Mentalization-Based Therapy for Borderline Personality Disorder with Robert Drozek

Hello and welcome to Being Well. I'm Forrest Hanson. If you're new to the podcast, thanks for joining us today. And if you've listened before, welcome back. I've been really looking forward to this episode, which I truly think is about one of the most important skills we can develop. We've all had moments in life where we jump from noticing something to just knowing what it means. Your friend took a few hours to text you back, so they're losing interest in you. Your boss gave you a critical piece of feedback, so you're probably going to be fired. You felt anxious, so there must be something to be anxious about. The conclusion is so obvious and so intuitive that there's no reason to question it. It just is. What's happening in those moments is a breakdown in what today's guest, Robert Drozak, calls mentalization, the ability to hold our own thoughts and feelings as just that, thoughts and feelings, with a lot of uncertainty around them. So Bob, thanks for joining me today. How are you doing? Wonderful. Glad to be here. Thanks, Forrest. So happy to have you on the show. We've been talking for a while about doing this to let you know a little bit more about Bob. Bob is a clinical social worker and a psychotherapist at McLean Hospital, where he serves as clinical director of the Mentalization-Based Treatment Clinic. He's also a teaching associate in the Department of Psychiatry at Harvard Medical School. And he's the author of what I think, at least, is the first book about mentalization-based treatment that's been written for normal people, for lack of a better term, rather than clinicians, Mentalization, Utilizing Reflection to Heal from Borderline Personality Disorder. So I would love to start at the beginning here, Bob, and ask maybe a deceptively simple question. What's mentalization? them? It's probably the best place to start, I would say. Yeah, I thought you did a really nice job kind of describing it and describing kind of examples of the breakdown. And then the alternative is sort of like when it's working well, we can think about it as the ability to read, access, and reflect on mental states in ourselves and other people. It's all the kind of invisible stuff of the mind. So thoughts, emotions, desires, attitudes, values, the stuff that we can't quite see, but we are regularly making assumptions about and kind of looking at, so to speak, in ourselves as well as other people. So could you give a couple of examples maybe of times when it's working well? Like what does good mentalization look like? Yeah, it's a great question. Well, one of the kind of the most important parts of mentalizing is that it's kind of a two-pronged capacity. Like it's directed both towards self and other. so I am talking with you right now and you know and I'm curious about what's going on inside of you looking at your facial expressions I'm looking at to some degree um you're into your body movements your environment I'm kind of considering a lot of different stuff I'm smiling a little you're that's landing with you you're probably having thoughts about why is for smiling a little oh it's probably because he's into what I'm saying all of that natural process yeah well exactly. And actually, you're going to get a good distinction there. There's the what, which is what is Forrest feeling, right? And then there's the why. What's that about for him? So that curiosity isn't just what people are feeling, it's like, where is that coming from? And broadly, it's held with some level of flexibility, curiosity, or uncertainty. So that applies to when we're mentalizing other people, but also to ourselves. I think it's often kind of presumed that, oh, well, of course I know what I'm thinking you're feeling, right? And to some degree, that's true. And, you know, I can kind of look inward and be like, okay, what is happening for me right now? But also the same curiosity that I was applying to you, and maybe flexibility should arguably be applied to myself as well. Like, you know, how am I feeling? I'm feeling definitely excited to be here, you know, excited to be talking with you, a little anxious, like how is this all going to go, right? And there could be more to the story that I'm not even noticing in myself. So that kind of same spirit of curiosity can apply to self as well as other. And that kind of stance of openness and curiosity is really kind of like the heart of mentalization. That's great. And implicit in that is something that is both obvious and completely falls under the radar for us much of the time, which is that we have to imagine that. I don't actually know what's going on inside of you right now, Bob. I can make some good guesses about it, but I don't actually know what's going on inside of your coconut. You don't know what's going on inside of my coconut, right? So we're making assumptions about other people's thoughts and feelings all of the time. So there are these two big questions that we've got. The first is, how accurate are those assumptions? Are those assumptions pretty accurate? Are they not so accurate? And then second, how willing are we to acknowledge that they might not be totally accurate? Because there's this progression that happens from I feel fill in the blank, I feel X, to X is objectively true about the world. But that progression then creates a lot of problems for people. And now you've written a whole book about this, and I would love it if you could expand a little bit on what I'm talking about here. These are great kind of questions. In some ways, the answer is, is somewhat complicated because it gets at, there are multiple, what we call like domains of mentalizing. And in terms of the ways that things can go wrong, like that kind of gets at it. And one of the ways in which it can go wrong is I actually can be confused about what's going on with myself and other people and really kind of not have a clear sense of that. So that's kind of disruption in what I'm mentalizing, you know, or content. But there's also the kind of problems of sometimes you can kind of like know you're feeling a certain way, but actually not be sure like where that's coming from. That's like the why of mentalizing. So that's kind of leads to its own sort of problems. And then the other idea, which I think is what you were getting at in the question is disruptions in, in how we're kind of holding mental states, which that's really with certainty. You know, we can be quite certain, like I am right. And I know that I'm right. and I guess a question could be asked, well, why is that? Let's say if I feel certain you're mad at me, why is that a problem in mentalizing? Why is my certainty that you're mad at me be a problem in mentalizing? And this may sound really basic, but it's in the moment of my certainty, I'm not noticing essentially that it's an assumption in me. It feels like a fact. And that's probably the problem in mentalizing, this issue of certainty or concreteness in thinking that, at least from an MBT perspective, we would say is one of the key drivers of human suffering. So could you give some examples here of how these problems with mentalizing that we're talking about could create then common problems that people experience psychologically, like emotional instability, all or nothing thinking, all of that kind of stuff? Yeah, yeah. One of the core examples that sort of I was just, you know, leading a group for kind of folks today, you know, with with, you know, personality disorders like borderline personality disorder and narcissistic personality disorder. one of the kind of biggest sort of areas of trouble here comes when in our feelings of certainty about ourselves. A lot of times when folks are really struggling, there are often negative views of self that are being held quite rigidly. You know, like I'm a bad person. I'm not good enough. I'm worthless. I'm unattractive. Maybe certainty about my future. like I'll never be able to get better. I'll never be able to kind of feel better. And the idea is in those moments, those kind of assumptions, so to speak, they don't feel like assumptions. They feel like facts. And under those conditions, they are in control. And then we see all of the kind of emotional instability associated with various forms of psychiatric illness kind of take charge. You know, there's shame, there's self-hatred, there's worthlessness. There's literally the difficulty moving and mobilizing oneself because I'm bad. I am bad. So it kind of takes charge. But similarly in relationships, what can happen a lot of times is let's say we're in conflict with someone that we love. A lot of times in those moments, I feel like I know how the other person is being problematic. It doesn't feel like an assumption. It feels like a fact. So if I feel like I'm relating to somebody who is objectively wrong, I'm not going to be as kind to them. You know, I'm not going to be as empathic. I'm going to be more likely to kind of be dismissive or talk down to them. So these are, I think, examples where kind of the ability to mentalize can get really shut down and lead both to emotional challenges, like in the first set of examples that I gave, but also interpersonal challenges like instability and disruptions in relationships. So you were alluding a second ago to these different ways that mentalizing can break down for somebody. And you give a great list of this in the book. First, certainty. You become highly certain in your own perspective. You call this psychic equivalence mode. The second one is called concreteness. You're focusing excessively on external things. Call this teleological mode. And then third, disconnection. You've lost contact with either yourself or other people in some kind of way. And you call this pretend mode. Could you walk us through some examples here of each, either ones we've already given and connect, oh yeah, that's this mode, that's that mode, or any other way you want to kind of approach that question? Oh, definitely. Those are the bread and butter of MBT. That said, I should say from the outset, all those terms you just mentioned, though, those were ultimately kind of developed and coined by the developers and researchers of MBT. So I don't want to take credit for that. Totally, yeah. Which you weren't implying that, but basically Anthony Bateman and Peter Fonagy developed and researched the therapy. So this was my effort to almost take some of these really groundbreaking ideas and sort of make them digestible to the common person, just to kind of note that. So in terms of that, you really just highlighted like three, what we call non-mentalizing modes. So the first, we kind of already talked about a little bit, it's psychic equivalence, essentially excessive certainty or rigidity in our thinking. If I think it, that makes it true. Now, the challenge of even that way of putting it, though, is that in the moment that we're in psych equivalence, we're not even thinking, oh, I think it, therefore it's true. We're just thinking it's true. It's very difficult to zoom out the lens here of what this experience is like, but I think we've all felt it. Absolutely. So if you're able to reflect back over history and go, these moments where, well, maybe it was this or maybe it was that, but it certainly didn't feel that way at the time. It felt like, oh, this just is. Exactly. Yeah, definitely. It's a felt fact. So yeah, so that's like equivalence mode. And then there's what we call teleological mode, which that's where we overly rely on visible things to understand mental states. A couple examples of that is definitely like the example that we often give when we're kind of teaching patients about this. This person didn't text me back. That's what's visible. And then we then presume they're mad at me. Yeah. So something is happening and therefore fill in the blank. Yeah, definitely. So that's a very common one. That said, one of my favorite, not favorite forms of teleological mode, but one of my favorite examples of it is not just about how we interpret others. It's also how we interpret ourselves. Because for example, I may think my worth is dependent on visible things. My worth is dependent on what kind of job I have, whether or not I effectively performed in this podcast, like how much money I have, you know, how people seem to be treating me. So that's also teleological mode. And we've developed this in MBT for Narcissism, what we call teleological self-esteem, where all of us to some degree can base our self-worth on visible things too. And again, under those conditions, the world can hijack us. And then we get kind of tugged around by like the world and what, how it happens to be treating us at any particular moment. To some extent, the punchline of all of this is that these are experiences that are particularly prevalent or intense for people who are, if we think about personality disorders as being a kind of spectrum, because that's what they are in truth. And you need to make harsh distinctions, harsh in quotation marks, but you know what I mean, kind of harsh distinctions based on how we do diagnosis about urine A or B. But the reality is that there's a lot of fuzziness, and people can have these different traits to different degrees. But these are all symptoms, everything that you're describing, that can be associated with, in particular, borderline personality disorder, which is clinically what you focused on in this particular book. And one of the parts of the book that I found extremely interesting, and we're getting a little bit into the weeds here, but this is a nerdy podcast. I'm a nerd. It is what it is. I love it. I really loved the framing that you had, I think, again, from Dr. Peter Fonagy, that BPD is essentially a deficit in mentalization, that that's really the root of it. Could you please explain what that means for people? That is Peter Fonagy's kind of core insight. And he wrote a paper on it in like 1989. And in some ways, the whole edifice of MBT kind of is built on this key insight. Basically, the proposal is that our ability to reflect on mental states, it's not a static capacity. It's not like we do it equally well all the time. It's what we call context dependent, but also it's dependent on activation of our own attachment needs. So the proposal is that the ability to mentalize is inversely proportional to the activation of our attachment needs. And what does that mean? Basically means the more insecure I am in a particular domain, the harder it's going to be for me to think. And so that's the proposal in MBT. There are two triggers, the sort of key disruptors of mentalizing. It's any experience of rejection or criticism or abandonment can really disrupt all of our ability to mentalize. And then also any intense emotion. So the proposal is that sort of for folks with borderline personality disorder, which research shows they're more likely to have more anxious or preoccupied attachment styles, that that's the key disruptor of their ability to mentalize. So in those moments where they feel insecure, rejected, criticized, folks with BPD can feel like they can feel confused about what they're feeling. They can feel like have a narrower perception of what you're feeling. They can be gripped by certainty. It can be the certainty that my life has no meaning or that I'm bad, I'm intrinsically bad. But also teleologically, the idea is the person can feel like the only way for me to feel okay is to take some action. That's sort of one of the characteristic sort of manifestations of teleological mode in borderline personality disorder is like the only way for me to change how I feel is to hurt my body or to, you know, direct aggression towards you. I need to do it. Essentially how Peter basically explains the behavioral discontrol that research shows is actually associated with borderline personality disorder. This gets to another piece of this that I just found so interesting as a non-clinician, but just thinking about my own experiences, the experiences of other people I know, friends, things like that. And again, these are not people who have a BPD diagnosis by and large. These are just people who are going through normal emotional ups and downs that we all face from time to time. And then, of course, it can get scaled up in intensity based on just who the person is, their experiences in life, and all of that. But a section that I found so interesting was when you talked about these kinds of emotionally driven intense behaviors. Everything from emotional volatility to self-harming behaviors, like you alluded to a second ago, as almost a kind of reflex when somebody loses mentalization rather than a chosen behavior. The person isn't fully like choosing the action. It's just kind of happening to them in a way. I think that this is a huge piece of the puzzle, including how it can help people with feelings of shame and low self-worth, but it can also be a little tricky to understand. So I would love it if you explain this a bit. Oh, I really appreciate that question because to be honest, that's one of the things about MBT that initially, I don't know if I fully agreed with. I felt like it was sort of like almost taking away the person's agency. but the more that I've kind of like learned about it, it's one of the things I love most about MBT, which is this idea that like really in these moments where sort of any of us lose the ability to reflect on mental states and kind of some of the ways that we've been discussing, essentially, we don't have a buffer for action. So it's really this stance of reflectiveness that kind of gives us the ability to have agency in our relationships. To make choices. Yeah. Absolutely. And the proposal is without that, the person is kind of a reflex. They become reflex. And actually that was going to be, I didn't know what exactly to call the book. I knew the first title of the book was going to be mentalization, but basically I was going to, the subtitle I was playing with this idea is like learning how to reflect rather than reflex. I do like that. I like it too. They love a not this, it's that and all of that. Yeah. Yeah. But it was, but ultimately we wanted sort of like borderline personality disorder in the title because it is evidence-based for BPD. But, but basically along those lines is that in, in these moments, the person with borderline personality disorder is really contending with a sense of incoherence in the self, like a sense of like fragmentation, like there I've lost myself in a way. And so a lot, and that's the thing in those moments, it's, this may sound like melodramatic and maybe it is, but it's a sense of like, there's an existential threat. And when you talk about it that way, sort of with patients with borderline personalities, sort of, they get it. It's like a threat. I cannot continue to exist under these conditions. And I love that model because if that's the case, like if really like myself, but who I am is under threat. And the only way for me to actually restore a sense of okayness or selfhood is to cut myself. I just think that is that that makes sense to me. You know, and it really like I think there's an empathy to it because it's sort of like this is not manipulative. This is not just sort of like the idea like I'm doing this to get attention. I'm doing this to continue to exist. Yeah, I was talking with my fiancée, Elizabeth, about this. And people on the show will know Elizabeth. She's been on a number of times. And she has complex PTSD. She came from a pretty unstable family system. And I was talking with her about these moments of activation. And she said something that really stuck with me. To paraphrase, she basically said, it's deeply embarrassing because you can't control or stop it. It just kind of happens. And I thought that was such a a one-to-one parallel to what you're talking about here in terms of her direct experience. And I'm sure you hear similar things from the people that you work with. No, and I appreciate that framing of it. And that's sort of one of the most difficult thing for folks who struggle with this challenge is that they don't have full agency to regulate their behavior, but they do have enough self-awareness at other points to know, like this probably wasn't the way that I should have responded and stuff like that. And so there's really like two currents in experience and the person is kind of divided unto themselves. And that can create a tremendous amount of shame, actually. So to keep helping people understand where this come from, how it works, and also to keep on humanizing it. One of the things that you talk about in the book is how mentalization isn't an innate ability. It's something that we develop. You know, if a kid is raised by wolves or the functional equivalent, they do not know how to mentalize. So how do people learn how to do this? And maybe that kind of developmental question will then help us kind of learn how we're doing it these days. Nice. Basically what research shows, and this may sound really obvious, but it's that parents and caregivers ability to mentalize predicts the child's ability to mentalize. And so the idea is like, so if I'm the child and I'm having an emotional experience, basically, there's no and this may sound there's a there's a primary emotion. But just because I'm feeling something doesn't mean that I have the ability to represent it as a child. Right? We all have feelings, babies have feelings, but they can't necessarily represent what they're feeling, right? So the proposal is that there needs to be a particular type of mirroring, mirroring process between caregivers and children in order for kids to really understand what they're feeling. And it's got to be contingent, which means that it's got to correspond to what the child is actually feeling. Right. So if like the child is feeling sad and the caregiver might go like, oh, that's that's really difficult. Right. There's something tonal there that kind of matches sadness. right? Yeah. Versus like, that's really difficult. That would be like a non-contingent response. But the other point made in the book that I mentioned is that it also has to be marked. There needs to be a difference between what the child is feeling and what the caregiver is reflecting. So that's a little harder to kind of define exactly. But like, when I say, that sounds really difficult. There's something about the tone of that mirroring that lets you know that Bob's not sad. Parent Bob is not sad. Yeah, the parents referring to the kids' emotions, not their own feelings about it. Exactly. And that piece of it, I think that particularly people who come from more unstable family systems, you can just look back on a million experiences as a nine-year-old or whatever of you saying, hey, parent, I feel this way, and them going, ugh, that makes me feel fill in the blank. That makes me feel angry that you feel that way, or that makes me feel sad that you feel that way, because now I have to perform a task for you, or whatever it is. And you could see how adding that up over time, there could be this kind of fuzziness around emotional content. Is that mine? Is that yours? Where are the lines here? Do I need to be invested in what you're feeling? Do I just get to pay attention to what I'm feeling over here? What do these emotions mean? And that then kind of like trickles down the path to some of the issues that you're talking about with mentalization as an adult. Very well described. And that sort of the issue is that the parent essentially co the child emotional experience And so what the child then takes in if it not kind of marked if it not contingent the child takes in an image of the caregiver feelings rather than their own. And that is what MBT calls the alien self. And I thought this was, by the way, again, such a cool idea. And I would love if you talked about it a little bit here. So the alien self is alien to what the child was originally experiencing. So essentially, if I only get the caregiver's sadness, you know, or whatever, or anger, whatever it happens to be, then I never really come to know my own sadness. And so it's sort of like there's so that leads to two kind of two problems. There's this felt thing that isn't fully named or understood that's left in the child, right? And then there's this other image, sort of like something that doesn't kind of quite cohere and it creates this disconnect or sort of disjunction in selfhood actually. And the idea there is that that actually lead, that is a kind of a problem in mentalizing. So the only way for me to understand you is to understand myself. Like I need to use myself as a kind of, I don't know, like an example, so to speak. I need to know my own sadness in order to see sadness in you. But the problem is, if somebody doesn't fully get that, then there's a way in which they're kind of not able to really put themselves in the other person's shoes or fully even understand really be in their own shoes. And that's when we start to see kind of psychiatric challenges. We'll be back to the show in just a minute, but first a word from our sponsors. I often struggle to fall asleep at night, and people who have a hard time sleeping often feel like they're stuck between two bad options. 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But because it's directed at them so frequently, there's this kind of like fuzziness that happens where it gets almost absorbed for lack of a better way of putting it. But that material, which then floats around inside of them, becomes a source to them of like shame or self-loathing. And you even had this phrase, I think, the need to get the badness out, which often takes the form of different kinds of self-destructive behavior. And I just thought that that whole frame of it was so interesting. And I think that people could also see their own experience in it. Yeah, yeah. So that's the idea. And this is sort of like, that kind of part of the theory centers on the idea that sort of for folks with borderline personality disorder, but also for folks with complex PTSD and traumatic experience early on, it's not just that there's a mismatch between what the child is feeling and what the environment is reflecting. It's that often what the environment is giving back to the child is aggression. It's not just that it doesn't match. It's scary. There's criticism, there's aggression, there's invalidation, there's psychological control. And so what ends up happening there is then the child takes in this negative view of them and that sort of becomes a part of the self. And then how do we sort of, and that actually gets at the incoherence that I was mentioning earlier. So then the person feels disconnected from their primary feeling because it was never fully seen. And they also feel bad. Like I'm not good enough. There's something wrong with me. I can't even fully explain it, but there's something wrong with me. And the proposal is how do we get the badness out as you're kind of saying there? Well, you'll hear this was sort of for folks who engage in self-injury, like self-injury, people will say one of the most common ways that they'll describe that experience like phenomenologically is the pain was moving from the, from the inside to the outside. And then I could finally think, and I could have some so the badness left the almost like the person's heart and and moved to their arm and you know and then i could think um but also you know part of like borderline personality disorder is associated with you know anger um you know anger issues you know criterion eight emotional explosiveness yeah exactly and if i'm really angry at somebody then the badness is on the other person they're mistreating me, right? So it may sound a little odd, but that's the idea is that that kind of getting the badness out, experiencing the outside as kind of harming us actually preserves a sense of self because it's like, I'm not bad, you are. And that can kind of explain sort of like the psychological necessity of some of these, like we might call them coping mechanisms in borderline personality disorder. For me personally, understanding the thought that went into the development of something like this, the basis of it developmentally in terms of people's early experiences and things like that can really help you get a sense of what the principles are that a certain intervention is kind of working from. And then so when you learn more about the intervention itself, you can see like, oh, okay, that's what that connects to, or that's what that connects to over there in a kind of way. But I would like to move on to how do you actually start developing this ability to mentalize more and some of the common issues that people run into. One really important aspect of the process is identifying and working with different kinds of triggers. And you mentioned earlier how a lot of this gets to different sorts of attachment injuries or feelings of relational instability with another person. Maybe we can start there in terms of talking about this. This is kind of like implicit in what we're talking about, but just to kind of mention mentalization-based treatment. It's an evidence-based therapy for borderline personality disorder, as we've been kind of discussing, but it's not just a way to understand borderline personality disorder. It's also, you know, really just there have been tons of randomized controlled trials showing that it really helps with some of the core symptoms of borderline personality disorder. So decreased self-injury, decreased depression, decreased hospitalizations, all that stuff. And so part of the version of MBT that's been like research involves at the early stages developing what we call like an MBT formulation. Sort of it's an early part of the treatment, which is really we're trying to kind of like itemize with patients their core problems in mentalizing. I really wrote the book so that people could develop their own MBT formulation. So by completing the worksheets in the book, by learning about the concepts that people will be able to kind of get a taste of this like highly effective form of therapy. So anyway, that's a bit of the backdrop of it. And then in terms of your specific question, so the first part of an MBT formulation is actually itemizing your triggers. What tends to kind of disrupt your ability to think? What tends to kind of lead you to feel rejected, criticized, abandoned, and actually kind of putting it in merely like objective terms. Seems like, well, why is that helpful? Really? You know, you might ask, well, that's, you know, because I know what triggers me, but that doesn't actually stop it from triggering me. Right. But the proposal is by really being aware of where my kind of vulnerability areas, the life of someone with sort of severe personality disorder or personality disorder can feel like it's a minefield. where there are these sort of landmines scattered about and you don't know where it's okay to step and not step. So the proposal with itemizing triggers or writing this up in a formulation is that it actually, it's like a map of your own personal minefield. Where is it dangerous for me to step? And the idea is if I know, hey, whenever I'm interacting with this person, it tends to be really, really difficult. Or whenever somebody gives me this sort of type of feedback, I tend to actually feel quite activated. Then I have more of an ability to hold onto my mind. And in some ways, without that, it's going to be very hard to use all of the other evidence-based strategies in MBT. So triggers can take like a lot of different forms for people, of course. But for many people, the ones that are going to be the most distressing, the most activating, are relational in nature. Friend took a while to text me back. I feel a certain kind of way about it. I see somebody, or I think I see somebody express disinterest in me. I share a story in a group. Nobody reacts the way that I kind of want them to react. These can then connect to different kinds of attachment injuries or attachment styles that people have if you've got a kind of sensitivity with regards to this stuff. Attachment-related information is out there en masse. It's incredibly popular. And it might be helpful here for people to draw some parallels between that and MBT. Well, yeah, I think your podcast specifically, it does a wonder you're very interested in attachment here. And I love it. You're very like a knowledgeable, you know, a lot about it. But also like a lot of your guests are just very kind of like knowledgeable folks on this stuff. But yeah, so this is the idea. So what happens when we get triggered, all of us have kind of particular responses moves interpersonally that can be kind of, you know, sort of distilled or seen through the lens of attachment styles. So, you know, one of the more kind of common ones is the distinction between attachment anxiety versus attachment avoidance. So this sort of idea of like, okay, when I tend to get triggered, I'm kind of thrown, how do I cope with that distress? Like, do I do it by moving closer to people, you know, or do I do it by trying to move away? that's another thing. It's not just what triggers me, but what direction do I go when I'm triggered? Am I more secure in my attachment approach? Am I more preoccupied so that I'm kind of feeling kind of badly about myself and looking to others to regulate me? Is this more avoidance, you know, where I kind of feel badly about myself and also have a sense that the world is unsafe? That's kind of avoidant attachment or fearful. And then, or is there more of a dismissive attachment approach where I actually feel like, you know, you kind of suck and I'm okay, right? And I sort of cope with difficulties through more noticing how different or better I am than other people. So that's sort of one of the big kind of questions. And that's the thing about attachment styles is that they're kind of, it's more nuanced. Like it's not like all of us employ the same attachment approach in like all of our relationships. Under what context am I more drawn to particular ways of relating to others when I get triggered. One of the things you also write a bit about is this idea of exciting triggers. And this is something that I think you mentioned being kind of underappreciated for people. And these are more positive attachment situations, but they're ones that raise the stakes in a way that can actually feel kind of intense for people. Would you mind giving an example or two of that? I thought it was pretty interesting. Yeah, yeah. That's one thing that I think is a little different about MBT's conception of triggers, because when often like in popular culture, you know, we talk about like trigger warnings and stuff like that, we kind of have painful experiences. Yeah, exactly. So but the whole idea is that especially for folks with difficulties with sort of unstable self esteem, or, you know, challenges and sort of relational stability, sometimes hope is just as triggering as dread. You know, so the idea is that sort of like, if there's a new potential relationship, where there's this sense of like, this person sees me, this person understands me, we might have a future together. And the person hasn't even done, you know, there's been no difficulty in the interaction yet. But the promise of some sort of, you know, experience of being seen is very, very threatening for folks a lot of the time. Because if there's a promise or a hope, That means I could lose it. So there are certain scenarios where, you know, for all of us really feeling like we're going to get something we want or that we've always wanted can just make it harder for us to think and harder for us to kind of be more flexible in our ways of experiencing that relationship. And that could be, I get a new job that's supposedly a great job, right? But then there's the concern, like, actually, what if I'm not able to perform? And then the whole tower actually topples. One of the categories of trigger that I think is kind of related to this, that I also connected with personally and think people probably will too, is this idea that it can also be painful for something to not happen, even if it wasn't that something bad happened. So an example of this is like, again, not getting the text from the person, a partner being distracted. when you're sitting down to do something together, a friend not noticing a mood that you were in. And that can be just as painful for somebody, particularly somebody who has this kind of attachment insecurity, as something bad actually happening to them. And so those feelings of lack or absence or the other person not noticing are just as painful or intense a lot of the time for people. And I think that that can be just sort of helpful for people to look at. Hmm. That's a good point. Yeah. It's in the book, I call that I'm valued interpersonal interactions not happening, which I've like, sure, that is so clunky. I wish I had a better way to describe it. It's hard to talk about. Yeah. But people know what you mean. Exactly. Yeah. But that's the idea is that when when there's this thing that I want, there's this thing that I'm hoping for, maybe I haven't, you know, fully represented it to myself. And then it doesn't happen. Then, you know, that can really kind of throw all of us off. Yeah. So I would love to walk through this with you. What's it like to maybe build one of these formulations with somebody? So somebody, you're sitting down with them, you're asking them, what's it like to be you on a certain level? That's a classic Rick Hansen join in question in therapy. It's one of his leaders. and the person says, oh, you know, I get upset easily and I just feel like I sometimes have a hard time kind of controlling my emotions and causing some problems for me. Okay, what happens from there? How do you move to something a little bit more specific? That's a really good question. It's almost that there's a difference between like exploration of kind of like presenting problems, we call them in psychiatry, and then actually the building of the formulation itself. So thus far in MBT, the way that it's worked is that, you know, we're doing these sort of early interviews with sort of folks coming into treatment. And usually it takes like about like four sessions of kind of just trying to kind of get a picture of where the person tends to struggle. And we're wanting to be curious about patients' goals, what do they want out of treatment. But as a clinician, because we have kind of access to these kind of the theory about the different problems and mentalizing stuff like that, essentially, I'm like listening to the person describe their challenges with an eye towards where does mentalizing tend to break down. But I would propose that there's a real limitation in that because why is it that me as the therapist sort of holds all of that information? Like, wouldn't it be useful if patients could actually be able to like look themselves at these sorts of challenges? And you can't just say, hey, how does your mentalizing tend to break down? Like you can't just ask somebody that, right? So that's sort of, I think what, you know, historically it's sort of like what will happen is that the therapist will write something up in a document and then present it to the patient, get feedback, and they'll kind of collaboratively revise it. But part of what my hope is with the book is that all of the worksheets in the book are really kind of like asking patients questions directly or not patients, readers, these questions directly so they can find their own problems in mental life. And that gets, I think, to one of the things about MBT that's really interesting in terms of like therapeutic stance and relationship where you guys, as far as I'm aware, and please correct me if I'm wrong here, you explicitly do not tell patients what they're feeling. because that's effectively the therapist doing a kind of psychic equivalence. You're making assumptions about what's going on in the mind of the patient, and you're expressing a lot of certainty about it. Got to tell you, essentially every experience I've had with a therapist has involved some amount of them telling me what I was feeling or making an assumption about what I was feeling. And that's a kind of natural, if you think, go all the way back to psychoanalysis, the clinical stance is the clinician is the one who knows, they tell you about yourself and you're just supposed to kind of do what the clinician tells you to do. And it feels like you're essentially doing the opposite of that in MBT. And I would love to give you an opportunity to talk about that. I love your questions for us. I think you get the heart of a lot of really important kind of the parts of what makes therapy works and how therapy works. I love it. Yeah, it feels very humanistic in terms of like the orientation. I don't know if it's thought of as explicitly a humanistic approach to therapy or not, but it's got a lot of that in it that's a good point yeah yeah no it's true humanistic or kind of like give quote patient centered or kind of like person centered yeah and egalitarian we also talk about it that way yeah so what you're describing in mbt we call the not knowing stance and basically the therapist is really forbidden so to speak uh for like filling in the content of patients mental states. We're just not allowed to do it. So when we have like, you know, I'm like a trainer in MBT and sort of help kind of therapists learn how to do it well. We have a may sound really, you know, technical, I don't know, but like, we have an adherence scale. And that's the heart of the adherence scale. To what extent is the therapist, essentially, like being more inquisitive versus declarative. And that's kind of the injunction for therapists. It's like, when you want to make a statement, ask a question. And it was definitely the hardest because I was trained psychoanalytically and sort of indefinitely, like you're saying in psychoanalysis, there's a more kind of interpretive stance where the clinician puts words on not just like what the patient is feeling, but what they're wanting and how that relates to their challenges. We can't do that in MBT. And the idea is absolutely, I love your point about psych equivalence, it kind of overtakes the patient's mind with our own certainty. But think about the stuff we talked about with the developmental theory, you see the parallels here, is that isn't that what caregivers were doing, right? Mm-hmm. A clinician is a person too. And that's part of what you're doing in the MBT process is there's an implicit instruction that's happening. And correct me if I'm wrong, but there's an implicit instruction that's happening in the room that, hey, the therapist is a person too. And they're also making assumptions about your thoughts and feelings. And they have their own thoughts and feelings. There's this kind of like, I don't know, like student-teacher sort of swirling together in it that is sort of implicit. it. But then it makes me wonder, well, then what are you doing? Like, how is this process happening with somebody? It's a really, really good question. So it gets at the kind of the distinction that I mentioned earlier, the kind of three types of mentalizing, what, why, how. So essentially, what do we do to start in a session? We always start with the what, you know, in this sense, I think it looks very much like traditional psychotherapy. And at the beginning of a session where we're actually kind of saying, okay, well, in MBT, we do set agendas in the session. So what do you have for the agenda today? Or what do you want to talk about? Right? But we always start by getting at the what. It's at what happened. You know, often when people come to therapy, they want to talk about something that's happened since they've last seen their therapist, right? So you ask a lot of clarifying questions, but then we've got to shift to mental states, the what of mental states. What do you think was going on for you around that? What do you think so-and-so is experiencing? Now, that sounds pretty basic, right? I'm sure, you know, our therapists sort of ask us questions like that all the time. But a lot of what we have to do in MBT is essentially like what happens when the person says, I don't know what I was feeling or I was angry. I was pissed off. This person sort of did this thing wrong. So essentially what we're trying to do there is really expand the array of mental states that the person is in touch with in themselves and other people. And through that process, we're actually going to be, we're listening and we're going to be asking ourselves the question, which you really started, you know, much earlier in this episode, you were talking about of where are the problems in mentalizing? And this is a little less, I would say, just strictly person-centered because that's the therapist's assessment. And they say, Is there a little bit of certainty here that is causing the person's trouble? Is there some concreteness? Are they overly relying on outside things to feel okay? Or we didn't talk as much about this, but is there a disconnection or pretend mode where they're kind of talking? They seem quite thoughtful and intellectual, but they don't seem to be feeling their feelings. And then at some point in the session, usually it's sort of we've been exploring matters for a while. we do need to kind of come in and try to actually help with the area in question. And it doesn matter like there no right or wrong answer to that Like the certainty is the problem or the disconnection is the problem But as an MBT therapist we going to try to target those areas where it seems like reflection might be shutting down So in practice, it's really easy for these modes to kind of flow together with each other, even though we hold them as being kind of distinct. So, for example, again, we're going to do the friend doesn't text you back example because it's just it's what we're doing today, I guess. First, their silence means that they're mad at you, and that's that teleological mold. And second, you're sure that this is the case. That's kind of psychic equivalence. And then third, maybe something like you go more emotionally flat, and you stop really caring about their perspective, and maybe it's slightly dissociative, or there's a little whiff of that. Okay, that's maybe more pretend mode. And so you're drawing these sharp distinctions between things, but pragmatically, There's a lot of blurring and blending of them together. And maybe we can kind of walk through each of these and you can give some actual advice on what a person can do about them. I think that that would be sort of helpful. Does that make sense? I love that. So what do we do about it, right? So the start is you got to actually identify what is the teleological equation? What's the teleological assumption that I'm making? And then if we were actually write it out and there are like worksheets on this, in the book itself of how to do this. It's essentially them not texting me back equals they're mad at me. Right. And then what do we do is like, what's your case for that? So we always start by actually looking at the person's own perspective, what supports this idea? And what's really important about that. And I would say this really for your listeners, is so important, can't just jump in to trying to change beliefs. People then feel very invalidated. They feel like they're kind of being talked down to. Could you give an example here of what you're talking about, like jumping into changing beliefs? Well, like a therapist will be like, you know, often therapists are like, well, what makes, you know, like... That's probably not actually happening. They really like you, Bob. You don't have to worry about it. Yeah. Exactly. And then it's also like, I don't know how you feel when I'm in teleological mode, I'll be like, well, actually, no, I'm right for this reason. It actually leads people. And also screw you, by the way, is how I feel a lot of the time. Like, what do you mean you're telling me how I feel? Okay, yeah. Exactly. Yeah, yeah. So you got to start. So in MBT, we got to start by the person validating their own perspective. You know, what leads me to really feel like them not texting me back kind of means this, you know? So that's kind of the first step is actually validation of the viewpoint. but then look at the consequences of it. What does that do to you to feel like them not texting you back means that they're mad at you? Well, I feel insecure. I feel bad about myself. I feel anxious. Maybe I then text them again. I engage in a behavior that sort of potentially can alienate the person from me. But this is actually a strategy is to kind of almost think through, okay, when I'm assuming this, how does that impact me in my life? And this all may sound odd. How is this inherently helpful? Well, because to put words on what leads me to believe something and to put words on how does it impact me when I'm holding this view so tightly, I can't do that without starting to relate to it like it's a belief. There's no way to do it. So we're moving it from the realm of fact to psychology. And then the next step to contextualize your suffering in light of the assumption in question. So to really consider the idea, is it possible that I'm feeling so bad? Not because the person didn't text me back, but because I'm assuming that them not texting me back means this thing, means they're mad. And again, may sound so obvious, like, but that again, makes it so that maybe the problem is not, they're not texting me back, but the fact that I'm kind of, you know, quite wedded to this perspective, a version of this too. I think that, you know, I see with a lot of patients is like, when there's teleology of self, it could be this idea, like, you know, is it possible that the reason why I'm feeling so bad is not because I don't have a prestigious enough job, but it's because I'm assuming that such a job like determines my worth. And just starting to consider that possibility is a game changer because it shifts the focus from this outside thing that we think is the problem to actually what's going on inside of us. That's the, that's the start of the trajectory of kind of treating these things. The next step is to actually actually think about, okay, what else could be in play? You know, other than what I've been assuming. What else could be true? Yeah, what else could be true? They're not texting me back. Are there any other things that could be in play for them? And we're trying to kind of expand it like, okay, maybe they have other stuff going on. They might be busy, maybe they need to think about something for a second, you ask them a question. Are you free? Fill in the blank. Maybe they need some time. Am I free? Fill in the blank. Sure. Exactly. Yeah. Yeah. So but the other piece, and this may seem a little less intuitive, it's that, well, imagine they did text you back. Okay. Could you imagine them texting you back and still being mad at you? Which is a kind of a funny move. But like, absolutely. You see how that challenges the equation? Yeah, totally. The reason that they didn't text me back is because they're mad at me well they might they could be mad at you and also just like respond immediately so yeah that's really interesting totally yeah and so it so it starts to challenge this categorical linkage so that's what we do we do it doggedly and also i want to encourage you know folks like your listeners if you struggle with these sorts of things especially like these teleological interpretations of others but i would say even more importantly like all of us have teleological interpretations of self, like I am only valuable if, try these strategies on that. And my experience with patients is when they're able to really doggedly try to articulate these teleological equations and challenge these linkages slowly, but consistently, we start to see improvements in self-esteem. So it's probably bad podcasting to just read a long quote from a book, but there There is one that I want to read, and it really gets to one of the big challenges with that certainty feeling, which I think for a lot of people is kind of the crux of the whole thing in some different ways. Effective mentalizing always involves some level of flexibility. Part of focusing on mental states entails understanding the pervasive influence of your mental states on whatever you feel like you are perceiving about reality. You only have access to your perspective on any issue. This perspective is saturated with your personal biases, meanings, and personality. And so it likely says more about you than about the issue in question. And then you go on to say that because of this, we should be relatively humble and cautious about our assertions about ourselves or other people or the world, and just kind of like hold it with a lot of what we're talking about, which is like uncertainty, don't know mind, all of that good stuff. Great passage. But my experience is that when people read something like that, they go, yeah, of course that's true. You know, everybody's got a perspective. But then when it comes time to actually think or act, they don't think or act with that knowledge running in the background. They go, oh, yeah, sure. Those other people should act with more perspective, but I'm seeing things accurately. So how do you help get some space around that, particularly in those moments where a person is like a little bit more activated, where these breakdowns tend to happen? Is that you're trying to like catch it before that happens? Is there something a person can actually do in the moment? Like what helps with that? That it really does get at the heart of it. And I would say personally, like that is what I end up hearing a lot from patients who are kind of in this spot. Like, okay, this sounds great. Well, I know that. So what's next? So there are a couple kind of responses I have to that. It's a really great question. One is we absolutely one of MBT's kind of sayings, especially for MBT for borderline personality disorder, is strike when the iron is cold. we really need to kind of when everything's going okay we need to be targeting the forms of certainty that actually can usurp the patient's mind we you know or just like we need to really be regularly kind of trying to bring reflection and potentially like shine reflection into those areas of the personality so for example just sticking with the one that i that i gave you know which essentially, which I see for so many patients, like my career determines my, my value. And if I don't have a good enough career, then I'm bad, which you can see for folks with borderline personality disorder, narcissistic personality disorder, it's sort of very, very common, that sort of view of achievement as determining worth, right? The, the proposal is sort of, even when you're doing okay, and almost especially when you're doing okay, can you try some of these strategies kind of challenging this linkage? And the idea is, hopefully, the more that we can do that, like when we're actually feeling okay, then it does sort of start to take the wind out of the sails. So that's sort of one piece. But then the other thing is, is that I don't know if I'm going to be able to say this correctly, because it's kind of a weird idea. A lot of times what happens is that when somebody tries to challenge their beliefs, they do it from outside the belief. They talk back to the belief. And really, I think this works best is we need to enter into the certainty and actually feel like I believe this is true. And from when we're within it, we need to begin to question it. And that makes all the difference. And I don't know, it's such a weird idea. Could you give an example of that? Yeah. Or maybe try to paint a picture here? Sticking with this idea, like, if I don't have a sort of career, sort of a good enough career, then I'm worthless, right? It's easy to say, oh, yeah, I know that doesn't matter. Like, I know that kind of like, I'm a good dad. And then like, you know, I care about people, so I'm fine. Like, it's like talking back to the belief, but it's over there. So what I'll ask people to do is I'll say, okay, close your eyes. And I want you to get really in touch with this thing you believe to be true. So, okay, really feel that, that sense of like, my career determines my work. Do you have it? Okay. Yeah, I got it. Open your eyes. I want you to consider from while you're feeling it, begin to question it. So you got to enter into the certainty and begin to question it while you're feeling it. And it's a weird thing to put words on. I don't know. Maybe you could put your... Could you give an example of questioning? What does you mean questioning? Are you saying... So examples might be, there are a lot of people who have this kind of an experience and I think that they're worthy. Why don't I apply to the same standards to myself? I'm just spitballing here. I'm wondering what you did. So my career determines my value. And so can I access that? Okay, I can access it. Open my eyes. can I imagine even with this sort of and for somebody who feels like they haven't achieved enough can you imagine at this moment you let's say you never get a job that you see as good can you picture yourself still feeling like you have worth as a person just imagine it you don't have to believe this but I don't believe that I don't believe that at all that's okay you don't have to believe it can you just see it in your mind what would that be like and just sort of like from within it, considering it. And then, you know, do you still have it? Yeah, I still have it. Okay. Imagine you got that job. You got the job that would finally give you value. Can you ever imagine still feeling, still hating yourself? Well, of course I hate, I, I, I would, I had this job before and I still hated myself. I've got plenty of other reasons. Exactly. I'll tell you all about them. Exactly. So that's what it means to sort of begin to challenge the linkage from the inside. And that sort of will be the prescription. And it's like a lot of people know this cognitively, but in the moment of shame, they don't pause to actually interrupt and disrupt some of these forms of certainty. So that's kind of where the rubber meets the road. In the moment where we're really feeling bad, we need to pause, put words on the certainty, and begin to try to see it in another way. And my experience is when people do that with doggedness, we start to see improvements in the area of their lives that really cause them tremendous pain. You give a bullet time metaphor in the book from The Matrix of my generation, this idea of kind of pressing pause and seeing things slow down. And this is the whole reflecting rather than reflexing, like you were saying in the original subtitle. And that pause doesn't necessarily mean that you're like solving the feeling. And I thought that this was a really essential part of what you were talking about. You're not suppressing it. You're not pushing it down. You're not even doing what you were saying a moment ago, that kind of like dogged, arguing against it on a superficial level. You're creating this reflective space where you're noticing, saying, oh, my mentalizing is kind of going offline here. You're having thoughts about your own thoughts to put it a certain kind of way. You're going, oh, I'm starting to make these assumptions here. Oh, wow. I'm really connecting the dots from point A to point B. And the more space that you can kind of create, the more of that a person is able to do because they're not so like gripped by what's going on. Am I saying that more or less correctly? Do you want to put a finer point on any of that? No, no, definitely. That's the idea. And I do think it's a really important. Actually, you and your dad talked about this in a reason podcast episode, not to like keep referencing your podcast, just this idea of like, sort of like making sure to make sufficient space for the problem itself. And whenever, if somebody, if there are these kind of pernicious, challenging areas of, you know, beliefs that the sort of the person has, we really need to not dismiss them. It's really this idea of, I believe this and really access, like what, where's the logic in that belief? Because it makes sense. Like we, none of us arrive at kind of any of these ideas that cause us pain just for the heck of it. Like we, there's a, there's a logic, there's even a wisdom to a lot of these, these sort of ideas. And right while we're in it, right alongside it, can we also see it from a different way without then trying to use the new idea to suppress the old one. That is key. And this is sort of what makes MBT so different than from CBT, is that really, like, this is not cognitive restructuring. This is, I see it this way, and I really believe it, and I'm going to try to see it another way. And the trying to see it another way, we would throw, that's where you start to see some relief, even if you still believe the original idea. Back to the show after a quick break. Now, back to the show. So there's something that I've been wondering about as we've been talking here. And it's a real problem that you'll see in therapy and that you see in life. Where we do all of this really good developing of, oh, we're not sure it's that. Maybe it's these other things. What if this thing? And we're getting more and more space around it. And then the person has an experience where their intuition, their assumption, their fear is actually true. It took the other person a long time to text back because they actually didn't want to talk to you. And that can be extra painful for somebody with these kinds of attachment fears, of course. But my assumption is that that can also really disrupt treatment. Because you've been telling me to think about all of these other possibilities, Bob. But it turned out I was actually right the whole time. What do you think about that? Oh, such a good point. How do you handle that? Like, what do you do about that, whether it's the person or as a clinician? Well, I love that point. People's favorite version to give of kind of the forms of teleology that we're talking about will be like, well, somebody cut me off in traffic and maybe they were rushing to the hospital to like tend to a loved one, right? And it's sort of like this Pollyanna-ish kind of idea that's sort of like, really, everybody's fine with me. It's like, no, that we don't want to kind of encourage, like, you know, maybe they're not fine with you, right? Maybe the person cut you off in traffic because, you know, they were, I don't know, they thought they had a better car than you and they deserve to do that, right? I don't think that this should be interpreted as this idea that kind of really everything's okay. This kind of overly positive, kind of naive interpretation of mental states, what I would say is that sort of like, what's the issue? Where's the problem in mentalizing that kind of the heart of it that's really fueling our suffering when that person doesn't text us back? Well, often, there's some deeper other form of certainty that's in play there. And it might be like, okay, how this person feels about me determines my worth as a person. So that, you know, like often, or it's a version of the kind of the point about my career determines my worth, like there's so often deeper forms of certainty there. So I think really clinically, what matters most that we get to these kind of core forms of certainty that actually make these things so upsetting. And it could be like, I need this relationship in order to kind of feel okay, you know, and if we're targeting those forms of certainty, it almost kind of doesn't matter, you know, why the person didn't text me back. Because actually, we're working on helping the person have a more flexible, robust, coherent sense of self, independent of what the world happens to be doing. The other point I would say to your point is that ideally, the therapist and MBT wouldn't be like trying to kind of convince the patient that, oh, this is sort of the way to interpret it. So in that sense, hopefully, you know, we wouldn't be kind of getting accused of like, oh, see, you said it was good, but it was bad because we're going to be like, you know what? Maybe actually, yeah, maybe they're mad at you. How do we figure this out together? How do we look at it? That's great. And makes sense in terms of also just as a clinician, what you're trying to do to not get in that unfortunate moment with another person because you don't know either, to your point. You're not sure that they're not texting the back because they like him or don't like of or whatever it is, right? Like it is a possibility. It's one of many possibilities that exists. Can we hold that possibility alongside all of these other possibilities in a more open and flexible kind of way? Exactly. Yeah. So one of the modes here that we've spent the least time talking about so far is what you call pretend mode. Yes. So unlike psychic equivalence, this is where a person is often like too kind of in or bonded to their assumptions or feelings. And teleological mode, which is more about being focused on those external cues, you know, this happened, so that must be true. Pretend mode is more characterized by this kind of like floating feeling. The person is like talking about their emotional life without actually being really in it. You know, you're in the head, you're not in the heart, whatever your metaphor is here. There's a particular version of this that I think that many intelligent, self-aware people will recognize them themselves, which is using insight as a way of kind of managing feelings rather than really experiencing them more directly. I, A, know this one personally, and B, I think this is something that the population of people who listen to a podcast like this might struggle with at a higher rate than the average population. And one of the challenges with it is that pretend mode can look a lot like progress in therapy. because what you're trying to develop a lot of the time as a therapist is more reflection and articulation and, oh, you know, I know this about that idea. Yeah, I can tell you all about my experiences growing up and so on and so on. So I'm wondering just how you interact with all of that as a clinician when you're working with somebody, like what helps you know that they're kind of more in pretend mode or versus just that, oh, wow, they've got really great insight about this or something like that. In my opinion, probably the most enduring and important contribution of MBT to the psychotherapy world is the construct of pretend mode. And it's important to note that both Peter and Anthony are psychoanalysts. They train together in London to become psychoanalysts. And they are both very concerned about pretend mode. And that sometimes, especially for patients with personality disorders, traditional exploratory psychotherapy where the therapist is kind of a little more passive and just kind of inpatients will just talk potentially can contribute to pretend mode. And this was the part of MBT that I found most challenging and important because I have, at least when I was first learning MBT, I had my theories about the mind that I was really interested in. And then when patients would sort of adopt them and agree with them, I'd be like, wow, this person's so insightful. They're so right on. And this is, not to cut you off here, Bob, but I just, you know, speaking openly about this. My dad talks about this all the time. He's like, one of the big problems you have to deal with as a clinician is the person who can write you a dissertation on everything that's wrong with them, but doesn't seem able to do anything about it. They keep on circling the same, you know, they're just going round and round without ever actually being able to drink the water that helps them get better. And like, man, there's a certain common style of therapy, as you're saying, that maybe even contributes to that a little bit. Definitely. And I would also say, and this is sort of, I don't know if this is a kind of controversial kind of thing to say, but I think that the thing that most contributes to it is the therapist's own narcissism. Oh, yeah. Because, damn, that's oof. Yeah, because therapists, like we all kind of have our pet theories, the stuff that makes us feel good about ourselves, right? And so then when the patient learns that language and then gives it back to us, then we're like, who wants to disrupt that? Let's go along with that because that makes me feel good about myself. Even as a coach, not even wandering into the world of therapy, I got to say, it feels really good sometimes to pin the tail on the donkey. And you gotta, you just gotta be self-aware about it. You gotta be careful. Totally. Definitely. So basically, this is one of my favorite things about MBT, but it's also very challenging. If there were one thing that took me the longest to learn in MBT is how to disrupt pretend mode. I should just note there are a couple forms of pretend mode or three forms that I talk about in the book. Disconnection from self, disconnection from others, and disconnection from reality. And so what therapists have to do is essentially we need to first notice the pretend mode in terms of, and how do we, how do we notice pretend mode? Well there can be a subjective feeling of boredom or there can be you know if you feel tired a little bit if you finding yourself be a little more distracted The other thing that can definitely be a sign in pretend mode is exactly what you talking about which is that the person can come to session you know with a lot of insight and kind of sound great, but the problems that they're struggling with outside of therapy do not tend to improve. So that's sort of not just pretend mode in the moment. It tells us there's some disconnectedness. Yeah, there's a translational issue happening here. Definitely. So a therapist kind of like, what do we do sort of about pretend mode? So one of the things that's most important as her as clinicians is that essentially no jargon. That's kind of the most important thing is all this, all this therapy speak, right? Where it's sort of these concepts that sort of everybody, people want to be the star student of a particular modality of therapy. If there's jargon being employed, we need to then say, what's a recent example where you've experienced that in your life? So that really automatically, and then the person will say something like, oh, it just happens all the time. I see experiences all the time. If you hear that, that's potentially a sign that you're actually accurately reading the pretend mode because the person can't spontaneously give an example. And then you say, okay, well, just give it a shot. What's a recent example where you felt like you had this fear of abandonment? And then, okay, it was with my wife the other day. Describe that moment. So we go from the head down to reality. And we've got to stay grounded in reality. Like ultimately, there's no mentalizing if it's disconnected from reality. So that's sort of one of the best, I think the most important things to monitor is are are we in a more heady intellectual place versus actually being grounded in reality? And so there's a bunch of strategies in the book. One that I'm actually kind of especially interested in, which, you know, just sort of by way of potential example, is what do we do when we're more disconnected from other people are actually struggling with empathic deficits? What are the different types of problems in empathy we can experience? And how does that then impact us in our relationships? So you actually mentioned it, I thought, really well when you're talking about my friend doesn't text me back. You mentioned that maybe we're kind of get a little intellectualized about it to avoid the emotion. But then the other piece is, well, maybe when I'm really angry at my friend for not texting me back, I'm actually disconnected from what they're going through. Right. I'm not as concerned. I'm concerned about what they feel about me, but I'm not as concerned about them. right and so part of it is sort of like in the book is sort of go through some of the strategies there we got to start by actually trying to put words on the other person's feelings so press pause what do i think the other person is feeling you know well maybe they're feeling anxious because i know that they've had a lot of difficulties sort of at work recently so they actually might be worried about you know this project they have to do but then i mean well they shouldn't be you know, they should still text me back though, right? So I still return to a more self-focused position. And then sort of like, okay, work, start by trying to identify with the person. Are there any ways in which you can identify with actually being quite distracted and kind of being preoccupied with things in your own life? You know, sort of trying to kind of like enter into that experience through actually your own kind of points of contact with the person. In addition, you kind of can like actually consider what would it look like if I were empathizing with the person? What would my focus be? What would I be curious about? Well, I think I probably would want to know what's been going on with their day. I would want to actually, you know, I would actually genuinely care that maybe they have a lot going on or something like that. It's a pathway into empathy. Absolutely. You get a little bit de-centered from your own narrow experience. You're bringing more in. Totally. Definitely. And then another kind of piece is actually look at my part. You know, usually when sort of I'm struggling with empathy with another person, I'm not actually looking at what's my contribution to this challenge. So, you know, how I maybe actually been a little self-centered in this relationship, you know, is there is a way in which, well, you know, I've been kind of more focused on my own stuff whenever we talk lately, and I haven't been as curious about them. And so like there's all these different mentalizing strategies that we have to kind of help get the person more connected. And it's a pretty cool thing. The more that we sort of do this, I see this and I see this in myself, but I see this in my patients. There's a softening that starts to happen. There's just something emotionally that starts to shift. And then now I'm feeling guilty like I've been being a little bit of an asshole lately. Like, okay, you know, I don't want you to feel bad about yourself, but that's a sign we're starting to kind of soften and open up in our perspective to really care about not just ourselves, but also the other. We could just talk about this endlessly, Bob. We've already run long. We're going to run even a little bit longer because I just think this is so, so great. And one of the places that I wanted to maybe end with, we'll see, relates to what you're talking about here and the words you're using to talk about it. The thoughts and feelings you're having about other people, your thoughts and feelings about your own emotional state, you know, what emotions are coming up for me, how do I feel about this situation, what else could be true, what was I feeling back then? It is really common for people to struggle with that kind of interoception. One of the things that is very comorbid with BPD is alexithymia, a difficulty kind of sensing into your own feelings or what my emotional state is and relating that to other people. And when people are asked to do that kind of interoception in a therapy context, they often feel a little bit like a fish that's being asked to climb a tree. You know, it's like the core process that mentalization is running on involves a certain amount of this. But this is something that people with the population that you're trying to work with can often struggle with. So my sense from reading the book is that you feel that this kind of capacity can really be strengthened and developed over time for most people. But I also know that there are a lot of people listening. We often get questions along the lines of, I just can't figure out what I feel or what I want, or you asked me to look inside and I see nothing there, all of that kind of stuff. And that person would probably go, man, you know, Bob's telling me I can do this thing, but I feel like I've tried and I just don't feel like I can. So I'd love to sort of give you an opportunity to talk about all of that here. Yeah, no, I appreciate that. And it's really true. Like, I mean, it can feel sometimes and trying to kind of build the capacity to mentalize that people can feel like I'm starting from scratch, you know, which is kind of like, you know, a scary place to be. I think it is a good note to kind of be like really putting emphasis on because in some ways, the ability to understand what I'm feeling and what each of us is feeling, it's almost the foundation of everything. From an MBT perspective, the ability to actually like look at and know, have understanding of what I'm feeling, but also to feel like it's valid is the foundation for selfhood. So the question is, when somebody really struggles with alexithymia, you know, like sort of what do we do about that? This is where psychoeducation, I mean, it may sound not like the most kind of fancy, exciting therapeutic tool, but it actually is a part of sort of the evidence-based model of MBT, which is we got to start in MBT by actually helping people get a sense of what are the emotions? What is an emotion? What are the different types of mental states? You know, that, and a lot of people who really get confused about these matters, they don't, it's not very easy for them to answer that question. So when you have a lexothymie, I think there are three types of mental states that are probably the most important to help people get in touch with and kind of hold distinctions around. One is, as you've been saying, emotions, but the other second is desires. desires are an affectively grounded mental state a lot of times when people struggle to put words on emotions they can tell you what they want so that's my experience is there's all often like when i'm getting stuck trying to use the not knowing stance to help people represent emotions i'll say okay well how did you want her to respond to you they can often easily represent that And then you say, well, when she didn't, what did that do to you? And then if they start with their own emotions, their own desires, they can get to their emotions. So in the third is what in the book I call self-state. So feelings about the self. So those are the three most kind of affectively grounded self-states. So part of what I do in the book is just kind of like go through what are the different emotions? What are the different types of desires? What are the different self states? And then what the person can do, what the reader can do is actually be like, okay, which ones are easy for me to find in myself? But what are the harder ones to find? And this is may sound really basic, but it's like, I can't try to find something unless I know what's missing. You know, so first try to like, what are my mentalizing blind spots? And there's a toolkit in the book where sort of folks can actually just write out, okay, this, these are the emotions I struggle to see in myself. These are the desires I struggle to see in myself. And I'll give patients assignments where it's like, okay, carry this toolkit around with you. And your job today is to look for sadness. That may be like a crazy idea because like who wants to look for, for, for sadness, right? But there's this stance of curiosity, this stance of kind of readiness for the emotion. And my experience is over time, people start to notice these things in themselves. And so that's the hope. There's a bunch more strategies that I could sort of be going over. But there's a bunch of kind of core kind of techniques that we can teach people. And over time, people seem to get more connected to their own experience. This has been really great, Bob. Thank you for bearing with me as I hold you, you know, a half an hour over time here. It was really fun. I'm glad you feel that way about it. I really enjoyed reading the book. I think it's a tremendous book. I really hope that people will check it out. These are skills that, again, just about anybody can benefit from. And one of the things that I like about the book is that you include in it a whole bunch of case studies from people that are, A, extremely relatable. And these are maybe not specific people. You're fudging the details about these people. you're protecting identity, all of that. But these examples are examples of people who are, for lack of a better way of putting it, extremely high functioning by and large. These are accomplished, smart, caring, empathic, cool, interesting, often very accomplished people who nonetheless are really benefiting from these kinds of interventions and these kinds of ideas when they come in and work with you guys. And I thought that that was an aspect of it that is so important, in part because BPD is such a stigmatized condition, to get a vision of it that is not, you know, kind of exaggerated or over the top or excessively negative, in terms of what that actually looks like for people. Well, thank you for noticing that. And that was sort of one of my goals in writing the book is just sort of like, I mean, my patients and sort of a lot of these patients, but definitely the people that I work with are sort of just lovely, fun, thoughtful, wonderful people who happen to have this sort of challenge that really causes significant difficulty. And so I wanted to give a picture of the illness that actually kind of like showed a less two dimensional portrayal of it. So I really appreciate that you kind of that it came through that way to you. Totally. And is there anything else you want to let people know about on the as we get to the end here? You mentioned an app earlier, for example, the book is sort of is out there. But actually, I'm excited to say that these techniques in the book have now been kind of like developed into an app. It's called Mentalization Coach. You know, it's made by a company, Resilience, out there in California that kind of specializes in evidence-based psychotherapy apps. And so what the app is, it's free. What you do is you can just sort of download it and like learn essentially all the strategies that we've been sort of talking about. And so, yeah, so the benefit of it is that you can sort of like be going throughout your day, throughout your life. Maybe you're struggling to kind of get connected to what you're feeling or sort of those sorts of things. And you'll actually have on your phone different strategies to be able to kind of get connected to yourself and ultimately get connected to other people. Thanks so much, Bob. I really appreciate you taking the time to do this today. Thanks. I really enjoyed it for us. I really enjoyed today's conversation with Bob about mentalization and mentalization-based treatment. He does fantastic work with people over at McLean Hospital. And I really believe that his book on mentalization is just an incredible resource for people if you are dealing with any of the challenges that can be related to issues with mentalizing. And again, I said this over and over again, but I just really want to reiterate it here at the end. I struggle with mentalizing sometimes. If you're listening to this podcast, it is almost a certainty that you struggle with it sometimes. This is just a human issue that we have. It is really easy to go from our thoughts about something or our feelings about it to this is just the way the world is. They are mad at me. The world is a scary place. I am going to be fired, whatever the example is for you. Because we are meaning-making machines. That's what the brain is trying to do. It's trying to go from all of that information that's out there in the world and make sense of it. And this is particularly important inside of our relationships. We can never really know what's in the mind of another person, but relationships are so central and so important for us in our lives. And particularly if you're somebody who has any kind of a form of insecure attachment, you know, anxious or avoidant, or even a little whisper of that. I think about my own relationships with other kids when I was growing up. I was definitely anxious about it. And I was definitely making a lot of assumptions about what they were thinking or feeling based on those anxieties. So anyways, this episode just really landed for me personally. I hope it did for you as well. And here we go into the recap. So what is mentalizing? Mentalizing is the ability to understand the thoughts and feelings of other people by imagining their experience. And this understanding then guides our behavior. We are making assumptions about what it means that they might be thinking or feeling something. And there are three domains that this normally takes place in. The first is the content of mental states. That's what other people are feeling. Second is the context of those states. That's why they're feeling that way. And then third is the how of it, the process of relating to mental states. So how you relate to your mental states versus how you relate to the mental states of other people. And we make assumptions about other people's thoughts and feelings all the time. We have to imagine what's going on inside of their mind because we can't possibly know for sure. So there are two big questions here. How accurate are those assumptions, and how willing are we to acknowledge that they might not be accurate? That jump from I feel something, I feel anxious, to this is objectively true about the world is something that we do all the time, and it creates huge problems for us. And as I talked about with Bob, this is what he called psychic equivalence mode, the experience where mental states aren't experienced as perspectives, but as objective reality. The big insight here in all of this is that your mental state has a huge influence on how you perceive reality and the assumptions that you make about other people, right? And for most people, most of the time, they can really get that. There was that passage that I read toward the end of the episode where I was talking about understanding that your thoughts about other people aren't necessarily objectively true, and we can never really truly know what's going on in the mind of somebody else and all of that kind of stuff. When you say that to somebody through the course of a normal day, when they're feeling pretty good, they're pretty regulated, they're pretty chill, they go, yeah, of course. But then when we're activated, those mentalizing abilities can really go offline for people. And I spent a lot of the episode talking with Bob about what that looks like when mentalizing falls apart and what some of the common problems are for people related to mentalizing. These practices can be particularly useful. Mentalization-based practices can be particularly useful for people who have borderline personality disorder in the diagnosed sense, or maybe they just have a sense of themselves as having borderline-ish traits and tendencies. Maybe they're not a diagnosed kind of thing. But you go, yeah, I've got some emotional instability. Yeah, I've got these kind of patterns of up and down in my romantic relationships with other people. Hmm, there could be something going on there. And one of the really interesting parts of MBT is how it frames borderline personality, not in a trait-based way or based on behaviors that borderline-ish people have, but rather as a deficit in mentalizing. And this idea that BPD symptoms are not the actual problem to be solved. These symptoms are the inevitable downstream effects when we lose our ability to mentalize. When somebody can't mentalize accurately, when they are certain that what they're thinking about other people is true, when they've gone from that kind of external, the teleological parts that we were talking about during the conversation where, oh, okay, they haven't responded to me and therefore fill in the blank where we do that really natural jump. When you're caught in those modes, all of these behaviors just start to kind of happen to you. They're almost reflexive in nature, where the person isn't really choosing anything. Their mentalizing ability has just gone offline, and so they can't really make a difference. They can't make a choice at all. Things are just kind of happening. And this was really driven home to me by Elizabeth's experience with this kind of thing, where she talked about moments of activation as being deeply embarrassing because you can't really control or stop them. And this can then help people from the outside, for starters, have some empathy for other people. But also I hope help people who experience this work with shame and feelings of low self-worth more effectively because, again, this stuff is just kind of happening. You're not totally at choice about it. We talked a bit about how mentalization develops and how issues with mentalization are often based on a lack of effective parental mirroring. So children want to feel like their parents get them in a deep way. It really helps them feel safe. And so when a parent reacts in a way that is congruent to the child's emotions, this means that their mirroring roughly matches the content of what the kid is experiencing. So if a kid is hurt, if a kid is feeling sad, there's this sense of like, oh, I don't want you to be hurt. I don't want you to, wow, oh, yeah. Then also there's something called markedness, which is that the caregiver's mirroring refers to the child's emotions, not their own emotions. And man, over and over again, when I talk to people who had difficult experiences growing up in life or a rough time with their parents or that kind of thing, they often point to this feeling that their emotions always became about the parent's emotions, that the parent had a hard time relating to the kid as having their own separate emotions and the child's emotions being the focus, where the interaction is about the kid's sadness, not about the parent's feelings about the kid's sadness. We then spent quite a bit of time talking about different sorts of triggers that people might have and the ways in which triggers relate to MBT. Typically, when somebody is more activated, they lose their ability to mentalize. And the basic idea here is that as you're going through this process of developing what Bob called the MBT formulation, you're getting a better sense of who you are, your vulnerabilities, your experiences, the stuff that really matters to you, the stuff that tends to kind of set you off a little bit more. And as you develop increased awareness around this, you get better at identifying the train when it's hurtling down the tracks to you. and you can sort of start to see the train coming. So you get more and more space between you and it. And as you do that, you then develop the ability to get yourself off the tracks before you get hit by the train. And Bob used a lot of language to describe this that was slightly more elegant than my train metaphor there. He talked about pressing pause or this idea of bullet time from the matrix or reflecting rather than reflexing. And those are all critical skills that a person is developing in the course of working with an MBT therapist. Toward the end of the conversation, I then hit Bob with a bunch of slightly provocative questions about MBT and about some of the common challenges that people might have with it. One of them that I thought was really interesting related to this idea of pretend mode. And what I asked was about how progress in therapy can often look like developing a lot of insight or becoming more reflective or being able to engage with a psychological idea in a kind of top-down way. But that actually has a lot of overlap with pretend mode. So how do you tell when a person is in pretend mode in a problematic way versus when they've just developed more insight? And I thought that Bob gave a great answer to this question, including when he talked about therapeutic arrogance and the narcissism of the clinician and the desire as somebody who's in any kind of a helping seat. I've only experienced this as a coach. I'm not a therapist, obviously. But that feeling of wanting to feel like you just really nailed it, or you said the right thing, or wow, you had this great insight about the patient's experience or whatever, sometimes that can actually get in the way of the process of therapy and just move you up to this constant cognizing about stuff without really exploring the underlying feelings that are often at the heart of our experiences. I hope you enjoyed the podcast. I had a great time talking with Bob. Again, I really hope that you will check out the book. The name of it is Mentalization, Utilizing Reflection to Heal from Borderline Personality Disorder. Of course, it can be enormously helpful for somebody who has BPD, but I think, frankly, most of us could benefit to learn from these skills a little bit more, and I got a lot of value personally out of reading the book. It is such a thorough treatment of this material. If you made it this far and you somehow haven't subscribed to the podcast yet, what's up with that? Take a moment, subscribe to it on Spotify, on Apple, on YouTube, wherever you are watching or listening to it on right now. I think I kind of messed up the language there, but I hope you understand what I mean. If you are watching on YouTube, you can leave a comment. If you're listening on Spotify or Apple, you can leave a rating and a positive review. That really helps us out. If you've got any questions about the show, you can reach us at contact at beingwellpodcast.com. And if you want to support the show in a different way, you can find us on Patreon. It's patreon.com slash beingwellpodcast. And for just a couple of dollars a month, you can support the show and get a bunch of bonuses in return. Until next time, thanks for listening, and I'll talk to you soon.