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Mentalization and borderline personality disorder (part one)

Sigmund Karterud is a pioneer of group therapy for borderline personality disorders. He focuses on mentalization: our ability to understand ourselves and other people in terms of mental phenomena – beliefs, feelings, wishes, and hopes. In the first of a two-part interview, I sat down with the Norwegian psychiatrist to explore the concepts, history, and effectiveness of the treatment.

Tell us a little about yourself.

Sigmund Karterud: I have been head of a specialised department for the treatment of persons with personality disorders for decades. I’ve been at Ulleval University Hospital my whole career, so I have, so to speak, followed the development of psychiatry since the 1970’s.

We started out with a small therapeutic community and have witnessed all the changes that have occurred over time. And actually for the whole period since the beginning of the 1970s, we have treated the same kind of people. During the early 70s, we had few concepts and few diagnostic labels, proper labels, for ailments; and then, development became clearer. Borderline personality disorder is a so-called ‘self-disorder’, or a disorder of the self where emotional dysregulation and problems with mentalizing are the two main components.

You realised that your patients suffering from borderline personality disorder had these two symptoms, emotional dysregulation, and mentalizing problems?

Sigmund Karterud: Yes. So the pioneering work on borderline disorders and mentalization took place here in London with Anthony Bateman as a key figure, and we’ve had some cooperation between Oslo, Norway, and London since the beginning of 90s. We were directly influenced by his ideas. We started to look at our patients in a different manner and it became clear to us that the way we used to treat these patients was not so good.

In what sense?

Sigmund Karterud: That we, I believe, treated them in a way that was too supportive. We didn’t challenge enough, and when we challenged people we challenged them in the wrong way, making them chaotic, turbulent.

What were the consequences of these realizations? Mentalization treatment is a combined psychotherapy, combining individual psychotherapy with group psychotherapy. The individual part is easier because that’s when you have a clear concept of what the disturbance is all about. It is simpler for the individual therapist to follow the other closely into the depths of the intra-psych, and how this plays out intra-personally and in society. But when it comes to the group component, it is not so simple.

The traps in group treatment with borderline patients are that when you gather together eight or eleven patients in a group, anger is easily triggered. All of them are emotionally unstable, all of them have identity problems, and all of them have interpersonal problems. You can easily end up with very chaotic group situations, as if people came to the group in order to fight rather than take part in the therapeutic project. Groups can also be very dull, very defensive; nobody daring to do anything through fear of triggering some type of psychological backfire. So it was too dramatic, too emotional, too aggressive, or too dull, rigid, and defensive with no vitality. This could make therapists stop giving patients group treatment because it is too challenging – too tense.

It was then a question of how we could modify the technique, to do it in a way which is adapted to more poorly functioning patients, yet still give them dynamic therapy where they can learn about interpersonal relations, emotional regulation, and how to mentalize better in a dynamic and vital way without being chaotic.

So how do you, when you’re creating a manual or a guide, have a balance between creating this positive and consistent approach, and treating every patient according to their own particular nuances?

Sigmund Karterud: Group therapy is like improvised theatre. The patient’s obligation is to bring in something from their current life, some kind of troublesome event, for discussion in the groups. The task is to try to talk about this event and try to understand it with what we call a mentalizing stance. [Group therapy] open[s] up the possibilities for a later development of something that should have been developed in childhood.

Our approach is geared towards how your personality problems are played out in current life. We are not so interested in any prior, underlying reasons from your upbringing. The main focus is on what troubles there are in your daily life, and how these are enacted, played out in the group. This type of work is rewarding, it’s funny, it’s vital. Empathy through group therapy is definitely psychotherapy and has many similarities with psychodynamic group psychotherapy and group analysis, which is popular here in London.

You do not benefit from a therapist telling you what is wrong with you. It doesn’t help you, because if you have mentalizing problems then you have problems with understanding other minds, understanding your own mind, and understanding intersubjective transactions, contextual issues. You become easily overwhelmed emotionally and you shut down your thinking. That’s what needs to be addressed.

If I met a patient before they started mentalization-based group therapy and then I met them again at the end, what differences might I see?

Sigmund Karterud: We have recently been doing interview investigations at a clinic in Bergen with very poorly functioning borderline patients who also were drug addicts. Substance abuse is very common in borderline patients. They were given this question. How were you before? How are you now? And most of them actually say it is two completely different worlds. ‘It’s almost like I can’t recognise myself in the person I was. It was so terrible…mentally I was in a fog’.

But of course, this is not a magic cure. Of course there are failures, but it is amazing to see how good this treatment system is, because borderline patients are so emotionally and interpersonally unstable. They just give up on other people. Of course they are also quick in giving up with their therapist treatment and efforts to treat them. So in the literature there will usually be a dropout frequency of 40%. At my clinic in Oslo, that frequency is 5%.

Featured image: The Conversation, Arnold Lakhovsky. Public Domain via Wikimedia Commons.

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