BPD: How to apply the principles of mentalization-based therapy in your practice

Prof Steve Trumble (00:00:01):

Welcome everybody and all of you who have joined us for tonight’s webinar on Borderline Personality Disorder: how to apply the principles of mentalization based therapy in your practice, and also to the viewers who are watching the recording further down the track. MHPN would like to acknowledge the traditional custodians of the land seas and waterways across Australia, upon which our webinar presenters and you as participants are located. We wish to pay our respect to the elders past, present and acknowledge the memories, traditions, culture, and hopes of Aboriginal and Torres Strait Islander people. My name’s Steve Trumble and I’ll be facilitating tonight’s session. I’m a GP by training that have been involved in medical education for many years and facilitating these webinars for MHPN for a number of years as well. I will introduce our panel. It’s a bit of a different webinar tonight. You will have seen their biographies that went out with invitations.

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I won’t go into them in detail, but this webinar tonight, we only have two panellists, both of whom are expert in the particular therapy we’re discussing tonight. Normally we review a case and talk about the implications of that from a multidisciplinary perspective, but tonight we’re particularly focusing on this concept of mentalization as a therapy to assist people living with borderline personality disorder. The peer of experts are very carefully chosen. They already do know each other, but I’ll introduce ’em to you. First of all is Dr. Julian Nesci, who is a clinical psychologist and also Dr. Cathy Ludbrook, who’s a psychiatrist. But first of all, Julian to you, why are you passionate about working in this area of clinical practise?

Dr Julian Nesci (00:01:50):

Well, Steve, I think what really gets me excited is actually working in a service where we can provide a treatment to people who might find it very difficult to access treatment in the community for a whole range of reasons. People who have all kinds of complex difficulties and as a service, being able to provide that for people within the public realm is something I’m really passionate about. The equity of access for complex difficulties.

Prof Steve Trumble (00:02:15):

Fantastic. That’ll be of huge interest to our audience tonight. Many of whom worry about access to the sort of services that you’ll be talking about tonight. So great that this is something to assist them along that way. What about you, Cathy? What is it that makes you passionate about working in this area?

Dr Cathy Ludbrook (00:02:33):

Thanks, Steve. I’ve always been very interested in therapy and so over many years have gravitated towards seeing clients with mental health issues that are treated with therapy. And more recently, about four years ago, I took up a position in the public mental health system and what I’m passionate about now is that we get to service what I see a marginalised population with personality disorders. And I’m particularly passionate about bringing people with personality disorders back into the mainstream of the mental health system because I think within our system there’s been a tendency over many years to marginalise them.

Prof Steve Trumble (00:03:21):

Great. Well, it sounds like you’re both coming from a very similar philosophy and I’m sure that’s going to inform the conversation tonight. We’ve got a bit of a luxury of time tonight to some extent, so I’m sure we’ll be able to get into some depth of conversation about how we can help this group of people and not marginalise the people who actually need to be very much supported within our community. I think you both work for, well, different organisations. Julian, you are with Spectrum, I believe in Victoria. What can you tell us about Spectrum?

Dr Julian Nesci (00:03:55):

Well, look, one of the first things to say about Spectrum is we are what’s called a statewide service. So meaning that we don’t just target one particular part of the state, we actually receive referrals from all across the state of Victoria, and importantly, we’re part of the public mental health system. One of the things that people might be aware of, it’d be good to highlight about what Spectrum does is the range of activity. So importantly relevant to tonight, we provide treatment to people with personality disorder and complex trauma, and I can tell you a bit more about that if we like in the question time. So we provide treatment, we provide training to clinicians to upskill the workforce, and I guess the other component of what Spectrum does in addition to advocacy is research in this realm as well. So there’s a whole range of activities in this space of personality disorder spectrum does.

Prof Steve Trumble (00:04:43):

Great. Julian, looking forward to hearing about that. And I see on the slide there there’s another logo, BPD co. I haven’t come across BPD Co. Cathy, can you tell us a bit about BPD Co?

Dr Cathy Ludbrook (00:04:54):

Yeah, sure. BPD CO is short for Borderline Personality Disorder Collaborative, which is a service that was established in South Australia five years ago and it has a lot of similarities to Spectrum in that we provide specialised clinical services to people with personality disorders. We’re a hub and spoke model and so quite a bit of our resource also goes into training and capacity building across the system and like Spectrum, we are fortunate enough to have a very solid research arm so that we can assess, evaluate what we are providing. So I think both of us work in pretty exciting services and the only two personality disorder service side project there in New South Wales, but we’re highly specialised and we’re statewide as well.

Prof Steve Trumble (00:05:54):

Okay, well I’m very lucky to be in Victoria and hopefully you’ll have something to share with those from other states as well. I just need to, excuse me a moment, you two, I just do need to run through a few of the features of the platform to make sure people get full use from it. The first thing is to remind people that you can click the view supporting resources button, which is under the video panel and that’ll give you access to the slides, which our two presenters will be showing us in just a moment as well as some resources that have been put together. And then the feedback survey, which is awfully important to us to know whether what’s been presented tonight has been useful to you. Also very important if you haven’t done so already, go up to the top right hand corner of your screen, you can see that little square speech bubble thing was stream chat written underneath it.

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Click on that to get into the chat room if you’re not there already. Publicity Russo’s there from Melbourne, it’s just arrived, Rachel Kahn, they’re all arriving from Darwin. So get into the chat room and you should be able to then communicate with each other as well as with me to keep our presenters focused. They can’t see your chat, but I have the role of judiciously feeding your comments from the chat to the presenters. So it’s a fabulous role that I thoroughly enjoy. But technical support, which unfortunately is sometimes needed, you can see there is the tech support button in the top right hand corner of your screen. But the key thing is if the webinars stopped, it’s usually at your end, sadly due to the internet connection. So you need to refresh the browser, just click on the URL line and it’ll reload and we should be back.

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And if you think you’ve missed anything in the time you’ve been away, the recording will be seamless so you can catch up on it then. So if you’re not certain reload and come back again if the webcast does stop at any time, do that in the ground rules for the chat room. Please be respectful of the other participants and the panellists. It is a public space there and try and keep your comments on topic rather than going off into other tangents about mental health because it just distracts people from what’s being discussed. Now, if we can move to the learning objectives, there they are. I won’t go through in detail, but it is all focused on mentalization based therapy, which we’re going to learn a lot about tonight. I do also want to point out though that what is being discussed is being discussed for educational purposes isn’t a clinical consultation for your clients or yourself.

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So the content in this webinar is for educational purposes only and does not constitute clinical advice. There will be some triggering topics potentially. So if any content in the webinar does cause distress, please seek care with your gp, local mental health provider or service or contact lifeline 13 11 14. So that’s how the platform works. Hopefully it all will go okay. We can see that there are people from Broome to Adelaide to Hobart, so we’ve got great coverage across the country. Let’s now rip into the presentations and our two presenters have dovetailed what they’re talking about, but we’ll start with Julian, over to you.

Dr Julian Nesci (00:09:19):

Alright, thanks Steve. Just picking up where you left off in terms of just to sort of set the scene about how we’re going to do things here, I’m going to talk a little bit about the theory and Cathy’s going to talk a little bit more about the practise principles and then perhaps in the question and answer session, we’ll both weave that together as we go. But the little bit of theory I think is important just to sort of set the scene and help you understand where we’re coming from when we’re talking about principles and how you might apply them, these sorts of things. But to start off, obviously we’re here to talk about mentalization based treatment. Many of you might be aware already. It’s what we call an evidence-based treatment for borderline personality disorder. Now in this context, what that really refers to is a treatment that’s been trialled and it’s the way it’s typically been trialled is in a format where someone does the treatment for 18 months and they receive weekly individual sessions and group sessions.

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Now to sort of bring it together about tonight, we recognise that many people in the audience might not be in a position to do an 18 month treatment. And the position we’re coming from in this webinar is to actually talk about the key principles that underline this treatment, which our view is that they can be applied in various different practise settings that you all might be working in, whether it’s standard outpatient care, inpatient units, emergency departments. We feel that the key principles behind this treatment are readily usable and highly practical in all these different sorts of settings. And we can talk more about that in the content and the questions.

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And look, as you can see on the slide there, there’s a whole range of evidence behind this. If anyone wants to dig into this in terms of the evidence base, there’s some references down below, but I won’t get too far into that tonight. Let’s get into the next slide so we can actually talk about what mentalization actually is. One of the key things to start off by flagging is that when we talk about mentalization, I’ll get into that in a minute, but we’re talking about a concept here that’s actually central as part of being human. It’s not something that’s specific to people with borderline personality disorder. Mentalization is something that we all are born with the capacity to do and it’s actually a key skill that all of us need for social cooperation and understanding and smooth relationships, these sorts of things. It can sound like a bit of a mouthful, but I’m sure you’ll recognise it in this definition.

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It’s the way our mind tells us what we’re feeling and thinking and why we’re behaving as we are. So it’s about ourselves and it’s also about how our mind tells us how someone else is feeling and thinking and why they might be behaving as they are. So it’s about self another, and for most of us, most of this meaning making system that we use operates fairly automatically. We don’t go around our day thinking about this stuff really explicitly. Usually it’s when something doesn’t really go to plan. Like for example, we might do something without really thinking it through or we might be having a conversation and encounter a bit of a look at someone looking a bit puzzled at us. And it’s in those moments that we sort of shift out of implicit or automatic mentalizing and really stop and explicitly think, hang on, what happened there?

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What made me do that? Or why is this person giving me a funny look? Where’s that coming from if I said something a bit silly? These sorts of things. So it can be automatic and then we can shift to explicit mentalizing or thinking about things in a very controlled way. When we run into a bit of an obstacle at understanding something, it involves ourselves, it involves understanding others, it involves understanding our thoughts, understanding our feelings, putting both of those things together and using that to give us information about ourselves and what drives us as well as imagine what might be driving other people to do what they’re doing or appear as they are. And lastly, the other part of mentalizing that’s important to talk about is how we actually sort of read people, how we make meaning about where they’re coming from. And BT says we do this in two main ways.

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We might read someone from the outside. So for example, we might look at their posture, their body language might listen to their tone of voice, their eye contact, and we might put that information together and use that to make a sort of an educated guess if you like about where someone’s coming from. And the other thing we might do fairly automatically most of the time I should add is we read people from the inside. We might take what we know about a person, either from our relationship with them or what they’ve said so far in the conversation, we might put ourselves in their shoes. And when we put all that information together, reading someone from the outside and the inside, it gives us if you like, a three-dimensional or a nuanced view of where someone might be coming from. Now the last thing to sort of say about mentalizing again is that it’s a common human thing that we all need, but we’re also very prone to losing the capacity to mentalize. So when stress occurs for any of us, this isn’t specific to people with borderline personality disorder, our capacity to think about these things I’ve talked about starts to wobble a bit. And by wobble I mean it gets less flexible, less nuanced, this sort of thing. Okay, next slide please.

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So why is this important? Well, I think I’ve already started to say in a way it’s an important skill that we all need for social interaction, for cooperation, for relationships, really making ourself known to another person in a relationship, understanding where someone else is coming from in a relationship, these sorts of things. Now, mentalization is not just about others and getting along with others. It’s actually central in forming various parts of our own experience. So for example, we need to be able to mentalize ourself that is understand our thoughts, our feelings, our values, drives yesterday, today, tomorrow, when we can put these things together, our motivations, our desires, that helps us form a building block of identity across time, a sense of who we are that’s continuous as opposed to something that changes from where we are. Being able to understand what we’re feeling, the sorts of emotions that are coming up for us as well as the context in which the emotions are coming up, gives us a fantastic opportunity to be able to actually smoothly manage the ups and downs of our emotional life day to day, let alone it gives us a great advantage and being able to communicate more readily with people about what we’re feeling and what we might need from others.

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And if we can do that, it helps us navigate boundaries between ourself and others and relationships and these sorts of things. Next slide please.

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Okay, so this is a brief slide, but it’s a huge topic and there’s actually incredibly long books written about this that are terrific and very interesting, but we’re going to keep it quite brief. For tonight’s sake, I think the key points I’d like you to take from all this is that actually we’re all born with the capacity to mentalize. Again, it’s not central to people with borderline personality disorder, whether you can mentalize or not, we’re all born with a capacity to do it. And MBT says that actually this ability to mentalize comes about we think in a relational way through the attachment relationship with our caregivers. And ideally that’s in the context of a secure attachment relationship, a relationship that helps us learn about our own mind and learn about relationships and that relationships can be the source of trustworthy and safe information to learn about yourself and the world around you.

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And MBT says that one of the important ingredients in an attachment relationship that helps mentalizing develop is this thing called contingent mark mirroring by the caregiver. Now it’s a bit of a mouthful. What I’d rather you focus on is rather than the jargon around all this, there’s really this image on the right hand side here. What we’re talking about when we’re talking about mirroring is really the importance of a caregiver. Often enough we don’t need to do this perfectly, but often enough picking up relatively accurately what the infant might be feeling and sort of understanding that as a caregiver digesting that so it’s sort of understandable and manageable and presenting that back to the infant. And we think that over and over time and time again when this process happens like this, it helps an infant develop a psychological understanding of themselves as well as an understanding that someone else can see them as a psychological being and at times have a different perspective to what the infant’s having.

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So if you like the attachment relationship as a central building block for the development of mentalization. Okay, next slide please to try and put the jargon aside for a moment and really talk to you about what does mentalization look like when it’s going well. Well, I’m sure you’ll all recognise terms that we’ve got on this slide here. So when it’s going well, if we’re mentalizing well about ourselves or others, it really means we’ve got an attitude of prevailing curiosity about what’s going on for us, why did I do that? Or where’s this coming from? What do I feel like right now? Being curious about where someone else is coming from. We also might approach things with a degree of uncertainty. So we might think we have a bit of a sense of where someone’s coming from, but we’re open to learning from them in a conversation as to whether our understanding lines up with the information that’s coming in towards us in a conversation.

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So we’ll be able to take other people’s perspective. It doesn’t mean that we have to agree with them, but we will be able to see where someone else is coming from and put that together with our own perspective, hopefully have some sort of workable interaction based on that. And as part of that, sometimes we come into a conversation with a certain understanding about someone else and as we talk and have a bit of a back and forth a to and fro, new information comes to light. And when we’re mentalizing, well we allow our understandings of ourselves or others to be updated by new information. So there’s some sort of level of nuance in understanding ourselves and other people. Now all this might seem fairly self-evident, but in contrast, when stress happens and our mentalizing ability begins to wobble what it looks like when mentalizing wobbles, there’s probably a little bit more clear I think so for all of us as opposed to slowing down and being able to think things through, things speed up when we’re stressed and we lose the capacity to mentalize, we start to mentalize fairly implicitly or automatically our curiosity can sometimes start to go off a bit of a cliff in terms of how well it operates.

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And we start to get very sure we know exactly why someone might be thinking and feeling the way they are, or we might be very sure we know exactly what we want about ourselves. And our thinking gets quite rigid if you like, or gets quite concrete either about ourselves or someone else. And one of the things that can start to happen in that space is we can start to feel quite flooded by emotions. We can kind of think less about our thoughts and feel like suddenly our emotions are upon us and we’re flooded, we’re suddenly going from zero to 100 and we’re not quite sure what we’re feeling or let alone where the feelings are coming from. And as the intensity of stress increases in our capacity to mentalize wobbles more, this is where we can start to see at higher levels of stress and lower mentalization a disconnection from emotion or an extreme levels dissociation might happen when mentalizing is not going so well.

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So let’s move on to the next slide. We’ll keep talking about these sorts of things to move from the general sense of mentalization and talk more about how does it relate to borderline personality disorder. Well, as I said, it’s not really a specific thing to BPD, but we think that people with BPD more easily lose the ability to mentalize under stress and in a way have a sensitivity to particular types of stress and the likelihood of losing this capacity to mentalize flexibly in the areas of relationship or interpersonal stress and the thinking goes that they’re more prone to losing mentalizing in these experiences and when they lose it, they tend to lose it more quickly and it can take longer to regain that capacity to mentalize flexibly. Now when this happens, MBT says that when mentalizing wobbles in a significant way, this is when we’re prone to seeing the symptoms of borderline personality disorder.

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So if the theory goes that a loss of mentalizing leads to the symptoms perhaps to no one’s great surprise, the main aim of MBT is to stabilise this capacity to mentalize and improve this skill so they can use it more readily in everyday life. And if we can do this, if we can improve this skill, then the symptoms that we see in borderline personality disorder tend to get better, and that’s what the research shows. Perhaps no one’s great surprise. So if we move to the next slide, we can keep talking more specifically about this. Now what you see here, there’s a couple of things to talk about on this slide first and foremost, and not a correct side and an incorrect side here. But what you see is some of the things that I mentioned in my first slide about mentalizing these different parts to it.

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And what I’ve got highlighted here is in a way sort of a classic example of how someone with borderline personality disorder might present in terms of losing their mentalizing. What might that actually look like if we take some of this theory and put it into sort of practise, what might it look like? So under stress, what we might see is people mentalizing much more implicitly, which is a fancy way of saying automatically. So when that’s happening, we might see someone thinking very impulsively, making very quick assumptions about either themselves or someone else’s thoughts and feelings without really slowing down to clarify or test or to check out whether what they’re thinking is accurate or not. As I mentioned, mentalizing is often about self or other, and we tend to see that under stress. A lot of people with BPD can become much more focused on others and in a way quite sensitive to other people’s moods and what they might be saying and what that might mean for where they’re coming from and their intentions. And rather than reading people from the inside, we tend to see a lot of people become very exterior focused. So what this means in a practical sense is someone might become very, very vigilant to reading people from the outside, their appearance, their posture, their body language, tone of voice really become markers of evidence for the person’s internal states and motivations. So in a way, I’ll know what you’re thinking by what you do or in fact what you don’t do.

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The other thing we might see, as I mentioned, thoughts and feelings, we tend to see them under stress quite in terms of a loss of mentalizing. It gets very hard for people with BPD to balance these two things together such that they tend to feel like they’re flooded with emotions that often feel like they’re coming out of nowhere. So the emotions themselves might be hard to individually identify, let alone put them in a context. And in that context for people it can feel like this, there’s a catastrophic level of intense emotional arousal that can feel intensely overwhelming. And this is, as I mentioned before, often in the context we see the symptoms of borderline personality disorder start to emerge where people might get affected by this effective arousal and find different ways to manage that, the desperate sort of pain that they’re in and trying to manage that the as best they can.

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Lastly, as I said before, is not a right side and a wrong side, but when we’re in mentalization based treatment, what we’re trying to do is not really to get one people to the right side of the wrong side, but actually good mentalizing for all of us I should say, involves all of us being able to move flexibly. And when we get out of balance in a way that you see on a slide like this, good mentalizing involves being able to bring both sides into it to shift across to be able to integrate both thoughts and feelings, self and other these sorts of things. So it’s just a way of representing things. Let’s move on to the next slide.

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Okay, and the last thing to say about mentalizing and stress is that it can present in some more distinct ways that we’ll just spend a moment talking about not for theory for theory’s sake here, but often these modes that I’ll say a little bit about can be important clinical markers of flags that mentalizing has dropped off in a particular way. And as clinicians we might respond to that in a certain way. So when we’re talking about these things that you can see on the slide called low mentalizing modes or pre mentalizing modes, to tell you a bit about what that really represents is if we think about mentalizing as a skill, it in a way represents the integration of various different sub components. And the idea here is that when old vulnerabilities collide with new vulnerabilities more under stress, our capacity to mentalize in an integrated way drops off.

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And so they sort of early building blocks, which are these low mentalizing modes, these early building blocks in which mentalizing is built start to dominate for people in a particular state for a particular length of time. And really in showing you these slides here, I don’t want you to get too distracted by the names on the left hand column, they’re fancy jargony words that have an important meaning in developmental psychology and there’s big books on these sorts of things. But I just want to spend a little bit of time talking about the right hand column here, which is what all of us might readily identify either in the people that come to seek our help or in fact in ourselves as clinicians or as humans because we too under stress can be prone to falling into these low mentalizing modes. So to talk through some examples here when we’re talking about things like psychic equivalent mode, if someone’s in this mode, their sense really is that what’s in their mind in that moment is with absolute certainty the way they think everyone else is operating.

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So for example, if I have a thought in my mind, someone out there doesn’t like me, I feel like I’m absolutely utterly convinced when I’m in this mode, I’m absolutely intolerant of any other perspectives, any other information bounces off and I can become very certain either about someone else or in fact if I have a view, for example, of myself as unlovable, if I’m in psychic equivalent mode, I experience that with the full conviction that I’m absolutely right and there’s no other perspectives. So if you like, you could think about it a little bit like someone gets into tunnel vision mode around themselves or others and how they think about things teleological mode, it’s a bit of a mouthful, but this really gets back to what I was mentioning before where if someone’s in this mode, they find it very difficult to sort of imagine someone from the inside.

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And in fact internal states of mind are reduced to observable behaviours. So really an example of that might be, I know where you are coming from or how you feel about me based purely on what you do or in fact what you don’t do. So for example, I might feel like you might not care enough about me if I’m one of your patients if you don’t extend my session time. It’s a bit of a cliched example in some ways, but that’s one example of it. Or similarly, I might get teleological about understanding myself if I’m flooded with emotion that I don’t understand or doesn’t feel valid, it might feel that the only evidence I have that I’ve got a valid problem is to see that problem represented in the physical world. And this for some people can be where we see things like self-harm, having a particular functioning to represent pain in a way that feels valid and understandable to someone.

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And the last mode to just mention briefly is what we call pretend mode. Now when someone’s in this mode for a period of time, it’s really they experience the mental world is being decoupled from the physical world. So how might we notice that in someone coming to see us? Well, it can manifest in various different ways, but one way is that someone might be stuck in endless inconsequential talk about thoughts without it really feeling connected to the emotions of what someone’s talking about. It might not feel genuine or rich or really the affect doesn’t match up with the content of someone’s thoughts. They appear to be disconnected from the emotion. And if you sort of think about this on a little bit of a continuum, if someone’s in a really sort of severe example of pretend mode, we might start to see symptoms of dissociation. So they might feel really cut off from the internal world, from the external world. And we can talk more about that later if we need to. Okay, next slide. I think we’re onto to you Cathy.

Prof Steve Trumble (00:29:03):

It looks like we are. So thank you so much indeed. Julian, I must say the feedback on your presentation’s been excellent. People have feeling a lot better about themselves just by the quality of your voice. I dunno if you’re doing that on purpose or it’s just,

Dr Julian Nesci (00:29:18):

It’s a default setting, I’m afraid.

Prof Steve Trumble (00:29:19):

Well, what you’ve said has been fabulous just there as reminders that mentalization is all about being human, but what a fragile thread that is and how it disappears. So we’re also seeing a few people have got their systems locking up on them. That happens mine has here, but just keep on reloading people. Not that you can hear me say that, but if it does happen in future, just keep reloading and you’ll be absolutely fine. But I think you’re quite right, Julian. The slides are now moving to Cathy’s presentation. There you are, over to you Cathy. So if you can make sure your microphone’s unmuted, I think it’s great you’re set to go. Thank you.

Dr Cathy Ludbrook (00:30:01):

Thanks. I’m going to speak a little bit about the application of mentalization within a therapy and I’m going to start with the therapist stance in MBT because there really, there’s a very characteristic stance to this sort of therapy. So the important thing to note is the main focus is what is happening in the client’s mind, not their behaviour. You need to show genuine curiosity. And I don’t think as a human being that’s actually very difficult to do. You’re curious about what’s happening in their mind, you’re curious about what’s going on for you. You’re curious about the interaction between the two of you. How are you affecting the other person? How are they affecting you? So you’re modelling curiosity and encouraging it in your client. Use active questioning because as Julian mentioned, you think of mentalizing as a skill and as a skill. It requires practise.

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And this is what we do within an individual session and in a group session. And the practise really is about encouraging the person to focus on a particular episode and break it down slowly and you’d be asking questions to bring about their controlled mentalizing, their conscious mentalizing. So you’d be asking, what did you think when they said that? How did that feel to you at that moment? So you’d be breaking it down to get them to actively mentalize you adopt a not knowing stance. And I’ll talk about this a little bit more in the next slide. Important aspect of MBT. And in fact, all of the evidence-based therapies for BPD is seeing the patient as an active agent in the therapy. They’re not a passive recipient, it’s a collaboration between the two of you. Thank you. Next slide. Now the not knowing stance, definitely not the same as having no knowledge, but what it is an attempt to do is to capture the idea that mental states what is going on in their mind is opaque. We can never be a hundred percent sure about what is going on in someone else’s mind. We can work very hard to try and understand by asking questions, showing curiosity, feeding information back to them just to check whether we’ve got it right and we can get pretty close, but we will never know. And that’s very important because I think that in some of the therapies there is a tendency to think that what’s happening for the person, and that’s definitely antithetical to mentalization based therapy.

(00:33:00):

You’re taking up a position where you’re attempting to demonstrate a willingness to find out about what is happening for your patient, what makes them tick, how do they feel, what are they thinking, what impact does the feelings and thinking have on their behaviour? So that is your interest. And I don’t think as a therapist I find that a very easy thing to do as in people are just inherently interesting. Next slide. Thank you more about their therapist stance, inquire and challenge when the content makes no sense here, I think there can be a tendency and we try and stay away from this, there can be a tendency to actually fill in gaps when you don’t quite understand what the other person is telling you about. You can think that perhaps, but it’s important to stay focused on do you really understand what they’re telling you?

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And if you don’t then you explicitly say when something’s unclear, I’m really sorry but you lost me just a moment ago. Would you mind if we just go back and cover that again so I’m clear in my own mind what you’re describing. Authenticity is important, it’s a real relationship as well as a professional relationship. And that involves authenticity, being a human being. And to that end in MBT, we do make our mental processes available to the patient as long as it’s in their best interests. So we’ve got to remember it has to be relevant to the treatment in the best interests of the person that we are seeing. So are you’re open about, look, I’m a little bit confused here. Can we go back? To be honest, I’m really quite anxious at the moment. So you make it available to the client, you’re monitoring yourself so you’re monitor your own loss of mentalizing, non mentalizing begets non mentalizing.

(00:35:15):

If you’ve got a client in front of you that is really struggling to mentalize, it tends to be contagious. So just be aware whether you’ve lost your own mentalizing, remember that the person’s mind doesn’t work like yours. I think we can all fall into that trap, not just in our work life but in our social life. There’re two separate minds. So you’re interested in how theirs is working. You model own your own misunderstandings and trying to be curious and invite the clients who work with you to understand that misunderstanding and try and clarify both perspectives. And don’t take over mentalizing for the person I know. In my experience, doctors love doing that, so don’t do it for ’em. What you’re trying to do is prompt them to create a better understanding of themselves. You doing it for them is not very therapeutic at all. Frustrating but not therapeutic. Next slide. Thank you.

(00:36:20):

Okay, I call them non mentalizing modes and Julian called them low mentalizing modes. It doesn’t really matter, but the psyche equivalence, the theological mode and the pretend mode, yes, they’re sort of highfaluting names, but personally I think they’re actually very, very important because they’re letting you know that the person has lost mentalizing. So there’s something going on in that room that you need to attend to because your job is to try and get them mentalizing again, which usually means lowering the arousal in the room further on from that. So you monitor the arousal levels carefully in the room and if you feel that there’s too much arousal, the person’s losing mentalizing, you actually slow down and you use empathic validation. And I’ll come to that in a moment to try and decrease the arousal level in the room and allow the person the best chance to reinstate their mentalizing if there’s too little arousal, which can also happen, you’ve got to create more emotional closeness and that’s quite often done by bringing the conversation into the room.

(00:37:41):

Can you tell me how you’re feeling at the moment talking about that tends to bring it some more increase the arousal in the room. The sessions are focused and we’ll talk a bit more about that in a moment. And I think this is really important that the interventions that are outlined in MBT are carefully matched to the mentalizing capacity of the client. And in my experience, it’s very easy to overestimate the mentalizing capacity and I’m happy to go into that more in the question time. I made a few notes from earlier. So you have to match the interventions to where the client is at and you need to spend some time working out the baseline mentalizing capacity of the person. And that’s done in the assessment. Thank you. Next slide.

(00:38:37):

Empathic validation. Very important in MBT foundational for the person to be open to learning from the therapy, they need to feel that their experience has been recognised by you. You’re not required to agree with the person. I like to think of it as, okay, I’m trying to get an understanding of what’s going on in their mind. I’m asking active questions to create a picture in my mind about what’s happening in their mind and then I’m giving them a summary to see whether I’ve got it right. And so for me that’s the process of empathic validation. So I just think to myself, do I understand what’s going on for them as best as I can. Thank you. Next slide process in therapy. So we’re just talking about a typical session in MBT therapy. You’d identify an episode that caused them some distress or difficulty during the week between appointments and you’d want it to be an episode that is relevant to the goals of therapy.

(00:39:55):

So for an example, I had someone that we were working on their tendency to make assumptions about what is going on in another person’s mind. So an episode would be discussed where they made assumptions about what someone else was thinking and feeling and it led to some difficulties in the relationship. So what you do is you rewind back to that episode and I think of it as micro slicing. You slow it down, can be quite painstaking and you are getting them to mentalize in a controlled, purposeful fashion, feelings, thoughts, behaviour. So you’re in almost a mechanical way, you’re getting ’em to practise the mentalizing skill to improve it.

(00:40:53):

You’re trying to get them to reflect on their thoughts and feelings basically associated with that episode and the effect that they had on their behaviour. Once they can reflect on their own experience. And because it’s thought that mentalizing self, the person needs to be able to do that before mentalizing other. So once you feel that they have mentalized themselves in that particular episode, you would carefully, if you think they’re up to it, look at the perspective from the other person. So it depends where the person’s at with regards to that. And then you’ll ask them about, we’re talking about it now, do you have any other reflections about that episode that happened last Thursday? So you give ’em an opportunity to reflect on that and then you would ask them how does it feel talking about it now? So you’re really looking at getting them to mentalize from every direction to do with that episode. Next slide. Thank you.

Prof Steve Trumble (00:42:03):

I think that’s the end of your slides, Cathy, but you did mention as you were speaking you wanted to go back to spend a bit more time on something and there’s been some really good conversation in the chat room. A comment from Pauline Ogilvy, how do you assess the baseline mentalization capacity? Was that what you were going to speak a bit more about? How to find out where the person is and what their capacity for this is?

Dr Cathy Ludbrook (00:42:28):

Yeah, I’m happy to. I think one of the comments that I just made notes when Julian was speaking is that I think sometimes we assume that people have the building blocks of mentalizing, and by building blocks, I mean being able to identify how they feel, label how they feel and communicate how they feel. And many people that we see have some major difficulties in that area. So you can’t expect someone to mentalize and be flexible within the poles if they haven’t got these building blocks. Another building block is that I’ve been interested in the difficulties people have too of linking a feeling and a thought and a behaviour. And I must admit, I guess I’d fallen into the trap of assuming that people have some capacity to do that. But I have been quite struck that some people find that incredibly difficult. And so if the person did have great difficulty in those areas, just getting an understanding of yourself and an understanding of yourself in relationships and an understanding of yourself in the world would be incredibly difficult. So that’s one comment just about building blocks. I’m happy to go into the assessment a bit unless Julian wanted to add something there, but

Dr Julian Nesci (00:43:57):

Yeah, sorry Steve, I can’t hear you. I think you’re on mute. Do you

Prof Steve Trumble (00:43:59):

Want to contribute at this point?

Dr Julian Nesci (00:44:01):

Yeah, I could do. I’ll say something brief, but also I think if you want to know more about any of these questions, bear in mind that one of the things that we do is actually provide training around these sorts of things where we can go into quite a lot of detail if you like about it. But I think if you were to take some of the ideas from tonight and sort transpose them into a practical setting tomorrow, one good way to start to get a feel about someone’s capacity to mentalize is really a bit like Cathy was talking about, get them to sort of describe a recent episode where something was difficult for them. And you might start to try and ask about some of these concepts we’ve talked about tonight, for example, when it was getting difficult for you, how easy was it for you to work out what you were feeling or where that feeling was coming from?

(00:44:44):

How aware were you, what was going through your head at the time? What were you thinking about other people at this point in time, these sorts of things or how fast did your mind move at that point in time? How easy did you find it to slow down and sort check out whether what you’re thinking was where that person was coming from. You might sort of start to ask these sorts of questions. And I think even if you sort of park any of the other terms we’ve talked about tonight, I think you’ll quickly get a practical sense of where some of the vulnerabilities someone might be having around these areas might lie.

Prof Steve Trumble (00:45:16):

Great. Thanks to both of you. Now I do want to remind people about how to ask questions using the buttons down the bottom there. There’ve been some really good questions coming up in the chat, but that is mirror fleeting tel and it goes as more and more messages push it up. So please do use the question box if you hover your mouse. It’s harder when you’re on a mobile I know, but if you hover your cursor over the bottom of the screen, those three dots ask a question, click on that and it’ll give you the form to ask a question. As you would probably expect. I have already made a promise to Bex Creasey that she gets first question because she was first cab off the rank. And her question is, and both of you please tip in on this. She’s wondering if pretend mode, as I think Julian outlined, might be a state that preludes or accompanies episodes of psychosis. Is that something that’s seen?

Dr Julian Nesci (00:46:14):

Well, there’s probably lots of different ways of answering that and Cathy, I’m interested in your take on this as well. I mean probably the first caveat I’ll put around this, I think for the sake of tonight’s topic and audience, let’s think about the transient psychotic states we might see in people with borderline personality disorder because psychosis is quite a broad term in and of itself. So if we think about it from there as a starting point, I think to me the short answer is both yes, but also it depends and be a bit careful and I think it reminds me of one of Cathy’s points actually sort of parking our knowing stance around this and being curious. But I think absolutely yes, pretend mode can be a bit of a prelude to someone slipping into a psychotic state. But also some of these modes that I was talking about, they kind of sound like they’re these unique discrete things and in a way, theoretically they are, but quite commonly someone might tumble quickly from one into another.

(00:47:07):

So for example, if I start off in a position of psychic equivalents where I’m absolutely sure that I know exactly what’s going on out there and what various things in my environment and meeting and telling me, I might start to become very overloaded very quickly and my internal world might start to decouple from the external world and I might start to feel like I’m a bit detached or as I said in extreme forms associated from things like that. So I think in that context quite commonly, yes, pretend mode could be a pre, but it might not be the only mode if you see what I mean, there might be other parts to it. So it’s important that we rewind as Cathy was saying, from a not knowing position and really try and track forward and work out. Hang on. What were the sort of the precursors to someone’s mentalizing, wobbling or slipping off in these sorts of ways? Cathy, I wonder if you’ve got anything you want to add to that?

Dr Cathy Ludbrook (00:47:58):

I think it’s not a clear cut answer. I think that you certainly don’t want to miss a true psychotic episode or true psychotic illness, should I say, that needs to be treated with antipsychotics. I think that there’s some situations that you come across where it’s very unclear whether the person’s psychotic symptoms are related to personality or a primary psychotic illness. So I do really think you’ve got to keep an open mind about it and certainly I think a priority is making sure they’re getting treatment for a primary psychotic illness if they’ve got it. But quite often you’re left not quite being convinced that they have a primary psychotic illness and you’re left with thinking, okay, this is part of the personality disorder. And then I think you can formulate the symptom in terms of psych equivalences. If they become very paranoid, I think that they can feel they’re in danger, fear. So I think that can be understood as psych equivalents, but I always think you need to hold onto humility and always keep an open mind that you could be wrong there. Yeah,

Prof Steve Trumble (00:49:25):

Thanks both for those comments. There’ve been a number of questions which are I guess revolving around a theme about particular aspects of people with borderline personality disorders and maybe other conditions that might impact upon their capacity for mentalization. One that came in before the webinar was about noting that mentalization appears to require self-reflection, which is often a less developed skill in people with BPD. And we have a question from Charlotte Guthrie that came in through the portal asking about how this form of therapy could be applied to a client who has both BPD and autistic spectrum disorder and where both theory of mind and interceptive awareness are impacted. And these appear to be core components of MBT and that also ties in with a few other questions about maybe people with intellectual disability. How do you go about modifying your approach to people that might have a different way of mentalizing?

Dr Cathy Ludbrook (00:50:32):

I’m happy to go. You can add Julian. Look, they’re both hot topics in the mental health system. The research suggests in when they look at people with a diagnosis of borderline personality disorder, you’re looking at about 4% that will have a SD. And if you look at an A SD population, about 4% will have BPD. So it’s not a high highly prevalent comorbidity. Having said that, what we are noticing and we’ve heard from other centres, and I’m not quite sure that Julian has his centres also noticed this is the people that we are seeing with the more severe and complex borderline personality disorder. It’s not uncommon that they have a SD. So I think that it can certainly make the symptomatic presentations more severe if you’ve got both BPD and A SD. In terms of theory of mind, I mean there has been some research I believe on in mentalizing in a SD, but I’m not quite sure of the results, but you sort of think that it’s intuitive that if people can improve in terms of people with a SD can improve in terms of their theory of mind, then MBT, it would make sense to give it a go.

(00:52:01):

I have to say that in our experience it’s a very small our experience of a SD and BPDI would have to say that I don’t think we’ve seen significant changes. But Julian, your experience,

Dr Julian Nesci (00:52:21):

Well look, as you say, it’s a hot topic and a complex one. Look, a couple of things come to mind. It’s worth touching on just from a theoretical point of view where we might see both people with either of these disorders sort of having difficulties with mentalizing themselves or others. And one of the things to bear in mind is that there might be different pathways to those challenges of why someone might be having difficulties mentalizing from a developmental point of view. Having said that, there was a paper that came out I think last year that showed a group trial with people with autism spectrum disorder, I think with comorbid BPD, and there was some improvements there. And I think my experience practically when we see a lot of people with neurodiverse presentations at Spectrum is that one of the things you said earlier, Cathy, we’ve just got to be really careful as clinicians I think in particular to make sure we don’t assume we know exactly what someone’s capacity is for mentalizing.

(00:53:18):

So sometimes when there’s neurodiversity, like what we’re talking about here, it can mean that sometimes we might need to be a little bit slower in terms of the rate of change we’re expecting these sorts of things. But my experience is I think the concepts are readily usable for people and clinicians. It might seem like someone needs to be sort of very insight oriented to use MBT. I think when you see MBT in practise, you can see, as Cathy talked about, it’s really if you like, a very frequent skills practise of this capacity to reflect. So even if someone’s capacity to do this, whether it’s they’ve got BPD or BPD plus a ST, if it’s impacted, we start low. We don’t sort of try and meet them with very head intellectual concepts. And so insight, reflective comments, we try and really build the skill from where it’s at, wherever the person’s presenting with. So I think that’s really important principle to hold in mind regardless of sort of diagnosis that someone might be presenting with.

Prof Steve Trumble (00:54:16):

Thanks. So we’ve really been focusing on factors that might through neurodivergence or other reasons, impact on a person’s capacity, but what about motivation? There’ve been a number of questions about engaging people who might be a little reluctant or avoidant to engage in this sort of therapy. Lisa, Heather, and a couple of questions before the webinar. We’re asking about your approach to people who might resist or be disinclined to engage. How do you get people turned onto the therapy?

Dr Cathy Ludbrook (00:54:48):

Look, I think that, I mean, there’s quite a bit of focus on creating a therapeutic relationship. And in my experience, the people that we have that are working in this area day in day out actually become very good at developing a therapeutic relationship. So I think that that’s the beginning point. Until you have some level of rudimentary alliance, I don’t think you can expect the person to be fully committed to it because they’re not quite sure who they’re committing with. So I think some people where trust is a major challenge for them, you end up going slowly and being patient and trying to build that trust and build their confidence in you as someone that is trustworthy. And that can take a year in people that are severely traumatised, for example, that can take a year. We’ve had people where that’s been the focus, developing a relationship for a long time before a more structured MBT could be embarked upon.

Prof Steve Trumble (00:56:06):

So I think Erin might’ve anticipated that, Cathy, and she’s already asked what would be the most clinically appropriate method to adapt the core of mentalization based therapy into a short-term support model. So being very practical when you’ve only got a limited number of sessions and you’ve got limited time, are the, and we don’t want to pull the eyes out of your approach, but what can feasibly be done in the practicalities of a short-term relationship?

Dr Cathy Ludbrook (00:56:36):

I think that’s a very good question. She’s on it. That’s a very good question and I’ll give you my think about it for 15 seconds and come up with it because I think that’s a very practical question because certainly there’d be many people in private that can have say, 10 sessions. Look, I think that it needs to be focused. I think you’d want to do some level assessment with the person. See, I’d be probably actually explaining to them psychoeducation about mentalizing, what it looks like when you lose it. Can you think of times when you lose it? And they might say, yes, I particularly get angry with my partner. That’s what I want to work on. Okay, well let’s understand that in terms of mentalizing and see whether we can improve your ability to mentalize for longer when you’re feeling anger developing. So I think I’d be quite focused psychoeducation then focused on a goal. That’s what I would do. That’s my Julian, take it away.

Dr Julian Nesci (00:57:46):

What are your thoughts, Julian? Sure. Well, I think you’ve done the heavy lifting now, but I think also coming back to motivation, I mean, whether we’re talking about motivation and a short window of time, for example, if you’ve got one session with someone, I mean, I think one of the things I wouldn’t do is sort of come in and say, look, you need to work on your mentalizing straight away. I think whether we’re working with someone for 18 months, 18 hours or 18 minutes, what tends to help with motivation as well as then where you go with things is really the person feeling like you can recognise their subjective experience of their problems. And I think if you can do that without necessarily using the language of mentalization to begin with, and so the person feels seen and recognised, they tend to be in that context more open to learning from you.

(00:58:29):

And like Cathy said, I think motivation tends to start to flow if the person feels seen and recognised and then can link what you’re talking about in terms of mentalization, whether you’re proactively providing some education to their problems. And I think usually when people feel seen and recognised in that context, they tend to be open to trust and to open to going with you a little bit to work out, look, what can we do if we understand your problems this way? How might we need to work on things? Whether that’s in a brief period of time or a longer period of time with whatever model you’re working on. I think what I wouldn’t try and do is to try and if you’re working with someone only for a very brief, just a one session interaction with someone, I think sometimes all of us can feel a bit compelled to get busy or to do lots if I somehow skill up a person or talk at them or educate them lots only got this.

(00:59:22):

I mean, sometimes that can be really important, but quite commonly people can walk away from an interaction like that feeling like actually hang on. The person doesn’t really get how things are for me. So I think to sort of go back and summarise, I would say slow down focus on helping the person to feel understood. And I think if you get that bit right with empathic validation, like Cathy was talking about, I think a lot of the motivational work is done. But equally and importantly, I think whether you’re in a longer term treatment or a shorter space of time, if someone is sort of showing some ambivalence in terms of their motivation, it’s important to come alongside that, try and understand where that’s coming from. Because often there’s really important information and if someone feels like you can actually understand why they might be a bit reluctant, for example, to work out what they’re feeling or where it’s coming from. And a common fear underneath that for people is, if I start thinking about it, then I’m going to start feeling it all at once and it’ll fly out of control if I talk to you about it. If you can open that up, then all of a sudden you’ve got a different pathway to help someone in that moment to help them feel seen. And I think quite commonly that helps with motivation, these sorts of things

Prof Steve Trumble (01:00:27):

That coming alongside and being curious about what’s going on for the course. And there’s such an important thread, isn. Cathy mentioned as well the concept of not knowing, but being curious about what’s going on. And I cannot get through one of these webinars without redeploying the motto we were given by a young woman with BPD who told us, don’t get furious, get curious when things are going difficulty. And that’s just been so useful in the past month since he said that. And it’s there again, it’s come up tonight in the chat about being genuinely curious what’s going on for people, but also being aware maybe that some of these therapies can be quite powerful. Question from Kerry asking about not triggering trauma. And this always comes up, it’s really important. How can I best support someone with mentalizing without retriggering trauma given some of the overlap between BPD and chronic PTSD?

Dr Julian Nesci (01:01:27):

Well, that’s a great question. Shall I start Cathy then?

Dr Cathy Ludbrook (01:01:30):

Yep. I’m happy to start and I’ll add, yep.

Dr Julian Nesci (01:01:33):

Yeah, look, there’s probably lots to say and I’ll try and be brief in my own way about this. I mean, I think one of the starting points for me is recognising that usually in a mental health setting, the setting is inherently relational. And I think for a lot of people when we’re talking about trauma and complex trauma and BPD, quite often an aspect of things that was traumatising for them was relational. So quite often you’re in this space where someone might be approaching the treatment setting in a way they already feel triggered. They might already be very vigilant to what you are doing or not doing, how you’re appearing as a clinician, how you might respond to them based on past interactions they might’ve had in their life and so on. So I think we’ve got to be thoughtful about that. We’ve got to actually be aware of people’s arousal levels and try and track that as we’re going in the session to make sure we’re sort of not charging ahead and as you say, triggering something equally.

(01:02:29):

We don’t want to avoid talking about things necessarily, but we want to make sure that we’re monitoring someone’s arousal level together with them so they feel like, actually this clinician sees me, they recognise how I’m going and that I’ve got a sense of control about this. So these are some of the things I would think about in terms of basic principles, how you might approach this. It’s already inherently a risky treatment setting, but be aware of arousal levels. I think some of the things we can actually do is also be quite pragmatic. For example, Cathy, we talked about a clinician’s mind being available and open to the person in treatment as a source of information. I think sometimes if we’re worried about triggering someone, it can be quite sort of pragmatic and practical to say, look, actually some of the things you want to work on might be really hard to talk about. Can you let me know as we’re going, whether this is starting to feel a little too much, and then perhaps we can backtrack together and slow things down. So I would try and stay fairly pragmatic about it. I hope that helps. But Cathy, maybe you might have some thoughts on this one too. I

Dr Cathy Ludbrook (01:03:32):

Think certainly a fairly frequent comorbidity that we see. I think that trust is a major issue. I think again, really probably reiterating what you said, Justin, Julian, I mean that the focus really is on developing a relationship and that may take quite some time and developing a relationship is being truly interested in that person’s experiences and helping them to find a language to even describe their experiences. I think that I probably am one in terms of trauma. I’ve got a psychodynamic background and I think we need to be patient. I think the person inherently knows at some level the pace they can go. And so I would really try and mirror where the person is at because I think particularly with a complex severe trauma history, it can take a number of years before you actually, or before they can find the language to put it into words about their experiences.

(01:04:55):

So I think you’ve got to be very patient and just painstakingly build that relationship and build some level of trust. And I do believe that the greater the trust from attachment theory, the trust, the greater the exploration. So as you find the trust builds within the relationship, the person will feel more able to explore their inner world, which will have the trauma. Certainly I’m very respectful. I think that if someone isn’t managing emotions and they’re risk of harming themselves or have been harming themselves, I would be very reticent to go into their trauma memories. So I would be staying away from them until I felt they had some capacity to manage emotions.

Prof Steve Trumble (01:05:50):

So doing harm is obviously, it’s obviously very important. And there happened to be a couple of questions that came together on my dashboard, which caught my eye. They’re both headed self-care and support for staff. One from Jennifer de Bruin and one from Michael Nielsen. And obviously the other person in all of this who could be vulnerable is the clinician. I’m just wondering what your thoughts are about what sort of self-care opportunities there are for therapists supervision maybe, and particularly Michael mentioned staff in a care setting that might’ve experienced an emotional outburst from a BPD client. And what supports that can be for clinicians who feel personally affected by the work.

Dr Cathy Ludbrook (01:06:38):

Yeah, I think that all of the evidence-based treatments for BPD have built into them peer supervision. So I think having regular meetings with colleagues, a MULTID team, you might be a little team of a couple of people, but having that regular opportunity to discuss your experiences in a safe setting I think is very important. I think when that isn’t available, certainly when I worked in private for many years, when I struggled with one particular person in terms of my feelings of distress about how unwell they were and how their trauma history, I sought supervision myself, which was very helpful.

Prof Steve Trumble (01:07:30):

Julian, any thoughts from you?

Dr Julian Nesci (01:07:31):

Yeah, look, perhaps echoing, I mean, maybe a metaphor that people might be familiar with is the aeroplane one, which is sometimes we need to put down our own oxygen mask first before we’re able to actually help others. And I think one of the things that I would really like to emphasise in this space is that actually normalise it as clinicians and as humans, we can find this work difficult for a whole range of reasons. And a point I probably made several times over really is that as humans, our capacity to think flexibly and nuanced takes a heat. When an outburst happens or something that someone might say or do in the treatment might push buttons for us. And I think we need to normalise that. And so that actually we build, whether it’s within a service of people being able to speak, and if different staff members have different views about what’s happened, that actually we can all adopt this spirit of mentalizing, which is, as Cathy said, no one person is sort of right. But actually it’s about coming alongside each other sometimes as clinicians and colleagues to work out, hang on, why am I having this reaction? How come you are having this reaction? Let’s try and look at this together so that we can sort of detoxify this sort of thing. And I think we can get external help for that. We can get supervision of course. I think that’s a good thing to do, but whatever we can do to help prop up our own capacity to think flexibly is going to be helpful in that regard.

Prof Steve Trumble (01:08:55):

Great. We actually have a survey of questions, which is a lovely situation to be in, but we’ve probably only got time for one or maybe two more before each of you wrap up with your top tips before people leave us. It looks like there are a few people who need to go somewhere. So we will finish at eight 30 eastern states time. But I just was curious about this question from Nelson Clemente, which picks up on a couple that were asked before the webinar about the evidence or potential for combining MBT with other established forms of therapy. EMDR is the one that is particularly mentioned there, and particularly in addressing trauma related emotional dysregulation. Do you pull in bits and pieces of other approaches, or do you try and keep your mentalization pure?

Dr Cathy Ludbrook (01:09:46):

We have pretty much a sort of a one therapist guideline where I work because we find that boundaries can become quite problematic, I think in terms of who’s doing what when you have two therapists, EMDR, I’m very happy to be corrected, but I guess my understanding of MDR R and looking at the training is that it’s actually a therapy in itself and that can go over for a couple of years. And so I see it as a separate therapy, I guess. I think so. I think it depends where we are working. We are trying to actually sort of stick to one of the therapies, but I have to say in my past life in private, I probably drew upon a few different ones at different times depending on who I was seeing. So I think probably the main thing is that you need a model, you need a formulation that makes sense to the client. I think it’s very hard to have a formulation that involves several different theoretical models. So I think it’s more straightforward to have when it involves one theoretical model and they need to understand that formulation and it needs to make sense to them in terms of explaining the difficulties they have. So I guess for me, trying to stick to one sort of modality largely is how I would go.

Prof Steve Trumble (01:11:19):

And actually, Cathy, that takes me back to our previous discussion the other night when you were talking about the importance of everybody knowing their role in the team. The interprofessional team is so important, but people have got to understand, I’m the therapist, you are doing this, you are doing that, you are looking after the social, whatever it might be. Absolutely.

Dr Cathy Ludbrook (01:11:37):

Because there’s often a number of people that are providing care for the person, and we spend quite a bit of time defining roles and responsibilities before we start because the personality disorders are about difficulties with relationships. So we are going to be nudged into taking different roles within our team and outside our roles and responsibilities. And we have to be clear in our own mind what are doing and how can I pick up when I am actually transgressing that a bit. If you’re not clear on your role and responsibility, you find yourself, I think potentially in hot water doing things that weren’t your role and responsibility.

Prof Steve Trumble (01:12:19):

Well, my role and responsibility is the timekeeper tonight. So I’m going to move us now to the final That’s known as a segue in the business of the final two minutes from each of you. Just the key points you wanted to leave the audience with tonight. Julian, yours first.

Dr Julian Nesci (01:12:35):

Sure. Well look, I think you had the line of the night with the don’t get furious say curious. I mean, I think if people were to take one word away from this webinar, I think it’s hard, hard pressed not to go with something like being curious. So it’s one of these things that I think as clinicians, it sounds like a very simple thing and we all kind of know it’s important, but perhaps being curious about when we stop getting curious as clinicians and helping the people that come to see us, whether it’s for a brief period of time or a longer period of time, be curious about their own internal experience and things like that. But perhaps another dot point I might leave people with is slow down. It’s so important in this world. We all know that validation’s important, but really when we’re working with people with complex difficulties like we’ve been talking about tonight, as Cathy mentioned before, trust is such a complex thing to establish. So slow down, really make sure you take the time to make sure that person’s subjective, experience feels heard and recognised. That tends to open them up a little bit more to learning from you. And that’s where you can start to think about, am I going to do a skill whether it’s within MBT, or am I going to take a DBT sort of focus, these sorts of things. So I think mentalizing is very compatible, but slow down first. Be curious.

Prof Steve Trumble (01:13:47):

Sounds like a pretty good recipe for life, Juilan just making a note of that one. I’m going to get to tattoo tomorrow. Thank you very much, Cathy, your final two minutes.

Dr Cathy Ludbrook (01:13:55):

Yep. My thought would be that to appreciate how much mentalizing is a human experience, that it’s something that we do. It’s something that our clients do. And I think that it’s a helpful skill if you call it that in everyday life. I think that if you start reflecting on yourself and when you might be losing mentalizing or mentalizing yourself but not the other, I think it’s quite, you notice that you lose it yourself. And I think so in terms of self-improvement and self-awareness and other awareness, you can apply it to yourself. And the other thing is that be interest in people. I think that we are the luckiest people in the world to be able to see people and try and help people with these complex problems. And I think it’s a privilege to have a licence to actually focus on understanding other people and their experiences.

Prof Steve Trumble (01:15:00):

It’s a pretty good gig, isn’t it? And thank you both for spending privilege, having time with you tonight. You’ve given us an awful lot to think about, an awful lot to put into practise. So thank you very much indeed. Now, just a few things to finish off. Please don’t leave us until you’ve done your feedback, all you people. I want to remind you that MHPN supports more than 300 networks where mental health practitioners meet online and in person to engage in free interdisciplinary networking of peer support and CPD. And tonight counts for CPD as somebody who’s asking before. If you’re interested in finding out more, please go to mh pn.org au. There are upcoming webinars coming on, working therapeutically with children who’ve experienced trauma from physical or sexual abuse. That’s coming up Thursday the 19th next week, partnership with Emerging mines, another BPD one. I think it’s the final on the series, caring for the carers, Wednesday the 9th of October, and then one of the Comcare work-related illness.

(01:16:02):

One the right time to return for work. Boy, I’m going to be at that one. Optimising work participation for patients or clients recovering from injury or illness, Monday the 14th of October. So five weeks away. Don’t forget the podcast series, mental Health in Focus, which is in partnership with karta coming soon and the old Creative Art Therapy. There you go. Episode one launches on Wednesday. So search MHPN presents in your preferred podcast app. So thank you for participating. Don’t forget the survey down the bottom there. The button below the video panel will take you to complete feedback survey. So please do that and you can send your messages to our panellists tonight. Mind you, what has been coming up in the chat has been pretty reinforcing of the value of what’s been said. Before I close, I would like to acknowledge the lived experience of people and carers who have lived with mental illness in the past and those who continue to live with mental illness in the present. So thank you to everyone, both online and the presenters tonight for your participation this evening. Good night.