Theoretical Framework of Mentalization Based Family Therapy

Objectives of MBFT

Help families shift from non-mentalizing to mentalization-based discussions and interactions, building a basis of trust and attachment between children and parents.

Promote parents sense of competence in helping their children develop the skill of mentalizing.

Practice the skills of mentalizing, communication and problem solving in the specific areas in which mentalizing has been inhibited.

Initiate activities and contexts within the family, with peers, in school, and in the community which reinforce mentalizing, communication skills and mutually supportive solutions to problems

MBFT and other therapeutic approaches

Addresses mentalizing processes within the family context; not focused on specific symptoms

A distinct approach with both similarities and differences from purist cognitive therapy, psychodynamic therapy, and systemic family therapy

Mentalizing focus provides an integrative framework bringing together understanding of ones own thoughts and feelings that is

central to cognitive therapyunderstanding of thoughts and feelings of others that is

central to family therapyappreciation of defensive processes and the reluctance to

change that is central to psychodynamic therapy.

Components of successful mentalizing

Relational strengths the capacity to mentalize others thoughts & feelings

Ability to perceive ones own mental functioning

Capacity for self-representation General values and attitudes that facilitate

mentalization

Mentalizing strengths I: Relational strengths

Curiosity - genuine interest in others thoughts and feelings and respect for their perspectives

Stance of safe uncertainty also referred to as opaqueness the open acknowledgment that one frequently does not know what other people are thinking without losing the sense that others reactions are to some extent predictable

Contemplation and reflection ability to reflect on how others think in a relaxed rather than compulsive manner.

Perspective-taking acceptance that the same thing can look very different from different perspectives

Forgiveness ability to understand others actions in terms of their mental states

Impact awareness - awareness of how ones own thoughts, feelings and actions impact on others

A non-paranoid attitude others thoughts not seen as a significant threat and having in mind the possibility that minds can be changed.

Mentalizing strengths II: Perception of own mental functioning

Developmental perspective understanding that with development ones views of others deepen and become more sophisticated and complex.

Realistic scepticism - recognition that ones feelings can be confusing. Internal conflict awareness - awareness of having seemingly

incompatible thoughts and feelings Self-inquisitive stance - curiosity about ones own thoughts and feelings

and about how the way other peoples minds function relates to oneself. Awareness of the impact of affect - insight into how strong emotional

states can distort ones understanding of oneself and others. Acknowledgment of un- or pre-conscious functioning - recognition that at

any one time one may not be (fully) aware of all that one feels, Belief in changeability - appreciation that ones views and understanding

of others can change in line with changes in oneself

Mentalizing strengths III: Self-representation

Rich internal life - the person rarely experiences their mind as empty or contentless.

Autobiographical continuity - capacity to remember oneself as a child and to experience the continuity of ideas

Advanced explanatory and listening skills -the persons ability to explain things to others and to listen and comprehend them

Mentalizing strengths IV: General values and attitudes

Tentativeness - lack of absolute certainty and a preference for viewing things as relative and complex.

Humility (moderation) - a balanced attitude to most statements about mental states, based on the acceptance of not being in a privileged position.

Playfulness and humour - allowing for interacting and reflecting in a relaxed and creative manner

Flexibility - allows individuals not to get stuck in one point of view or position, but permits to change their minds in response to feedback, considering alternatives.

Give and take - enables individuals to solve problems, by involving others and appreciating turn-taking

Responsibility and accountability - taking ownership of ones own thoughts, feelings and actions, rather than conveying a sense that these happen to the person

The Modes of Psychic Reality That Antedate Mentalisation and Characterize Suicide/Self-harm

Psychic equivalence: Mind-world isomorphism; mental reality = outer

reality; internal has power of externalExperience of mind can be terrifying (flashbacks)Intolerance of alternative perspectives (I know

what the solution is and no one can tell me otherwise )Self-related negative cognitions are TOO REAL!

(feeling of badness felt with unbearable intensity)

The Modes of Psychic Reality That Antedate Mentalisation and Characterize Suicide/Self-harm Pretend mode: Ideas form no bridge between inner and outer reality;

mental world decoupled from external realityLinked with emptiness, meaninglessness and

dissociation in the wake of traumaLack of reality of internal experience permits self-

mutilation and states of mind where continued existence of mind no longer contingent on continued existence of the physical self In therapy endless inconsequential talk of thoughts and

feelingso The constitutional self is absent feelings do not

accompany thoughts

Components of impaired mentalizing

Generalized mentalizing difficulties Partial mentalizing difficulties Concrete mentalizing difficulties Pseudo-mentalization difficulties Misuse of mentalization

Generalized mentalizing difficulties

Generalized or trait deficits in mentalizing ability, eg in a child presenting with oppositional behaviour.

Oppositional behaviour typically represents a non-mentalistic, physical effort by the child to control his feelings and generate a response in others.

Angry or violent outbursts force caregivers to experience what the child experiences, offering the child a sense that their feelings can have an impact.

In the medium term, this immediate impact fails to secure effective support reciprocity, control or self-coherence.

The childs non-mentalistic, coercive behaviour evokes non-mentalistic efforts of behavioural control from the caretakers, with resulting self-reinforcing and self-perpetuating cycles of non-mentalizing, coercive interactions.

Partial mentalizing difficulties

Capacity to mentalize may break down intermittently when dealing with particular thoughts and feelings - eg parents who suffered physical abuse may lose the capacity to mentalize when faced with a reminder of their own states of helplessness, anger or shame

Mentalizing capacity may become impaired in an episodic,state-dependent fashion eg a depressed child may experience her thoughts and feelings about herself as entirely real, and lose the perspective that would allow her to think differently about herself or others or to realize that her feelings might change

Problems may be context specific eg a parent may keep a great deal of distance from some areas of his or her adolescent childs life, for example sexuality

Concrete mentalizing difficulties

Difficulty in emotion recognition Confusing a feeling with a thought, e.g. because I feel sad, the world is a

miserable place Understanding behaviour in concrete terms (e.g. in terms of external

circumstances or other behaviours rather than in terms of internal states) Difficulty in observing ones own thoughts and feelings Not recognizing the impact of ones thoughts & feelings on others Inability to see how one thing has led to another, e.g. a thought led to a

feeling which led to an action, and a reaction from someone else Over-generalizing from mental states, e.g. feeling that because one

upsetting thing happened, everything has gone wrong Not being able to be flexible and explore different ways of thinking about

situations Feeling that somebody elses thoughts are dangerous Struggling to relate thoughts to reality Acting without thinking or avoidance of thinking

Pseudo-mentalization difficulties

Apparent thoughtfulness, but lacks some essential features of genuine mentalization

A partial understanding, containing some truth; not intentionally abusive

Tendency to express absolute certainty about others thoughts and feelings

Limited or absent recognition of the inherent uncertainty about knowing someone elses mind

Thoughts and feelings in others or the self are recognised as long as these are consistent with the individuals self interest or preferences.

Types of pseudo-mentalization Preserving a developmentally early view of the child/parent: the

parent/child continues to think of the other person in the dyad from an earlier perspective.

Intrusive mentalizing: lack of respect for the separateness/opaqueness of minds within a family someone thinks they know what another person thinks/feels.

Overactive inaccurate mentalizing: parents invest a lot of energy in thinking or talking about how people in the family think or feel, but this has little or no relationship to the other persons reality.

Completely inaccurate attributions which can be traumatic, leading the child to inhibit their capacity to mentalize: bizarre attributions (you are trying to drive me crazy, your grandma is in

league with your father against us), denials of objective realities (you provoked me, you fell down the stairs, I

never hit you), denial of the childs feelings (you enjoyed it when I touched you like that,

you dont care about whether your Dad is here or not, you dont care about me, you would be glad if I was dead).

Misuse of mentalization

Understanding of mental states is not directly impaired, yet theway in which it is used is detrimental:

Manipulative use of understanding of the child childs mental states are recognized but used for something else, e.g. as ammunition in marital battle.

Self-serving distortion of the childs feelings the childrens feelings are exaggerated or distorted in the interest of the parents unspoken intention or attitude.

Coercion against the childs thoughts. parent appears to undermine the childs capacity to think by deliberately humiliating the child for her or his thoughts and feelings.

Therapist stance

Therapist Stance

Not-Knowing Neither therapist nor patient experiences interactions other than

impressionistically Identify difference I can see how you get to that but when I think

about it it occurs to me that he may have been pre-occupied with something rather than ignoring you.

Acceptance of different perspectives Active questioning Eschew your need to understand do not feel under obligation to

understand the non-understandable.

Monitor you own mistakes Model honesty and courage via acknowledgement of your own mistakes

o Currento Future

Suggest that mistakes offer opportunities to re-visit to learn more about contexts, experiences, and feelings

Therapist stance Empathic is about how they are thinking and

feeling, getting them to describe important Cannot explore before empathy Use not knowing what to say as clue that

something does not make sense and there is something to be curios about

Curiosity about experience, probing about patients experience serves to validate the experience

Normalizing is component of moving to transference work stating feelings in first person: I would feel X, so surprised you appear not to

The mentalizing therapists stance

Inquiring and respectful of other peoples mental states Convey a sense that understanding the feelings of others is

important Help the family make sense of what feelings are

experienced by each family member Highlight how miscommunication or misunderstanding (or

lack of understanding) of these feelings leads to interactions that maintain family problems

Strike a balance between allowing the family to interact naturally, or indeed actively eliciting habitual and naturalfamily interactions around problematic issues, as well as being directive and intervening at critical moments

Essential to the Stance Keep it current what the patient feels right now Start by empathising finding a way of stating

that you genuinely understand distress Explore in the relational realm not just the intra-

psychic Lower arousal by bringing it to the person of the

therapistWhat have I done?

Stick to mentalizing aim in somewhat dogged manner

Quickly step back if patient seems to lose control

Therapist Stance

Reflective enactmentTherapists occasional enactment is

acceptable concomitant of therapeutic allianceOwn up to enactment to rewind and exploreCheck-out understandingJoint responsibility to understand over-

determined enactments

Workshop exercise

Mother states that she does not think that her partner will agree to attend for a family meeting.Therapist stance of not knowing and motivating

positive attitude.

Workshop Exercise

Family report that they do not feel that you understand and think that it would be better to have another therapist.Therapist to maintain a therapist stance whilst

clarifying of problem

Session Structure and Content

Therapists core skills Show warmth and respect for each family member Be inclusive of all family members Identify and highlight strengths, including in the area of

mentalizing Aim for more positives between family members (as they

define it) Encourage family interaction in session Avoid blame Positively connote the attempts and role of each family

member Refocus family members repeatedly if they wander Provide clear time boundaries - 60 minutes per session Speak confidently about MBFT and its aims Help family members understand that they are choosing to

participate

Aims of the first session

Clarify the reason for referral

Agree on the purpose of the assessment and therapeutic work

Develop a mutually agreed care plan

Preparing for the first session: who should attend?

The family decides who should attend with help from the therapist via phone contact if required

The family are encouraged to consider the prosand cons of bringing different individuals

The person context is negotiated for each subsequent session, discussing again the prosand cons of having the whole family present or only certain individuals

Confidentiality and secrecy need to be considered if individual or couple sessions take place

First Family Session Structure

Relational introductions Brief explanation of the MBFT approach Problem(s) exploration

- nature and emergence of the symptom- contextual characteristics, fluctuations and exceptions- each family members understanding and attempts to deal withthe symptom(s)

- the effects of the symptoms on family and others- the outside help sought to date and previous treatment(s)

Identification of each persons wish / desire Contract or care plan

Care plan components

Brief description of the treatment model Commitment by each participant to participate

collaboratively, including informing the therapist if they cannot attend

Agree number and duration of sessions (6 sessions,1 hour, in weekly/fortnightly intervals)

Review session after 6 sessions Family is asked to complete initial outcome and follow-up

measures at the end of treatment and once thereafter, The care plan is written down and given to the family

when they next attend.

Subsequent Family Session Structure Find out how family has managed Agreeing on themes / topics / agenda Selecting a pertinent problem example in which:

- the child was upset or distressed- there was conflict between the child and parent(s)

Asking mentalizing questions: What do you think your child might have been thinking when he/she became

scared/upset/angry/argumentative (use as appropriate)? What were you thinking during the situation? How did you feel? Why do you think your childs reaction was different or similar to yours? What do you think your husband/wife/sibling might have been thinking?

How did he/she feel? Can you comment on differences or similarities? What do you think your child might have thought you were thinking? How

might this have left him/her feeling? Would you have wanted this scenario to work out differently? In what ways?

Selecting and reviewing in-session intervention Setting and reviewing homework task Sharing the formulation Concluding the session

Review Session (session 6) Review therapy and consider the pros and cons of future therapeutic

work or terminating therapy altogether. Provide an opportunity for the therapist to meta-communicate about the

process of therapy via the presence of a second consulting therapist

Review process1. Consulting therapist invites the therapist to narrate the work to date2. Family members are invited to reflect and comment on the therapists

narrative3. Consulting therapist encourages family members and therapist to enter

into a discussion as to the pros and cons of more therapy4. Consulting therapist then leaves the room and the therapist focuses the

family on this task. 5. If family decides to have more therapy, the therapist gets the family

members to consider the intervals between sessions.6. If a decision is made to terminate therapy, the protocol for the final

session applies

Final Session

The family is invited to set the agenda The therapist specifically asks about positive

family activities The role of the therapist in the family's life is

discussed and how this space can be filled when therapy is terminated

The family is invited to predict likely difficulties for next weeks and months and to think about preventive action

MBFT Techniques

The Nine-Step Loop

1. Observing interaction2. Checking for consensus3. Questioning problem 4. Mentalizing status quo5. Pausing, reviewing and marking6. Generalizing7. Inviting vision8. Planning action9. Checking feeling states

Steps 1 & 2: Observing interaction and checking for consensus Step 1 (observing interaction): the

therapist makes a statement about an interaction between two or more family members, focusing on an emerging pattern of how family members relate to each other

Step 2 (checking for consensus): The therapist then checks his observation by inviting the family and its individual members to connect with and perhaps share this observation, but also gives them the chance to dismiss it

Steps 1 & 2: Observing interaction and checking for consensusI notice that when Sally does x (cry), David it looks as if you find it very hard to understand what exactly she is feeling and why, and without this understanding her behaviour doesnt seem to make sense (step 1a ). Have I got this right or am I totally off the mark? (step 2a) Can you see what I am talking about? Well, let me continue to me it looks that when Sally does x (cry), this makes you feel (or act) really y (confused), and so you do z (cut off) or respond in y (confused) way.

Step 3: Problem questioning

If the observation resonates with some (or all) family members, the therapist asks whether it is experienced as being problematic for any members

Do you feel all right about the way this isthis kind of going round in circles (are you happy with that)? If not, why or how does it bother you? Is that the way you want it? Is that something you want to change? Does it ever cause you a problem? Do you sometimes get stuck?If you kept this going what might be the outcome?

It is only if or when at least one family member perceives the observed interaction as being problematic, that the therapist can focus on this issue

Step 4: Status quo mentalizing

Share and provoke curiosity amongst and between the family members about the minds of others and

Model the attitude that learning about how others are thinking and feeling is enlightening

Facilitate emotional brainstorming, encouraging mutual exploration to unfold and gain its own momentum

Step 5: Pausing, reviewing and marking

Once emotional brainstorming is underway, slow down the interactions between family members, questioning or expressing a specific interest in exactly what person x is feeling as this interaction unfolds

Encourage family members to form a working party to think about interactions and find some buzz words to mark the interaction sequence and the associated feeling states

Aim to find a word or phrase that becomes some form of mantra which family members can recall after sessions, when similar stuck interactions evolve

Step 6: Generalizing

Help family to move from a specific interaction in the session to more general observations and reflections on how similar interactional patterns tend to evolve spontaneously at home

What is observed in the here and now of the session is looped out into life outside the session, in an attempt to identify recurring dysfunctional patterns

Step 7 and 8: Inviting vision and inviting action

Inviting vision: Ask each family member to identify different ways of overcoming stuck interactions and to think about alternative ways of dealing with recurring problematic interactions

Inviting action: Ask family members to consider specific concrete action

This may require them, in the first instance, to negotiate which particular vision should be translated into action

First action step should be specific and achievable

Step 9: Checking feeling states

Conclude the therapeutic sequence by getting each family members to view what happened from a meta-perspective

This helps to evaluate what may have been a new and emotionally charged experience, giving them the opportunity to reflect on what happened and the possible consequences

What did you make of what happened? Can you talk together about what this was like for each and all of you? Are there any conclusions you can draw from this?

Exercise

Family of parents and 2 children Parents blame each other for a problem in

the family and start to say so during the meeting.Therapist to Observe, Check, Question

problem, Mentalize status quo, Pause, Review and mark, Generalize, Invite vision, Plan action, Check feeling states

Specific mentalizing techniques

Helping the family to simmer down Working to disentangle feeling states Individual resonating Colombo style curiosity (nave questioning) Ballooning and buffooning

Specific mentalizing techniques

Searching for positives Mini role plays experimenting &

rehearsing Enacting problem scenarios Perspective taking Weighing pros and cons Subtitling

Mentalizing Checklist

Place: Where is it present? Everywhere, only at home, only at school?

Time: When and for How long? All the time, when certain feelings or particular interactions emerge, or when one person becomes depressed, anxious, manic, or uses drugs?

Type: How is the mentalizing expressed, recognized, and responded within the family?

The mentalizing matrix: Questions to ask in assessing mentalizing capacity Does one person tend to answer for others? Do the caregivers try to help the child / young person / partner

express him/herself or come to an understanding of his/her experiences?

Do family members regularly refer to their own and others thoughts and feelings?

To what extent do family members spontaneously seek out the point of view of other members of the family?

Do family members mention different perspectives or the possibility that they might be wrong about how others think and feel?

Do family members talk about feelings being open to change (in self or other)?

Do family members refer to particular experiences that might make one person feel and think differently about something than another?

Are family members comfortable with speaking about thoughts and feelings?

The mentalizing matrix: Questions to ask in assessing mentalizing capacity Are descriptions of family interactions dominated by non-psychological, all-or-

nothing explanations? Do caregivers support each others effort to help, support or understand the

child? Is there a spontaneous give-and-take, two way communication between the

parents, between each parent and the child and between the family as a whole?

Is there playfulness and humour in the interactions between the family members?

Is there a sense that the child, each of the parents or other family member experience that they can choose how they behave and how they interact with one another?

Is there freedom to talk about the full range of thoughts and feelings, or are certain feelings or thoughts avoided or result in a breakdown incommunication?

Do family members convey a sense of purpose and intention when talking about their behaviour? Do they convey meaning when talking aboutthemselves or someone else?

Generating a working hypothesis

The therapist generates a hypothesis by asking (himself) a number of questions:

How and why has the family agreed on their target problem?

Which mentalizing problem will seem most relevant and plausible for the family to tackle? Which is most urgent problem for the family?

Which mentalizing problem may be implicated in leading to, maintaining or exacerbating the target problem?

How amenable is this mentalizing problem to a brief intervention?

Sharing the hypothesis with the family

Step 1: Identify a strength that the family has demonstrated

Step 2: Select a context where the family has more difficulty mentalizing and describe this to the family

Step 3: Link this difficulty with examples from the previous session (derived via 9-step model)

Step 4: Make links between mentalizing difficulties of each family member. (e.g. because you are concerned about Johnny, you try very hard to help him understand his feelings, but it may be that this sometimes makes him feel a little confused and means he gets less practice working this out for himself and telling you how he actually feels).

Step 5: Link these formulations to the referred problem

Child-focused techniques

Role-playing Coaching Thought guessing Feeling spinner game

Child-focused techniques: Coaching

Useful in situations where the child was not thought about properly, but could not elicit a response from the parents that would have enabled them to see the childs feelings and thoughts as these were at the time

The therapist suggests some ways of responding that the child may not have thought of during the moment. For example, the therapist might say: When your mom was talking about your room being messy, I saw you start to get upset. I wonder what might have happened if instead you

Aim is not to correct the experience but to encourage flexibility in the childs behaviour repertoire in relation to this type of experience.

This activity can also be used with parents in the absence of the child.

Theoretical Framework of Mentalization Based Family TherapyObjectives of MBFTMBFT and other therapeutic approachesComponents of successful mentalizingMentalizing strengths I: Relational strengthsMentalizing strengths II: Perception of own mental functioningMentalizing strengths III: Self-representationMentalizing strengths IV: General values and attitudesThe Modes of Psychic Reality That Antedate Mentalisation and Characterize Suicide/Self-harmThe Modes of Psychic Reality That Antedate Mentalisation and Characterize Suicide/Self-harmComponents of impaired mentalizingGeneralized mentalizing difficultiesPartial mentalizing difficultiesConcrete mentalizing difficultiesPseudo-mentalization difficultiesTypes of pseudo-mentalizationMisuse of mentalizationTherapist stanceTherapist StanceTherapist stanceThe mentalizing therapists stanceEssential to the StanceTherapist StanceWorkshop exerciseWorkshop ExerciseSession Structure and ContentTherapists core skillsAims of the first sessionPreparing for the first session: who should attend?First Family Session StructureCare plan componentsSubsequent Family Session StructureReview Session (session 6)Final SessionMBFT TechniquesThe Nine-Step LoopSteps 1 & 2: Observing interaction and checking for consensusSteps 1 & 2: Observing interaction and checking for consensusStep 3: Problem questioningStep 4: Status quo mentalizingStep 5: Pausing, reviewing and markingStep 6: GeneralizingStep 7 and 8: Inviting vision and inviting actionStep 9: Checking feeling statesExerciseSpecific mentalizing techniquesSpecific mentalizing techniquesMentalizing ChecklistThe mentalizing matrix: Questions to ask in assessing mentalizing capacityThe mentalizing matrix: Questions to ask in assessing mentalizing capacityGenerating a working hypothesisSharing the hypothesis with the familyChild-focused techniquesChild-focused techniques: Coaching