
in turn accentuates distorted and disorganized
internal representations, generating a deep sense
of internal discomfort. This is then dealt with by
the constant and unremitting need for externaliza-
tion of self-destructive alien aspects of the self
Copyright © 2011 John Wiley & Sons, Ltd
Commentary 87
(Fonagy, Target, Gergely, & Jurist, 2002), present-
ing as a constant pressure for projective identifica-
tion. To some extent, the uncontrollable and
ultimately destructive behaviour evidenced by this
patient during her treatment in the intensive pro-
gramme may have been provoked by the very
attempts to help her.
Feeling states in complex personality disorders
tend not to be represented but embodied. The
patient’s affects have at their core an action ten-
dency and despite the long process of childhood
and socialization, feeling states have not been
‘desomatized’ and mentalized, leaving them vul-
nerable to rapid action. There can be no ‘as if’
quality to the experience. Symbolic processing of
subjective experience, necessary for tolerance of
emotions and cognitive articulation of feeling
states, is rudimentary. This is psychic equivalence
which is matched by the patient’s teleological
understanding of the world. The patient described
in this paper creates change around her in the
physical world. Her subjective sense of self is sta-
bilized through the actions of others. She breaks
‘rules’, is verbally abusive, denigrates the therapist
and is eventually denied group treatment. She is
in danger of creating a non-mentalizing world
around her. The formulation can protect against
this. It should predict and consider areas that
might need special attention in forthcoming treat-
ment. Of particular importance in this patient is
her tendency to deny the effect she has on oth-
ers—‘she rarely offered thoughts about problems
that other patients presented and the few times she
did, her responses were insensitive and mostly pro-
voked anger’. This is a core problem for those
patients with characteristics of ASPD.
Empathy and ASPD
Generation of empathy for others arises out of
simulation and an awareness of intersubjective
experience. We read how we would react in a situ-
ation, and this allows us to understand what
someone else is feeling. Patients with ASPD are
able to build a representation of others’ internal
5: 85–90 (2011)
DOI: 10.1002/pmh
88 Bateman
states, and they may be exquisitely sensitive to
particular states of mind of others such as depen-
dency needs. Their failure lies in an inability to
anticipate the psychological disarray that emo-
tional states have on others. This important exten-
sion of empathy beyond a simple representation of
a feeling state is not part of their abilities, and so
they are unable to recognize the depth of another
person’s internal state or may even appear to be
indifferent to the effect that distress may have on
someone, for example. During group therapy, this
patient apparently has little concern for other
patients in the group to the extent that she is not
allowed to return back into the group, and yet she
asks to return as she is aware that the group is
‘somehow helpful to her’. Indeed it is. Groups
harness the impact the representation of an indi-
vidual’s mind by a number of people strengthening
a person’s competence in mentalizing. This is not
only because more people reflect on the patient’s
subjective experience but also because the patient
has an opportunity to reflect on the experience of
many others, most importantly, in the context of
trying to understand how their mind impacts on
another mind in a relationship which does not
directly involve them, that is, between other
members of the group (Karterud & Bateman, in
press). This patient needs to develop such capaci-
ties urgently. Given her diagnosis, this aspect
of her functioning needs emphasizing in the
formulation.
Modified formulation and MBT for ASPD
In MBT for BPD comorbid with ASPD, the clini-
cal corollary of this mentalizing perspective of the
diosrder is that, first, there needs to be a clear focus
on emotional aspects of empathy, helping the
patient build a capacity to recognize accurately
what someone else feels; and second, an emphasis
on the effect that emotions have on internal states
of the other, that is, an exploration and recogni-
tion of the level of psychological disarray that a
person experiences as he/she feels. Patients with
Copyright © 2011 John Wiley & Sons, Ltd
ASPD need to be aware of the effects their states
have on the mind of others, and to some extent
this can be addressed in the formulation.
Taking all this into account, I concur with the
suggestion of Simonsen and his colleagues that the
formulation for patients with ASPD or with BPD
and ASPD needs modification, and that the
process as well as the end product needs to be in
keeping with the patient’s mentalizing capacity.
This patient’s abilities fluctuate. At times, when
she talks about things, she becomes ‘softer and
more alive’, suggesting that she is fleetingly able to
represent her own emotional states at least. It is
the continual engagement in this process, that is,
the task in therapy, if a more robust mentalizing
process is to be developed.
The formulation for patients with low reflective
capacity needs to be succinct and to the point. In
some ways, it should not look like a therapy for-
mulation but more like a few key areas that are
going to be important in therapy. In addition, it
should be stated that it is a work in progress and
can easily be modified. I disagree that the formula-
tion will necessarily only reflect the therapists’
representations of the patient’s inner life. The
therapist needs to do justice to the depth of the
patient’s subjective experience in the formulation.
While this is by definition the therapist’s represen-
tation, it has to show that he has understood some
critical aspects of the patient’s inner experience if
he is to develop a meaningful formulation under-
standable to both patient and therapist. Inciden-
tally, I have no problems with the patient writing
his own formulation about herself or indeed the
therapist. Below, I try to illustrate how to capture
the patient’s experience of her life. I cannot do
justice to the depth of her experience as I do not
know her but to say that her life has been ‘terrible’
must capture something of the absolute nature of
her inner experience. From there, it might be pos-
sible to begin to tease out more positive aspects but
the overwhelming sense has to be her experience
of her inner subjectivity not being taken with the
seriousness that it deserves during her childhood
and later.
5: 85–90 (2011)
DOI: 10.1002/pmh

Intriguingly, the patient described in this paper
is able to work on the formulation despite the
protestations of the authors. When given the for-
mulation, she states immediately, ‘Are you crazy?’,
referring to the length. In effect, she is over-
whelmed by what she is confronted with, and yet,
the formulation should not have come as a surprise
or be presented in a form beyond her capacity,
which suggests that the therapist has not under-
stood the mentalizing process of generating the
formulation. Being accused of being crazy is perfect
for MBT. In this circumstance, the MBT therapist
has to consider his own failure—Is he being crazy,
and if so, in what way? Here, the therapist can
immediately ask the patient in what way does she
mean. If she describes the length as being well
beyond her after reading the first sentence, then,
she and the therapist need to start working on
cutting down the formulation. The therapist could
say let’s take the first heading then and consider
that. In the end, taking the headings from the
formulation, I would be happy with something like
the following:
Reason for referral
You have been referred because your life has been
terrible and now you keep trying to harm yourself
or others and feel angry a lot of the time. You
cannot use your obvious abilities.
View of self
You do not have a view of yourself that you can
sign up to. This will cause a problem for us as we
might see you as something, which you feel you are
not. This can lead to frustration, which might lead
you or us to think about giving up.
View of others
You do not seem interested much in others, or at
least seem concerned about what effect you have
on them. This is going to make working in a group
a problem. We need to discuss this further and
watch out for it when you start in the group.
Copyright © 2011 John Wiley & Sons, Ltd
Commentary 89
Mentalizing
Something happens when you are asked to think
about yourself. Our experience is that you become
emotional and we are not sure what happens. This
means that therapy itself is a problem as we will
ask you to consider yourself more and more in
addition to getting you to scrutinize what effect
you have on others. We need to talk about how we
might manage this without us pushing too many
sensitive areas in you and you in us.
Positive mentalizing
It is great that you have managed to calm down at
times and talk about what has been happening to
you. It is this aspect of your abilities that we want
to increase. It is a good sign that you and I have
managed this, and you say it is because I speak in
an ordinary way and that I am not therapy like. I
will continue to be so because that is who I am.
So let us not throw out our formulation baby
with the bath water. I am grateful for Simonsen
and colleagues for opening this discussion, allow-
ing me to comment and reminding us that each
formulation has to be considered in the context of
each patient, and that it is the process of develop-
ing the formulation that is important and not the
actually formulation itself.
References
Bateman, A., & Fonagy, P. (2004). Mentalization based treat-
ment of borderline personality disorder. Journal of
Personality Disorder, 18, 35–50.
Bateman, A., & Fonagy, P. (2006). Mentalization based
treatment: A practical guide. Oxford: Oxford University
Press.
Bateman, A., & Fonagy, P. (2008). Comorbid antisocial and
borderline personality disorders: Mentalization based
treatment. Journal of Clinical Psychology: In Session, 64,
1–14.
Bateman, A., & Fonagy, P. (in press). Mentalizing in mental
health practice. Washington, DC: APPI.
Domes, G., Schulze, L., & Herpetz, S. C. (2009). Emotion
recognition in borderline personality disorder—a
5: 85–90 (2011)
DOI: 10.1002/pmh
90 Bateman
review of the literature. Journal of Personality Disorders,
23, 6–19.
Fonagy, P., & Bateman, A. (2007). Mentalizing and border-
line personality disorder. Journal of Mental Health, 16,
83–101.
Fonagy, P., Target, M., Gergely, G, & Jurist, E. (2002). Affect
regulation, mentalization, and the development of self.
London: Other Press.
Karterud, S., & Bateman, A. (in press). Mentalization based
treatment: Group therapy techniques. In A. Bateman &
P. Fonagy (Eds.) Mentalizing in mental health practice.
Washington, DC: APPI.
King-Casas, B., Sharp, C., Lomax-Bream, L., Lohrenz, T.,
Fonagy, P., & Montague, P. R. (2008). The rupture and
repair of cooperation in borderline personality disorder.
Science, 321, 806–810.
Copyright © 2011 John Wiley & Sons, Ltd
Lynch, T. R., Rosenthal, M. Z., Kosson, D. S., Cheavens,
J. S., Lejuez, C. W., & Blair, R. J. (2006). Heightened
sensitivity to facial expressions of emotion in borderline
personality disorder. Emotion, 6, 647–655.
Marsh, A. A., & Blair, R. J. (2008) Deficits in facial affect
recognition among antisocial populations: A meta-
analysis. Neuroscience and Biobehavioral Reviews, 32,
454–465.
Address correspondence to: Professor Anthony W.
Bateman, FRCPsych Barnet, Enfield and Haringey
Mental Health NHS Trust, Halliwick Unit, St
Ann’s Hospital, St Ann’s Road, London N15 3TH,
UK. Email: Anthony@mullins.plus.com
5: 85–90 (2011)
DOI: 10.1002/pmh