Battles of the Comfort Zone: Modelling Therapeutic Strategy, Alliance, and Epistemic Trust—A Qualitative Study of Mentalization-Based Therapy for Borderline Personality Disorder

Folmo, Espen; Karterud, Sigmund; Kongerslev, Mickey; Kvarstein, Elfrida Hartveit; Stänicke, Erik

doi:10.1007/s10879-018-09414-3

Cited by 27 publications

(38 citation statements)

References 26 publications

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“…When they have conflicts with group members, they dwell on it long after, and therapists must not overestimate their capacity to deal with these difficult and complicated phenomena by themselves. This also resonates well with a recent study where high-quality and low-quality therapy sessions were analyzed, and it was clear that high-quality MBT involved in confronting and addressing negative and difficult feelings in the room with the patients (Folmo et al, 2019).…”

Section: Discussionsupporting

confidence: 85%

“…Recently, a qualitative investigation of high vs. low quality MBT concluded that hallmarks of high-quality MBT in which high-rated therapists investigated maladaptive patterns were more challenging and brought patients out of their comfort zone (again, challenging and “demanding”). This therapy style facilitated the alliance and created a constructive therapeutic process (Folmo et al, 2019). From our investigation of patients’ experiences of change, we found that they experienced meaningful changes in their ability to cope with mental states in self and gained a more flexible understanding of others (Morken et al, 2017a).…”

Section: Introductionmentioning

confidence: 99%

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Mentalization-Based Treatment From the Patients’ Perspective – What Ingredients Do They Emphasize?

Morken

Binder

Arefjord³

et al. 2019

Front. Psychol.

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Objective: The aim of this study was to explore how patients with personality disorder (PD) and substance use disorder (SUD) experience mentalization-based treatment (MBT), in particular what they consider useful and less useful elements of the therapy. Method: Semi-structured qualitative interviews with 13 participants were conducted. Participants were interviewed on their experience of the different elements of MBT, their experience of working in the transference, and their view on MBT as a whole. Thematic analyses were performed within a hermeneutical-phenomenological epistemology, with an emphasis on researcher reflexivity. Results: The following themes were found in the material: “I am not alone,” “Taking blinders off,” “Just say it,” “The paradox of trust,” and “Follow me closely.” Three of these themes concerned therapist interventions; these involved addressing the relationship with the patients, addressing negative or unspoken feelings in the sessions, and validating and tolerating patients’ affect. Two themes concerned group therapy experiences; these were the experience of sameness with co-patients in group and the experience of discovering different perspectives in group. Conclusions: Patients’ experiences of useful elements in MBT resonate with theoretical tenets of (borderline) personality pathology, in particular attachment disturbances and emotional dysregulation. Patients highlight what we would label working in the therapeutic relationship, addressing transferential and counter-transferential processes explicitly, emotional validation, and enhancing mentalizing in its own right.

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Section: Discussionsupporting

confidence: 85%

Section: Introductionmentioning

confidence: 99%

Mentalization-Based Treatment From the Patients’ Perspective – What Ingredients Do They Emphasize?

Morken

Binder

Arefjord³

et al. 2019

Front. Psychol.

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“…However, we do not have session by session quality assessments over time, nor assessments of all therapies. There is reason to expect that the quality in this respect may be variable, in particular when levels of mentalizing are poor and/or the situations are highly emotional or indicative of high-risk such as violent or self-destructive behaviors ( 58 ). Moreover, the data does not allow distinction between treatment fidelity in dyads were the patient had more impaired social cognition.…”

Section: Discussionmentioning

confidence: 99%

Social Cognition Capacities as Predictors of Outcome in Mentalization-Based Treatment (MBT)

et al. 2020

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Background: Mentalization-based treatment (MBT) is an evidence-based treatment for borderline personality disorder (BPD). Differences in treatment outcomes related to specific capacity of social cognition need further attention. This study aimed to investigate social cognition as a predictor of outcome. Method: The study included 31 BPD patients who completed a test of social cognition (Movie for the Assessment of Social Cognition, MASC) before outpatient MBT. The MASC-scores indicated a person's theory of mind (ToM) and different error-types. During treatment repeated self-reports of alliance and clinical outcomes (symptoms, interpersonal problems, social functioning) were applied. Longitudinal analyses were based on Linear Mixed Models (n = 24). Results: The most frequent error-type was excessive ToM (hypermentalizing). Higher levels of excessive ToM were associated with greater improvement of alliance over time and good clinical outcomes. Insufficient ToM errors and low levels of accurate cognitive ToM responses were both associated with poorer improvement over time. The subgroup with frequent insufficient ToM errors had a larger total number of ToM errors. Insufficient ToM errors were associated with more childhood trauma, comorbid avoidant PD traits and/or PTSD, extensive prior treatment, and/or treatment irregularity. Conclusion: This study demonstrates considerable variation of social cognitive capacity among BPD patients and good outcomes for patients with mainly ToM errors of hypermentalizing. It also indicates that poorly responding patients may represent a cohort with more complex problems of social cognition and insufficient mentalizing.

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“…For patients with positive developments, it seems they became able to collaborate (Goals and Tasks), and cocreate a trusting relationship (Bonds). A qualitative study of therapist interventions in MBT described how therapists within a good working alliance context not only validated and supported the patient but could also challenge maladaptive patterns (Folmo et al, 2019). A positive alliance process could indicate that the patient gradually comes to understand the importance of working on the problems focused in therapy and becomes increasingly willing to be challenged directly on these matters.…”

Section: Main Findingsmentioning

confidence: 99%

Development of therapeutic alliance in mentalization-based treatment—Goals, Bonds, and Tasks in a specialized treatment for borderline personality disorder

Folmo

Stänicke

Johansen

et al. 2020

Psychotherapy Research

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Objective: Mentalization-based treatment (MBT) is an evidence-based long-term treatment for borderline personality disorder (BPD). Alliance is central for effective psychotherapies. Few studies have addressed aspects of working alliance in BPD evidencebased treatments. This study aimed to investigate alliance development in MBT therapies with different clinical outcomes. Method: The sample included 155 patients in an MBT programme. Clinical outcomes were based on Global Assessment of Functioning (GAF). The sample was divided in two subgroups according to GAF levels at the end of treatment (cut-off = 60). Working alliance was assessed by patient report (Working Alliance Inventory, subscales, Goals, Bonds and Tasks) and assessed repeatedly over 36 months. The method for statistical analyses was linear mixed models. Results: Initial levels of Goals, Bonds, and Tasks did not differ by subgroup, but change over time differed significantly by subgroup. In the good outcome subgroup, ratings of Goals, Bonds, and especially Tasks increased significantly over time. In the poor outcome subgroup, paranoid PD was associated with poorer alliance development over time. Conclusions: Good outcome therapies were characterized by a process where the working alliance grew over time. Results encourage an explicit focus on tasks in therapy particularly for patients with high levels of mistrust.

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Battles of the Comfort Zone: Modelling Therapeutic Strategy, Alliance, and Epistemic Trust—A Qualitative Study of Mentalization-Based Therapy for Borderline Personality Disorder

Cited by 27 publications

References 26 publications

Mentalization-Based Treatment From the Patients’ Perspective – What Ingredients Do They Emphasize?

Mentalization-Based Treatment From the Patients’ Perspective – What Ingredients Do They Emphasize?

Social Cognition Capacities as Predictors of Outcome in Mentalization-Based Treatment (MBT)

Development of therapeutic alliance in mentalization-based treatment—Goals, Bonds, and Tasks in a specialized treatment for borderline personality disorder

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