Battles of the Comfort Zone

Quiz

1. What is the focus of this study?
   A) The impact of therapeutic alliance on psychotherapy outcomes
   B) The effectiveness of mentalization-based treatment for borderline personality disorder
   C) The relationship between therapeutic strategy, alliance, and epistemic trust in mentalization-based treatment for borderline personality disorder
   D) The role of counter-transferences in the therapeutic process
   
   
2. How did the authors conduct their study?
   A) Through a randomized controlled trial
   B) Through a meta-analysis of existing research
   C) Through a qualitative analysis of therapy sessions
   D) Through a survey of therapists
   
   
3. What did the authors find in their analysis of the high-rated MBT sessions?
   A) Therapists were too accommodating and lacking in confrontation
   B) Therapists were able to focus on the alliance and transparently explore transference reactions
   C) Therapists were unwilling to challenge the patients
   D) Therapists were not able to mentalize during the session
   
   
4. What did the authors find in their analysis of the low-rated MBT sessions?
   A) Therapists were too accommodating and lacking in confrontation
   B) Therapists were able to focus on the alliance and transparently explore transference reactions
   C) Therapists were unwilling to challenge the patients
   D) Therapists were not able to mentalize during the session
   
   
5. What did the authors suggest may happen when therapists are able to competently challenge problematic patterns and maintain a clear therapeutic strategy?
   A) The therapeutic alliance may be weakened
   B) The therapeutic process may be hindered
   C) The therapeutic alliance may be strengthened
   D) Epistemic trust may decrease
   
   
6. What did the authors propose may develop as a result of a persistent focus on tasks and goals in therapy?
   A) Epistemic freezing
   B) A stronger therapeutic alliance
   C) A weaker therapeutic alliance
   D) Epistemic trust
   
   
7. What is mentalization?
   A) The ability to understand and interpret behaviours of self and others as expressions of intentional mental states
   B) A specific, evidence-based treatment for borderline personality disorder
   C) An attitude of epistemic trust in the listener
   D) A lack of mentalizing on behalf of the therapist
   
   
8. What is epistemic trust?
   A) The ability to understand and interpret behaviours of self and others as expressions of intentional mental states
   B) A specific, evidence-based treatment for borderline personality disorder
   C) An attitude of trust in the listener's ability to take in personally relevant knowledge about the social world
   D) A lack of mentalizing on behalf of the therapist
   
   
9. Why is mentalization important in the treatment of BPD?
   A) Mentalization helps to improve emotional regulation and increase security in close attachment relationships
   B) Mentalization is a strong predictor of psychotherapy outcome
   C) Mentalization is one of eight specific, evidence-based treatments for BPD
   D) Mentalization helps to reduce the patient's ability to mentalize
   
   
10. What are some evidence-based treatments for BPD?
    A) Mentalization-based treatment and cognitive-behavioral therapy
    B) Psychoanalytic therapy and interpersonal therapy
    C) Group therapy and pharmacotherapy
    D) Hypnotherapy and art therapy
    
    
11. What did the authors of this study analyze to understand how therapeutic alliance, therapeutic strategy, and epistemic trust interact in the treatment of BPD?
    A) The authors analyzed the impact of different therapeutic strategies on BPD patients.
    B) The authors analyzed the effectiveness of different treatments for BPD.
    C) The authors analyzed the role of attachment relationships in the development of BPD.
    D) The authors analyzed the interactions between therapeutic alliance, therapeutic strategy, and epistemic trust in the treatment of BPD through a qualitative analysis of MBT sessions.
    
    
12. What is the model proposed by the authors for how therapeutic strategy, alliance, and epistemic trust interact in the treatment of BPD?
    A) The authors proposed a model where therapeutic strategy, alliance, and epistemic trust all work independently to affect the therapeutic process.
    B) The authors proposed a model where therapeutic strategy and alliance work together to facilitate the therapeutic process, while epistemic trust is not a factor.
    C) The authors proposed a model where therapeutic strategy, alliance, and epistemic trust all work together to facilitate the therapeutic process.
    D) The authors proposed a model where therapeutic strategy and alliance are not important in the treatment of BPD, and epistemic trust is the main factor in the therapeutic process.
    
    
13. What is the "warm climate" or "background of safety" in the therapeutic relationship?
    A) A positive, supportive relationship between the therapist and patient
    B) A neutral, distant relationship between the therapist and patient
    C) A negative, confrontational relationship between the therapist and patient
    D) A relationship in which the therapist is in control
    
    
14. What did the authors suggest may be a crucial part of the "warm climate" or "background of safety" in the therapeutic relationship?
    A) Trust
    B) Control
    C) Distance
    D) Confrontation
    
    
15. What is the concept of "battles of the comfort zone"?
    A) A metaphor for the struggle to confront problematic patterns in therapy
    B) A metaphor for the struggle to maintain a positive therapeutic alliance
    C) A metaphor for the struggle to maintain a neutral therapeutic relationship
    D) A metaphor for the struggle to maintain control in therapy
    
    
16. What is the role of epistemic trust in the therapeutic process, according to the authors?
    A) It helps patients feel more in control of the therapy process
    B) It allows patients to better understand their own problems and behaviors
    C) It helps patients feel more comfortable discussing sensitive topics
    D) It helps patients feel more open to new ideas and perspectives
    
    
17. What is the main conclusion of this study?
    A) MBT is an effective treatment for BPD
    B) The therapeutic alliance is the most important factor in the effectiveness of MBT for BPD
    C) Epistemic trust is a crucial component of the therapeutic process in MBT for BPD
    D) Therapeutic strategy, alliance, and epistemic trust all play important roles in the effectiveness of MBT for BPD

Answers:

1. C) The relationship between therapeutic strategy, alliance, and epistemic trust in mentalization-based treatment for borderline personality disorder
2. C) Through a qualitative analysis of therapy sessions 
3. B) Therapists were able to focus on the alliance and transparently explore transference reactions
4. A) Therapists were too accommodating and lacking in confrontation
5. C) The therapeutic alliance may be strengthened
6. B) A stronger therapeutic alliance
7. A) The ability to understand and interpret behaviours of self and others as expressions of intentional mental states
8. C) An attitude of trust in the listener's ability to take in personally relevant knowledge about the social world
9. A) Mentalization helps to improve emotional regulation and increase security in close attachment relationships
10. A) Mentalization-based treatment and cognitive-behavioral therapy
11. D) The authors analyzed the interactions between therapeutic alliance, therapeutic strategy, and epistemic trust in the treatment of BPD through a qualitative analysis of MBT sessions.
12. C) The authors proposed a model where therapeutic strategy, alliance, and epistemic trust all work together to facilitate the therapeutic process.
13. A) A positive, supportive relationship between the therapist and patient
14. A) Trust
15. A) A metaphor for the struggle to confront problematic patterns in therapy
16. B) It allows patients to better understand their own problems and behaviors
17. D) Therapeutic strategy, alliance, and epistemic trust all play important roles in the effectiveness of MBT for BPD

Introduction

Given the current state of psychotherapy research where talented therapists evidently produce a stronger alliance without researchers being able to identify what they do (Fonagy, 2010; Lemma et al., 2011), this study aimed to investigate how highly rated and low-rated MBT therapists tailor their treatment to patients. The Quality Lab for Psychotherapy measured 108 individual sessions with the newly developed adherence and competence scale for individual MBT (Karterud et al., 2013). In a qualitative design, our question was what characterized selected sessions with high and low ratings. Avoiding the circular logic of answering the question in terms of the MBT framework, we investigated whether observed differences could be explained in terms of the common factors.

Mentalization as a core mechanism of change

As we all know, mentalization—the ability to mind others’ minds, to understand misunderstandings, and to see oneself from the outside and others from the inside—has been proposed as a fundamental CF among psychotherapeutic treatments. It is defined as the ability to understand and interpret, implicitly and explicitly, one’s own and others’ behavior as expressions of various intentional mental states (e.g., thoughts, feelings, desires). People are very different with respect to mentalizing capabilities. For most of us, mentalizing collapses only sometimes. For others, mentalizing is very difficult most of the time. Poor mentalizing is connected with poor social functioning and psychopathology (Fonagy et al., 2002). The operationalization of mentalization in research is most commonly the (RF; Fonagy et al., 1998) scale. The core assumption in MBT is that an increase in RF will mitigate BPD, and improvements in RF are indeed indicated in effective BPD treatments (De Meulemeester et al., 2018; Levy et al., 2006). The interpersonal process pursuing an open exchange of minds in an attachment relationship with the therapist is assumed to be an effective means to increase mentalization (in borderline patients). Mentalization is thus believed to be facilitated by the quality of the attachment relationship (Fonagy et al., 2002). Thus, the ability to reflect about own’s own and others’ minds will not develop unless being minded by another human.

Epistemic trust

Sperber et al. (2010) and later Fonagy (e.g., 2015) and colleagues knowingly borrowed the term epistemic from Aristotle (epistémé; Schwartz, 2011), as “before coining new terms, it is always advisable to look in a dead and learned language to see whether it might not contain such a concept and its appropriate expression” (Kant, 2007, p. 297). However, the merger of Western psychology and Zen Buddhism has proven productive for DBT, and there are probably similar reasons why when investigating proposed universal principles in psychology, such as epistemic trust, there is a long tradition of cross-cultural studies (Passer & Smith, 2004). Therefore, let us first observe that within Indian epistemology, philosophers go into long discussions about apta-vakya (“true knowledge from true sources”) and on what grounds they should trust the testimony of the āpta and just how far such trust should extend. The Nyāya school asserts that all forms of valid knowledge are valid only by reason of extrinsic causes, a position known as parataḥprāmāṇyavāda (Hatcher, 1999, p. 64; Picascia, 2019), which roughly translates to “hetero-epistemic theory” (Ram-Prasad, 2013) or “extrinsic validity of cognition” (Shida, 2011). However, we should also observe that Indian epistemology includes (and transcends) Aristotelian logic in its logical tetralemma (Langjord, 2009), such that the Western mind, based on the theory of the four quadrants, will conclude that epistemic trust not being in the upper-right quadrant (e.g., can be explained by biology), such as Fonagy et al. (2015) seem to suggest, does not mean that it cannot be part of the upper-left quadrant (interior individual perspective) instead. A somewhat similar logic will also inform us that the fact that mentalizing plays a significant role in evidence-based BPD treatments does not imply that it is the underlying shared mechanism at work in these treatments. Acknowledging this, Bateman et al. (2018) propose epistemic trust for this purpose: “For this we consider it necessary to recognize how individuals ‘learn’ or fail to learn about themselves and the social world” (p. 45). They further highlight three communication systems central for amending epistemic trust: 1) communication system 1: the teaching and learning of content; 2) communication system 2: the re-emergence of robust mentalizing; and 3) communication system 3: the re-emergence of social learning. The idea that therapy is primarily a learning arena in some form is far from new; for example, Bohart (2000) identifies five “learning opportunities” provided by therapy. Closely related to epistemic trust, psychoeducation, and skills‐based strategies, the importance of a pedagogic stance seems implied in evidence-based BPD treatments. Such a pedagogic stance seems somewhat contrary to the “not-knowing stance” championed by a more rigorous MBT. Therefore, at some point one might suspect that the architects of MBT have “thrown the baby out with the bathwater”, that is, that their attempt to avoid psychoanalytic interpretations has excluded the focus on the art of transmitting knowledge (typically denoted pedagogy). However, as psychoeducation is already a crucial part of the MBT program (Ditlefsen, 2020) and we have seen that psychoeducation in itself (e.g., Zanarini et al., 2018; Zanarini & Frankenburg, 2008) shows good effect for BPD patients, there are indications that a pedagogic stance may be central for MBT.

Epistemic trust: A “royal road” to understanding psychotherapy?

In an attempt to reintroduce the baby—hopefully without too much bathwater—a “pedagogic stance” has recently been advanced as an MBT intervention in the Scandinavian manual for MBT (Karterud et al., 2020). Transmission of knowledge means that the overarching strategy should be in accordance with the patients’ level of insight or (lack of) knowledge (Goldfried, 2008). This is probably the most established principle of pedagogy; for example, according to Aristotle, “[a]ll teaching is from things previously known” (Schwartz, 2011, p. 119). However, “what is grasped by epistēmē (epistētoñ) is what is demonstrated, and since there have to be first principles of demonstration, there is no epistēmē of the principles of knowledge. That is to say, principles of demonstration cannot themselves be demonstrated” (Schwartz, 2011, p. 119). Or, as Alan Watts eloquently put it, “the knower is never an object of its own knowledge” (1999, p. 69), to which he added “because fire does not burn fire” (Watts, 2004, session 6).

 

Therefore, opening the channel for epistemic trust or fostering “the miracle of understanding” (Gadamer et al., 2004, p. 309) is a sophisticated art, and there are good reasons why pedagogic interventions of poor quality should be avoided. First of all, therapists need to avoid preaching what they themselves need to hear or trying to convince the patient of some of their own opinions. This would be considered toxic in terms of MBT quality and would most likely be awarded a rating of 1–2 on a scale of 1–7 (Karterud & Bateman, 2010; Karterud et al., 2020; Karterud et al., 2013). Therefore, introducing the pedagogic stance in the MBT framework comes with substantial risk, as do all ambitious (MBT) interventions, such as the use of countertransference or challenging unwarranted beliefs (e.g., Piper et al., 1991). At this point, it is perhaps good to ask what MBT actually is. Disregarding the problem of the chicken and the egg for a second, one might, for instance, ask if MBT is what is defined by the manuals and thus somehow abides among the platonic forms publicized by the architects of the treatment (theoretical) and/or whether is it better described by what MBT therapists are actually demonstrating (empirical). If we lean slightly towards the upper-right quadrant in this question, it becomes of interest to see what we can learn from 327 MBT individual sessions rated by the Quality Lab for Psychotherapy at Oslo University Hospital (Table 1). Surprisingly, Folmo et al. (2021b) and Karterud et al. (2020) found that the most prevalent intervention used by Nordic MBT therapists is “validating understanding” (Item 16; Karterud et al., 2013). In fact, this intervention accounted for 32% of the identified interventions. This simple finding is remarkable, given that this item even surpasses “exploration, curiosity and a not-knowing stance”, which should be the hallmark of MBT. Shifting our focus to the upper-left quadrant, our best explanation of this is that therapists use this item to be (indirectly) pedagogic, often in a concealed way, because interpretations are to be avoided according to the manual (Karterud & Bateman, 2010). Therefore, despite MBT being operationalized as a “not-knowing” therapeutic approach, pedagogic interventions (just like in the other three evidence-based treatments for BPD) pervade the actual therapies performed and also seem to color all other intervention types to various degrees (ibid). Employing interpretative phenomenological analysis (IPA) to nine MBT-G and 24 MBT-I sessions, Folmo et al. (2021b) concluded that MBT seemed to mainly address communication systems 2 and 3 (Bateman et al., 2018), while the more skills-based treatment for BPD may involves system 1 (learning of content). Folmo et al. (2021a) also identified what seemed like nine prototypical versions of interventions targeting impaired epistemic trust (including missed opportunities); see Table 2. The possible existence of such discrete categories for pedagogic interventions (targeting specific domains of impairment in epistemic trust) signals that it may be possible to identify a limited number of overarching strategies for pedagogic stance, even within a psychodynamic and understanding-driven approach as MBT. Folmo et al. (2021a) indicated that pedagogic interventions strengthened the alliance and epistemic trust in MBT, and “pedagogic stance” is now proposed as an intervention in MBT (Karterud et al., 2020).

Pillars of alliance in mentalization-based treatment

In light of the above discussion, it becomes especially interesting to ask what it is that connects the specific ingredients in the MBT potion with the CFs (i.e. alliance). As alliance in other psychotherapies has been referred to as the “quintessential integrative variable” (Wolfe & Goldfried, 1988, p. 449), it is of interest to us how one can establish a stable expression of the relationship (alliance) with patients whose primary pathology is substantial problems with making and maintaining stable relationships. The very low dropout rate reported in MBT (Kvarstein et al., 2015) indicates that patients experience a good working alliance with the treatment, structure, and most likely the therapists. How does the therapist co-create a working alliance with someone with relational pathology and disbelief in others’ knowledge, that is, disturbed attachment and low epistemological trust (Fonagy & Allison, 2014)? And what does it look like when this is rated highly or poorly according to the adherence and competence scale for individual MBT (Karterud et al., 2013)? BPD patients are likely to be in for a long and tough ride in therapy, and one might reason that agreeing on the goals and tasks and experiencing a safe personal bond is paramount for these patients. BPD patients display schematic, rigid, and sometimes extreme views (Gunderson et al., 2018), which an effective treatment needs to address and challenge. Therefore, to prepare and deliver a potent “magic potion” to this population, we need a larger system (the MBT program), highly trained and competent therapists, and a clearly defined recipe (manuals). MBT programs consist of four structural pillars built to establish a “strong alliance”: 1) psychoeducation, which is an important tool in agreeing on goals and tasks because it explains central features of BPD, mentalizing, affect, attachment, and the treatment program (Karterud, 2011, 2019); 2) an individual dynamic MBT case formulation (Karterud & Kongerslev, 2019); 3) individual mentalization-based psychotherapy (Karterud & Bateman, 2010; Karterud et al., 2020); and 4) MBT-G (Karterud, 2015). All patients are required to participate in 12 sessions of psychoeducation when enrolling in the MBT program, and the overall focus is on integrating all aspects of the treatment. For example, the individual therapist encourages the patient to attach to the psychodynamic group and vice versa. The manual for individual MBT (Karterud & Bateman, 2010) states that “If a patient drops out of one of the components, then the other components are automatically terminated” (p. 42). Without such clear practice, the therapist will easily fall victim to borderless borderline patients whose personality is often specialized in pushing, pulling, and forcing others into their own scripts/schemas/patterns. Therefore, counteracting these forces, the alliance-fostering ingredients in the MBT potion are arguably stronger (more caring, strict, pushy, normative, and committed) than in many other psychotherapy orientations and are based on goals that the patient deeply commits to. The task the patient is embarking on (radical change in personality) is also considerably more difficult than in therapies with less disturbed patients.

 

Mentalization-based treatment or plain old therapy?

MBT has been called both “plain old therapy” (POT) and (purified) old wine in new bottles (Allen, 2012). The novelty of MBT is that it keeps a steady focus on mentalization, which is the basic ability to understand relations, inner processes, and guesstimate others’ mental content (the specific ingredient in the “magic potion”). However, an increase in mentalizing ability would most likely be the hallmark of all effective therapy with a focus on relationships, feelings, and self-understanding. The purification, then, is the clear focus on mentalizing, mental states (minding minds), the absence of interpretations (performing the mentalizing for the patient), defocusing on insight or historical content, and an unwavering spotlight on the 17 colors in the spectrum of building a strong alliance. MBT is a manualization of a non-technique-based psychotherapy (Perepletchikova et al., 2007; interventions are driven by understanding), in which the relationship with the therapist and interactional processes play a central role. Therefore, in addition to the clear focus on the 17 constituents, the manual also states that “The therapist must offer himself/herself as a possible attachment figure, thereby becoming emotionally involved in the patient’s life. The therapist must ‘care’” (Karterud & Bateman, 2010, p. 43). In individual MBT, this strong alliance is differentiated into 17 core activities the individual therapist must employ to facilitate the long journey from having a personality disorder to manifesting “a life worth living”. Simply stated, one could say that the “strong alliance” (patient and therapist agreeing that the goal is to improve mentalizing and reduce BPD traits) can be broken down, as light through a prism, into these 17 defining items in individual MBT (Karterud et al., 2013) and 19 in MBT-G. These ingredients are different ways to obtain an intact and efficient alliance in MBT (e.g., challenging, exploring in a not-knowing way, validating, acknowledging, displaying genuine interest, exploring the therapy relationship, stopping pretend mode, stopping psychic equivalence, being open and transparent about one’s own mind). As these 17 and 19 elements comprise a totality, address different cornerstones for change, and prevent possible escape routes for the patient (e.g., “pretend mode”; pretending to be normal), it is important that all are applied (in a way tailored for the patient). This means one can have a high adherence score on individual MBT even though not employing all 17 items in one session, but a certain sign of poor MBT would be neglecting one of these areas if it were indicated in the session. One central aim of the current study was to investigate if observers can agree on the 19 ingredients in MBT-G (Paper I).

 

The problem of manualizing mentalization-based treatment

Despite MBT supposedly being based on “the most fundamental common factor among psychotherapeutic treatment”, it has been criticized for being too abstract and relying too heavily on expert supervisors who can translate dense psychodynamic theory into practice. Hutsebaut et al. (2012) reported in their implementation study that MBT‐trained therapists felt insufficiently prepared to apply their new knowledge and skills in everyday practice. MBTs include some skills‐based learning and general strategies, such as increasing mentalizing flexibility by regulating emotional activation and being transparent about one’s own mind. MBT manuals suggest curiosity, a high level of genuine care, intellectual humility, low rigidity, and high tolerance for transferences as core facets of a mentalizing stance, “but granular‐level, behaviorally anchored guidance is not provided on how to achieve these” (Sharp et al., 2020, p. 3). As a consequence of this lack of specificity, MBTs may be difficult for novice therapists to learn. Sharp et al. (2020) suggest that “[c]oncrete protocols may be needed to reduce therapists’ uncertainty and anxiety” (p. 3). However, many specific examples of behavior in manuals for psychodynamic therapies could make the treatment rigid, and slavish adherence to treatment protocols has been suggested to result in deterioration of the therapeutic relationship (Henry et al., 1993). Manualization may also become too rigid by generalizing principles that are valid for the vast majority of patients but are not necessarily applicable to the specific patient. Therefore, the core of MBT, like most psychodynamic therapies, is non-directive and non-instructional; a “one size fits all” approach would be somewhat in contrast to the core of co-creating a safe learning environment with the unique patient (working alliance). All three core components of MBT are manualized (Bateman & Fonagy, 2016; Karterud, 2015, 2019; Karterud & Bateman, 2010; Karterud et al., 2020), but it is hard to manualize how to create and maintain a mentalizing therapy culture amongst therapists. The treatment presupposes a well-functioning team and video supervision services that manage to integrate the different components and different therapists involved (Bateman & Fonagy, 2016, pp. 155–156), and organizational disruptions may affect the outcome of MBT (Bales et al., 2017a; Bales et al., 2017b). Therefore, successful MBT demands a system that supports these challenges where the therapist must redefine and rediscover her/his role as therapist and attachment figure with every patient.

 

The patient’s contribution to competence

It has generally been assumed that adherence and competence are therapist characteristics (Baldwin & Imel, 2013). Wampold and Imel (2015) summarize their understanding of the Boswell et al. (2013) study thus: “Although not quite statistically significant, it does show that it is the patient’s contribution to competence ratings that is related to outcome rather than the therapists’ competence relative to other therapists“ (p. 238). MBT is a dynamic psychotherapy, and the manual is based on and driven by understanding. Therefore, the competent MBT therapist must be interpersonally skilled, able to work collaboratively with a range of patients, express empathy (therapist empathy is a core specific ingredient in the treatment), and effectively engage the client in the treatment actions. This indicates a need to investigate the “role of responsiveness in treatment adherence and competence with particular patients (e.g., when and why a therapist ‘goes off track’ with a given patient), including the immediate and direct impact of patient characteristics on therapist behaviour and decision making” (Boswell et al., 2013, p. 453). In MBT, it would seem plausible that individuals with different pre-treatment levels of mentalizing capacity may differ in their ability to engage in psychotherapy (Katznelson, 2014), and different capacities for mentalization need different kinds of therapeutic approaches (Antonsen, 2016).

 

Adherence and competence/quality for mentalization-based treatment

In an exemplary RCT, “based on video recordings of the therapy sessions, independent observers assess how closely the therapists adhere to the treatment manuals (adherence), and how competent they are (specific therapeutic competence)” (Jørgensen, 2019, p. 53). A recent review of the evidence‐based status of MBT (Malda-Castillo et al., 2019) found that fidelity to treatment was poorly reported in almost half of the studies (47%). Importantly, there is currently no consensus as to what counts as good fidelity measures, which is why the current dissertation reports different numbers here. Based on the Norwegian manual for individual MBT (MBT-I; Karterud & Bateman, 2010), an adherence and competence scale (MBT-I-ACS) was developed (Karterud et al., 2013). It provides possibilities for the documentation of model fidelity in treatment studies (e.g., Kvarstein et al., 2019; Kvarstein et al., 2015). It has also been used for in-session studies of therapists’ interventions and their relationship to outcome (Moller et al., 2017). The Quality Lab for Psychotherapy has implemented the MBT-I-ACS as part of its quality control system, and the scale has also been employed for educational purposes. Recently, MBT-G has been manualized (Karterud, 2012, 2015) and provided with practical guidelines (Bateman & Fonagy, 2016). Karterud’s manual (2015) follows the recommendations of Luborsky and Barber (1993) and includes (1) a theoretical rationale; (2) presentation of the main principles underlying the therapeutic techniques; (3) concrete examples of all techniques being described; and (4) scales and instruments that can assess the skills of the therapists for this particular treatment model. The manual also contains a 19-item adherence and quality scale for MBT-G (Karterud, 2015). So far, the scale has been used in process studies and to explore similarities and differences between psychodynamic group therapy and MBT-G (Beck et al., 2020; Kalleklev & Karterud, 2018; Karterud, 2018).

 

Methods

The material for this study was selected from the Quality Lab for Psychotherapy at Oslo University Hospital (http://www.psykoterapilab.no).

The Quality Lab for Psychotherapy

Karterud et al. (2013) reported a G coefficient (G-study) of .84 and .88 with seven raters for adherence and competence, respectively for MBT-I. This study formed the backbone to initiate the “Norwegian MBT quality lab”, which later became the “Quality Lab for Psychotherapy”. Its primary task is to assist local MBT programs with quality control of their treatment integrity. Local MBT programs deliver video recordings of therapy sessions to the lab. The two main tools for the lab are the MBT adherence and competence scale for individual MBT sessions (MBT-I-ACS) and the adherence and quality scale for group MBT sessions (MBT-G-AQS; Karterud, 2012, 2015; Karterud et al., 2013). The term competence was replaced with quality in the group scale. In addition to MBT-I-ACS ratings, the local MBT programs receive a clinical evaluation providing clinical guidance (e.g., regarding both alliance and technique). The individual MBT-I-ACS consists of 17 items (see appendix A). The item descriptions and rating procedures are presented in the “Manual for mentalization-based treatment” (Karterud & Bateman, 2010). The MBT lab has assessed MBT treatment integrity for research projects at the Psykiatrisk Klinik Roskilde in Denmark, the Department for Personality Psychiatry at Oslo University Hospital in Norway, and the Stockholm Centre for Dependency Disorders in Sweden.

Sample

The four most deviant (extreme) sessions were sampled from a total of 108 individual MBT sessions previously rated with the MBT-I-ACS. The data material in the qualitative analysis consisted of anonymous transcripts of these sessions. All four sessions were part of comprehensive MBT treatment programs. This means that 1) all patients suffered a PD in the borderline range and 2) the individual sessions were part of a broader program that also included psychoeducation (during the initial stage) and MBT-G therapy. At the time of the video recordings the treatment had lasted for various time periods ranging from 6–24 months.

 

Therapists

The four therapists were experienced psychotherapists with a mean age of 55. All four therapists had completed advanced training courses in MBT. All therapists received regular MBT (group) supervision.

 

Verbatim transcripts

In this study, the four sessions were transcribed. Personal data was altered and anonymized (i.e., names of friends and relatives, workplaces, toponyms).

 

MBT-I-ACS ratings

The ratings this study was based on were performed by the MBT lab and included both independent separate ratings and consensus study of video-recordings. In further analyses in the present study, authors EF and SK re-evaluated transcripts independently and by consensus. The rating procedure for the 17 different MBT-I-ACS is identical to that for the MBT-G-AQS.

 

Raters and reliability

The reliability between EF and SK was assessed based on 30 previous MBT-I-ACS ratings. The reliability was very high (mean value of absolute G coefficients) at .95 for adherence (range: .87 [Item 9]–1.0 [Item 15]) and .9 for quality (range: .82 [Items 2, 10, and 11]–.98 [Item 17].

 

Qualitative methods

After completing the ratings, the complete transcripts were searched for relevant excerpts to describe, exemplify, and illuminate the macro- and micro-processes where the therapist displayed a clear focus on the main goals of the treatment/session (e.g., to stimulate mentalizing, to challenge unwarranted beliefs, to negotiate ruptures in the alliance, to handle aggression). Our epistemological stance regarding the present data is grounded in philosophical hermeneutics (Gadamer, 1975; Habermas, 1986; Schwandt, 2000) in which meaning is negotiated and understanding is interpretation that presupposes, ideally, the engagement of one’s own biases and prejudices. The interpretation of a given text will change depending on the questions the interpreter asks of the text. Gadamer (1975) reconceptualized the hermeneutic circle as an iterative process through which a new understanding of a whole reality is developed by exploring the details of existence. The four sessions were analyzed using the framework provided by interpretative phenomenological analysis (IPA; Smith et al., 2009).

 

Interpretative phenomenological analysis

IPA is a recently developed qualitative approach that has rapidly become one of the best known and most commonly used qualitative methodologies in psychology. Between 1996 and 2008, 293 papers presenting empirical IPA studies were published (Smith, 2011). IPA is typically concerned with the detailed examination and interpretation of personal lived experience and one makes sense of that experience. IPA is an experiential psychological approach that draws inspiration from phenomenological philosophy and hermeneutic theory. In this spirit, IPA encourages researchers using the approach to engage with its theoretical and epistemological underpinnings. This is in line with Habermas (1986) and Ricoeur (1970, 1996), who provide the fundamental building blocks in our analytic approach (IPA).

 

Habermas is central in the hermeneutic tradition, which together with phenomenology comprises the backbone of IPA (Eatough & Smith, 2008, p. 194). Therefore, Habermas’ (1986) three validity claims form the epistemological foundation for the current article. IPA is in the upper-left quadrant (I), and subjective sincerity or transparency is the key to applying this hermeneutic method for analyzing data. While hermeneutics constitute the theory and methodology of interpretation, the other central element of IPA is the study of structures of consciousness as experienced from the first-person point of view, phenomenology. When building theories from our observations and reflective processes, the following passage from Habermas underscores how we understood the phenomenological process in "Battles of the comfort zone": Analytic insights, he argues, “possess validity for the analyst only after they have been accepted as knowledge by the analyst himself. For the empirical accuracy of general interpretations depends not on controlled observation and the subsequent communication among investigators but rather on the accomplishment of self-reflection and subsequent communication between the investigator and his ‘object’” (Habermas, 1986, p. 261). However, as we did not check our interpretations with the patients or the therapists, we did our best to (phenomenologically) inhabit their lived experience (Smith et al., 2009). Somewhat overlapping with mentalizing, one central structure of individual experience is intentionality or some theory of what motivates action. This presupposes researchers’ ability to mentalize, and IPA is thus closely connected to the investigated material.

 

Such an analytic position becomes clearer when we introduce Ricoeur (1970, 1996), who suggested there are two kinds of hermeneutics: 1) Empathic interpretations are motivated by a desire to get as close to the meaning of a text as possible by trying to understand it “from within”, just like mentalizing is also defined as understanding others from within and yourself from the outside. However, such interpretations focus on how (rather than why) something is experienced and presented. 2) Suspicious interpretations, as the term implies, have deep connections to a detective bureau but also classical psychoanalysis, where nothing is accepted at face value but is rather an expression of something hidden. If we were to place different research traditions on this continuum, then Grounded Theory, Q Methodology, Phenomenological Methods (e.g., IPA) lean towards empathic interpretation, while, Discourse Analysis, and Psychoanalytic Approaches lean towards suspicious interpretation. However, the idea of a continuum is misleading, as the entire point is the dialectic circle these forms of interpretation imply. However, these two ingredients can occur in various amounts in the larger cocktail (Smith, 2011).

 

Consequently, while MBT promotes a mentalizing stance, Ricoeur invites us into the hermeneutic circle through a Hegelian dialectic between understanding based on an “empathic stance” and explanations stemming from a “suspicious stance”. Just like quantum theory, the concept of the “hermeneutic circle” acknowledges the impossibility of approaching a phenomenon without adopting a particular perspective or stance in relation to it. Without a standpoint, we would not be able to find meaning in what we examine. Therefore, we need to apply assumptions and ideas to begin to make sense of what we investigate. However, we avoid pretend mode and do not simply project our expectations onto a blank screen in the outside world and then find what we are looking for. In this interaction between our ideas and the world, our ideas evolve to accommodate what we have encountered. This implies an interdependency between the parts and the whole; the words within this sentence are best interpreted on the basis of the sentence, the paragraph, and the larger dissertation it is part of, which again is part of a larger system, which again meets your mind and your ever-evolving evaluation of what on earth is going on when this sentence stops. Such progress is not always linear (or even curvilinear), and in meeting another subject the miracle of understanding is that no like-mindedness is necessary for recognition (Gadamer et al., 2004, pp. 309–310). IPA can be understood as a framework to underpin such a process or a way to structure and/or organize it.

 

IPA starts with probing the particular and ensures that generalizations are grounded in the idiographic details. However, in an attempt to create chain reactions from the particular and uniquely specific (e.g., like splitting the atom), IPA invites an intensive investigation of individuals’ intrinsic psychology in the epistemological journey to universal laws and principles. Such a science is always aimed at a cautious climb up the ladder of generality, seeking universal structures but reaching them only via a painful, step-by-step approach (Eatough & Smith, 2008). Smith (2011) has developed a set of evaluative criteria for IPA that include a sustained focus on a particular aspect of experience, rich experiential data, assessment of the thematic structure using a measure of prevalence, careful elaboration of themes, and, of course, detailed, interpretative engagement with the material.

 

Hermeneutic circles thus encompass the deep insight also encountered in the double slit experiment (e.g., Penrose, 2006) in quantum theory—the fundamental interconnectedness of observer and observed. Thus, just as the knife cannot cut itself, we cannot free ourselves from our presumptions about the world.

Rather, said Hegel, we must realize that thoughts are not merely a reflection on reality, but are also a movement of that very reality itself. Thought is a performance of that which it seeks to know, and not a simple mirror of something unrelated to itself. The mapmaker, the self, the thinking and knowing subject, is actually a product and a performance of that which it seeks to know and represent. (Wilber, 2000, p. 59)

It follows that the scientific ideal in IPA is a transparent stance when interpreting information.

 

IPA is often applied to interviews in which the phenomenological interpretations are supported by a discourse with the subject and typically recommends researching few in-depth interviews. "Battles of the comfort zone" includes four transcripts, but the sessions do not count as interviews. However, despite this limitation, we believe that clinical expertise allows for close investigation of such transcripts, especially in terms of the theories, experience, and treatment method. IPA seemed ideal in terms of a fundamental investigation of phenomena such as alliance, epistemic trust, and strategic competence. The IPA analysis in "Battles of the comfort zone" involved five steps (see the published paper for details):

 

1) The four sessions were transcribed and studied in detail.

2) We phenomenologically investigated the therapeutic alliance (goals, tasks, and personal bond).

3) Four emergent themes began to appear.

4) These themes were debated in light of psychotherapy research.

5) The authors decided on the major themes in the investigated sessions.

 

Reflexivity

It is important to be transparent about our interpretations (Finlay & Gough, 2008). In "Battles of the comfort zone", the first (EF), second (SK), and last author (ES) were most involved with the transcripts and the IPA. The third (MK) and fourth (EK) authors were part of the later analysis and the overall interpretations in the manuscript. EF originally had the idea of merging the CF and EST approaches within this field when he became a rater at the Quality Lab for Psychotherapy in (January) 2013. As a student, he had rated hundreds of therapy sessions from a previous RCT (Svartberg et al., 2005) and trained other raters in the project headed by Leigh McCullough at Modum Bad (where he discovered that he preferred the alliance in psychodynamic therapy above that in cognitive therapy). EF was strongly influenced by McCullough, but his psychodynamic orientation is perhaps closest to object relations theory (e.g., Bion, Kohut, Fairbairn, Winnicott, and Guntrip) and Eastern philosophy traditions (especially Buddhism). This would have influenced his preference for a highly open-ended approach (e.g., listening before talking and being non-judgmental and accepting) colored by a well-timed transference of knowledge. Therefore, some time elapsed before EF accepted the battling stance evidently associated with highly rated MBT. However, EF also feels very much at home within the mentalization tradition and finds that an active therapeutic stance seems natural when treating PDs. EF has also been a professional musician since a young age, and the pedagogic stance embodied by the eminent pianist Sir András Schiff comes close to his ideal of such an approach—deeply listening to each student to try to bring forth their unique quality. EF has also been deeply impacted by being a student of the Diamond Approach from 2004–2018. This approach advocates that one size fits none and that each meeting between two individuals is unique. When analyzing the four selected sessions in "Battles of the comfort zone", it became evident that EF has a tendency to prefer transparent therapists who lean towards self-disclosure, such as the therapist in Session B who uses his bond with Elsa to nudge her into group therapy ("Battles of the comfort zone"). ES shares many of the same preferences and comes from a psychoanalytical background, being most interested in the fundamental mechanisms in psychotherapy. It was also very beneficial for the analysis that one author (ES) is not in the field of MBT. The rest of the authors are all experts in MBT. "Battles of the comfort zone" was ambitious in terms of trying to convey something deep, while being firmly rooted in empirical observations.

 

The first author of this article may have been influenced by being co-author on the new Nordic MBT manual (Karterud et al., 2020). One example of this is that the proposed mechanism of change in MBT is to stabilize mentalizing in certain focus areas to create a psychic buffer between affect and behavior to foster affect regulation, reduce impulsivity, and promote functional supportive relationships. This is reached by employing “contrary moves” to create more flexibility in using the different poles of mentalizing. (Taubner & Volkert, 2019, p. 8; Volkert et al., 2019, p. 25)

Such “contrary moves” are not considered specific MBT interventions in the new Nordic MBT manual (Karterud et al., 2020)—not because they fail to be clinically relevant, but because they seem hard to define (e.g., evaluate for adherence and quality). Indeed, the reader may be able to easily imagine numerous psychotherapeutic interventions (strategies) that are not contrary moves, and many of them likely also characterize manualized MBT. Further, I have thought that the field of MBT may be ill served by proposing such abstract theories, as if they are the sole solution, and also somewhat making mentalizing the cornerstone of all psychotherapies, typically arguing that neuroscience “strongly suggest that mentalizing is an evolutionarily prewired capacity” (Luyten et al., 2020a, p. 298). I fully agree that “mentalizing may be commonly found as a factor associated with recovery in a range of psychotherapies” (Luyten et al., 2020a, p. 299), but perhaps due to the absence of a clear definition of such conceptions, I fail to understand why it needs to be stated that mentalizing may be a change agent also when the therapeutic discourse is not focused on mentalizing:

[I]nterventions that may not explicitly focus on improving mentalizing nevertheless may be effective in reducing mental health problems as they may foster mentalizing and salutogenesis in particular through different routes. (Luyten et al., 2020a, p. 299)

 

Further, in terms of working with the concept of the alliance, one needs to be as aware of one’s preconceptions as possible. The alliance, whether interpreted by observer, therapist, or patient, needs to be seen in the context of the features of purposive, collaborative work specific to the given treatment (Horvath, 2018). Consequently, the specific treatment will inform us how we are supposed to judge the alliance, a consensus we may or may not adhere to, depending on our preferences. An excellent alliance in CBT may not be very similar to an equally strong working relationship in psychoanalysis. Hence, the alliance is a term that needs to be defined clearly in order to inform the reader exactly what kind of behavior it denotes. This is also true in terms of time, for instance, an alliance rupture could denote events between sessions, within a whole session, between segments of the session, between grammatical units, or within utterances (Horvath, 2018). As all these time frames represents a legitimate and meaningful conceptualization of disruption in the alliance, we tried to bring awareness to such perspectives in the IPA.

Ethics

All patients gave written informed consent to participate in the study. The procedures for recording and transcribing the sessions were approved by the privacy ombudsman at Oslo University Hospital. One session was approved by the Psychiatric Research Unit at the Psychiatric Clinic in Roskilde, Denmark. The other was from an earlier RCT study (Mentalization-Based Treatment for Dual Diagnosis) conducted at the Center for Dependency Disorders at the Stockholm County Council and Karolinska Institutet in Sweden. This project was approved by the Regional Ethical Review Board in Stockholm. The therapists consented to this publication. Interpreting the style of individual therapists, perhaps especially in the low rated cases, raises several ethical concerns. It may weaken the therapist’s self-esteem and thus impact future treatments. It may also make the therapist reject the MBT model and perform therapy in a manner where they are not evaluated by strict raters of adherence and competence/quality. We strived to communicate that highly rated and poorly rated MBT does not mean good and bad therapy but that such ratings only concern how much MBT the relevant sessions contain. This is a challenging task, which is also a continual challenge for the Quality Lab for Psychotherapy. Achieving a very high rating may cause similar problems, and the same message was communicated in these instances (i.e., high ratings only imply that the therapy resembles the ideal in MBT).

Results

Embedded alliance represents a marriage of the common and the specific psychotherapeutic factors, and its importance is one of the major conclusions of this article. "Battles of the comfort zone" was conceived from the viewpoint of the embedded alliance, but primarily described findings in common factor terminology. As mentioned, this was largely in order to avoid a circular logic. Further, one of the core research questions was whether the differences between highly rated and low rated MBT could be explained (in the language of) CFs. However, as this article concludes that the alliance is largely a product of the applied method (MBT), it seems reasonable to present the results from the viewpoint of the embedded alliance. Below, we will first present the findings from "Battles of the comfort zone", and then I will use the 17 MBT interventions (MBT-I-ACS) as a conceptual backbone for describing how the specific technique (MBT) fosters alliance (embedded alliance).

 

The four themes constituting battles of the comfort zone

The four themes that emerged from the IPA were labelled: 1) alliance, 2) strategic competence, 3) quality, and 4) battles of the comfort zone. Our observations indicated these were related in the following manner. All four identified themes seemed to interact and reinforce each other. For instance, in the highly rated MBT therapies, therapeutic alliance was fostered by battles of the comfort zone, quality, and strategy. As long as there seemed to be an adequate alliance, therapists nurtured the alliance through battles of the comfort zone. When therapists competently challenged problematic patterns, despite disclosing discomfort, they seemed to fortify the alliance. This appeared to create somewhat of a snowball effect, such that the stronger the alliance the more the therapist could challenge the patient, thus being able to foster further enforcement of the alliance. The epistemic trust seemed to grow stronger through the experience of being seen and by having obtained (significant) new understanding about oneself as a product of the therapist having dared to follow the patient through painful terrain. Quality partially overlapped with strategic competence but could also be seen as a measure of the alliance strength. In highly rated MBT, the three first identified themes (alliance, strategic competence, and quality) worked together in such a way that the patients were brought out of their comfort zone, resulting in beneficial therapeutic work.

Let us first summarize the four sessions, before we explore different intervention types and how they informed our interpretation (IPA). In the summaries of the four sessions, in order to highlight the interconnectedness of MBT and the CFs (embedded alliance), the MBT-I-ACS ratings (not published in "Battles of the comfort zone") will also be presented.

Summary of session A (Elsa)

This session concerns a female patient in her fifties who also receives treatment for heroin addiction. She starts talking about a funeral she helped arrange. The therapist challenges her self-devaluation and the patient eventually comes to acknowledge the good work she did for others and herself with the funeral. In the next sequence, the therapist comments “… and then you have not been in the group therapy, have you?” Her absence from the group is the main theme for the rest of the session, alternating with worries about her son’s suicidal thoughts and the relationship to some friends. The patient strongly dislikes the group being a theme in the session: “No, that damned group. I hoped that you would forget about it”. Initially, she resists, but slowly they approach the underlying painful theme of returning to someone who has hurt her. She promises to go to the next group session. In this session, “battles of the comfort zone” emerged in the therapist’s effort to sustain a focus on mental states, as did the use of the positive bond to challenge the patient’s massive resistance to the theme.

This session received a rating of 7 (excellent) for both adherence and quality. The number of interventions that adhered to the manual was high (N = 160), and the percentage of MBT interventions relative to all interventions was very high (85%).

Summary of session B (Maria)

This session concerns a female patient in her early thirties who starts with her hesitations about starting her college education at the same time as being in treatment. Lately, she has felt much better. However, the chronic feeling of emptiness is still present. The therapist suggests exploring this theme: “When did you experience that last time?” After the last group session, she says, and the group theme fills most of the remainder of the session. She is fairly new to the group and admits being irritated with senior group mates who have been reluctant to include her. The therapist explores in detail exactly what it was that provoked her. Gradually, a picture of a patient who has harbored strong resistance to the group therapy component emerges. When she eventually turned up, she was met with skepticism. She felt an urge to leave the group, thinking “fuck you”. The therapist asks if some of her thoughts and feelings could be shared with the group. But she feels strangers should have no access to her inner life! This theme resonates with other relationships in her life. She has become rather lonesome. Her emptiness after group sessions is explored even more. The therapist asks, “Talking about it here, how does that affect you?” She replies, “Irritated/annoyed, really irritated/annoyed”. She vents her feelings to the therapist, whom she feels is pushing her. It becomes a relief to have said this, and her feeling of being different and lonesome fills the last part of the session, now with tears and sadness. This session received a rating of 7 (excellent) for adherence and quality. There was a high number of interventions that adhered to the manual N = 193), and the percentage of MBT interventions relative to all interventions was high (76%).

Summary of session C (Diane)

This session concerns a female patient in her late twenties who attacks the therapist from the very beginning: “I was angry with you the last session. You said I was irritated. I was not; I was angry.” The therapist seems to be taken by surprise and quickly becomes defensive. He has difficulty understanding the patient’s point of view while also excusing his own behavior. The patient takes the initiative and talks on about several things, often in a pseudo-mentalizing way. The talk is about how the patient feels under pressure at work, about a good friend who does not understand her, about the patient’s relationship with her mother (a theme the therapist is bringing in), about her general sense of not being understood (from within) and of being judged from the outside, and about the difficult task of writing a study paper for the next day. The patient treats the therapist in a top-down manner, and the therapist succumbs. The therapist loses his mentalizing stance and moves into a kind of passive listening and supportive therapy. The therapist is harshly treated by the patient in the first quarter of the session and he submits to the patient’s dominant style. Towards the end of the session, the therapist suggests an extra session to deal with the patient’s manifold problems; this seems like reaction formation. The patient turns down the offer, saying that her problem actually is her limited time to write a study paper and that it will not help to talk to the therapist. In this session, the therapist did not battle the comfort zone and abandoned the main therapeutic project and goal (Theme 1). This session did not reveal relevant therapeutic work. It is quite possibly the therapist’s own wish for a good, pleasant transference challenged the application of a focused technique and overall strategy. The session received a rating of 2 (poor) for adherence and quality. The number of interventions that adhered to the manual were few (N = 50), and the percentage of MBT interventions relative to all interventions was low (38%).

Summary of session D (Monica)

This session concerns a female patient in her early twenties who has resumed therapy after having missed a number of sessions due to a traumatic sexual assault five weeks earlier. The session is for the large part educative and counselling and is focused on practical issues regarding the patient’s current life situation and how she deals with it, ways of taking care of herself, legal actions in relation to the assault, economic issues, advice on medication, etc. The therapist behaves in a caring and warm way and seems sincerely interested in the patient’s situation. The therapist talks a great deal, leaving little room for the patient to speak about what she thinks and feels in the moment. The focus on mental states is largely left out of the session. In all, the session reveals a supportive kind of therapy with very few MBT interventions. Towards the end, the therapist takes up the subject of what kind of dress the patient is going to buy for the season and steers the conversation to superficial topics. The session ends 5 minutes before regular time, as the therapist and patient have no more to say. This session received a rating of 2 (poor) for adherence and quality. The number of interventions that adhered to the manual were few (N = 52), and the percentage of MBT interventions relative to all interventions was low (19%).

Quantitative characteristics of the MBT-I-ACS ratings

The mean number of ratings of highly rated MBT was 177 (80% of the total interventions), while low-rated MBT sessions averaged 51 ratings (28% of total interventions). Table 5 and Figure 1 show a large difference in numbers of MBT ratings for highly rated and low-rated MBT. Note that each intervention might receive several MBT ratings. Tables 5, 6, and 7 present different quantitative aspects important for our basic understanding of what is going on in these sessions. Figure 2 displays the mean adherence profile for high- versus low-rated MBT. The most frequent intervention for highly rated MBT was Item 17, “Integrating experiences from concurrent group therapy”. In the low-rated MBT sessions, Item 3, ”Challenging unwarranted beliefs”, was absent, while in the highly rated sessions, Item 3 averaged 6.5. In summary, the highly rated MBT therapists employed far more interventions, especially Items 3 and 17. The low-rated MBT therapists mainly used Item 16, “Monitoring own understanding and correcting misunderstandings”.

 

Results presented through the lens of embedded alliance

As we remember from the introduction, the term embedded alliance seems to adequately address the working alliance (e.g., agreement on tasks and goals) in line with the therapeutic model (theory of pathology and change). We have also seen that the 17 ingredients in individual MBT can be viewed as strategies to achieve a good alliance despite dysfunctional dyadic patterns. "Battles of the comfort zone" found that MBT can be described without using the specific concepts in MBT, which also avoided a circular logic. However, as one overall aim of the current article (the fourth question) is to put the puzzle of measuring MBT together, in the following I will show how the results from "Battles of the comfort zone" can be understood in terms of embedded alliance. For this purpose, the 17 items of individual MBT will provide structure, as I present those items that seem particularly important for the overall article.

 

Items 1, 4, and 6: Tailoring the treatment to the patient

MBT sessions of high quality display a good working alliance (the bond part, warmth, being part of Item 1) and high therapist competence and flexibility in tailoring the therapy for the specific patient/situation. The ability to adopt and maintain a mentalizing stance at the maximum of the patient’s current mental and emotional capacity would be the chamber pitch of well-tempered MBT (Items 4, 5, and 6). MBT requires that the therapist recognize the patients’ difficulties in mentalizing and try to join the process to amend this. Whenever the patient outlines their inner process, this is an opportunity for the therapist to focus on, train, and teach mentalizing. One patient (Diane) tries to mentalize in her first and second utterance in Table 7. However, the therapist does not follow up on this invitation, presumably because he has lost his own mentalizing ability due to the patient saying she was angry with him in their last session. In session A, it only takes about 2 minutes from the session start before the patient is emotionally engaged in trying to understand herself. This hallmark high alliance is displayed by cultivating the core principle of treatment (mentalizing). This attests to the therapist’s ability to combine Item 1 (“Engagement, interest, and warmth”), Item 2 (“Exploration, curiosity, and a not-knowing stance”), Item 4 (“Adaptation to mentalizing capacity”), and Item 6 (“Stimulating mentalization through the process”), as defined by the manual for MBT-I (Karterud & Bateman, 2010). This ability to initiate and join the patient in her mentalizing process also unlocks her epistemological trust. Early in the session (5 minutes), she states: “Oh, damn, what a skillful therapist you are! Thanks.” The patient may not agree with the therapist or be able to understand all his views, but she is open to them, respects his opinion, and his statements make her investigate her own mental processes with sincere interest. The manual simply says: “The most important sign of a successful MBT session is that the patient gets involved in a mentalizing discourse” (Karterud & Bateman, 2010, p. 44). "Battles of the comfort zone" found that MBT with a high rating indicated active therapists who succeeded in engaging the patient in a mentalizing discourse, a sign of embedded alliance in MBT. Let us take a closer look at what this mentalizing process may look like.

 

Item 2: Mentalizing stance

As session A and B come to an end, it is with a distinct sense that the patients are left with alternative perspectives and improved mentalizing capacity (sign of high alliance). This change comes about because the therapists remain steadily anchored in an inquisitive but calm and open state of mind. All details the patient brings forth are seen as pieces of a larger puzzle, and the therapist advocates detailed accounts of experiences rather than explanations, in line with guidelines for MBT (e.g., Bateman & Fonagy, 2006). Still, there is a paradox in a “not-knowing stance” because the therapist applies all their knowledge and theories about the patient to guide the process (being steadfast to the project) through a practice of open-ended scrutiny. However, it is an art and a question of the therapist’s best understanding to choose where to ask for and explore different alternatives. Early in Session B, the patient says: “Yes. Yes, yes, and I am also prepared that, if it should be, that I cannot, so if it should be, that, that my teacher does not want to give me dispensation, then I am fully aware that I will have to drop the education.” The therapist could have but does not take this opportunity to explore if there could be alternatives to “drop the education”, which seems somewhat nonattending to the outside observer, as this was an opportunity to challenge unwarranted beliefs. Item 2 (“Exploration, curiosity, and a not-knowing stance”) importantly tells the therapist to be active and curious. In Session D, there are many examples of the therapist taking a knowing stance, and such closing the door to training of mentalizing, and instead joining the patient in pretend mode (Table 8). The therapist here guesstimates instead of asking openly and joining the patient in the scene she describes. The end result is that the therapist presents an answer to the patient without first invoking any Socratic curiosity, asking for permission to present her own understanding. The therapist says, “This has been a… really an intense experience for you”. To make this intervention mentalizing, she could have said: “From the sideline, it looks like this has been an intense experience for you”. In this way, she would have made her own mind accessible to the patient, and the therapist would enter the scene with the patient and show/explain why she thinks like she does. Instead of stating that “What you are in the middle of now has to do with that rape”, she could have described what she observes that makes her think that what the patient is in the middle of now has to do with the rape.

 

The therapist needs to be able to see the scene the patient paints with their words and then enter a conjoint process of trying to understand different perspectives in this scene while indirectly teaching strategies for understanding oneself from the outside and understanding others from the inside (mentalizing). Let us look at another such missed opportunity from Session D (Table 9). Here, the therapist could, for instance, have used Item 2 (“Exploration, curiosity, and a not-knowing stance”) and simply asked what a new beginning means and explored the patient’s thoughts on this subject. "Battles of the comfort zone" showed that perhaps the most important task for the MBT therapist is to maintain a flexible, playful mind that can mentalize well despite the patient demonstrating low levels of mentalizing. However, such interventions are not random. Next, we investigate how to navigate MBT sessions.

 

Item 12 and overall strategy for navigating and structuring sessions

One central feature of highly rated sessions of MBT is that the therapist never loses their overall goal (increase the patients’ mentalizing) and remains steadfast and committed to this. Intervention number 12 (“Stop and rewind”) would be one way of returning to any topic, but it can also shine through any other intervention whereby the therapist simply redirects attention to their chosen agenda. As the MBT-I manual does not contain any step-by-step recipe for how to structure sessions but is rather based on a fundamental understanding of the psychodynamic process in general, it is illuminating to see how this process plays out in highly rated MBT. The first theme the patient introduces in Session A is that she cannot take in (believe/accept) compliments for having successfully arranged a funeral over the last six weeks. This is a melody the therapist recognizes and is therefore able to explore openly (“have you always had the role of a helper?” [Item 2]) to remind the patient this is a recurrent issue (“but what could this old way of behaving be all about?” [Item 2]), to define/confirm it (“yes, it feels really good for you to get that approval”), to validate her difficulties telling others about her success (“most people find that a bit difficult” [Item 13]), to challenge it (“why should others have yelled at you if you had not made it?” [Item 3]), and to ask her how it felt to finally get recognition [Item 11]. At 6 minutes into the session the therapist states: “Yes, you have been working on this for six weeks, you have succeeded, and you get credit for it”. She then says: “It feels really good!” [Item 10]. As this feeling is now brought into the open and is part of the field between patient and therapist, the therapist then simply repeats this expression of healthy pride: “Yes, it feels really good?!” [Item 10]. Having achieved this aim, the therapist now focuses on the group.

 

Session C opens with the therapist not knowing if he has sent a statement on behalf of the patient. Instead of using this moment to initiate and display (exemplify mentalizing by, for instance, saying “I really want to help you with this statement, but now I am getting a bit insecure about what to say because I am actually not quite sure if it was sent. And I wonder how that will make you feel. I am actually a bit anxious about it, which may be connected to our last session.” See Table 10. When the patient states that she was angry with the therapist, he misses a second opportunity to train in mentalizing. Here, he could have asked a question such as “How could I have understood or noticed that?” or “Thanks for letting me know, but I am not sure why you were angry with me; could you help me understand this better?” or basically any intervention aimed at elucidating the patient’s inner workings regarding why she was angry with the therapist, why she tells him now, how this affects her, how she knows she is angry, etc. Instead, he enters a teleological stance where he heads directly into checking whether the statement was sent.

Item 17: The conjoint aspect of MBT

The therapist’s focus on the conjoint aspect of MBT (Item 17) is crucial for beneficial treatment (Table 6) and reflects the alliance to the overall treatment program. In both sessions A and B, we see an intense focus on the conjoint aspect of MBT (Item 17 “Integrating experiences from concurrent group therapy”), combining MBT-I and MBT-G. This item, which is by far the most frequent (mean = 49) in highly rated MBT, pertains to the overall program and is of course at the root of establishing a strong alliance. In low-rated MBT sessions, there are few interventions about the group (mean = 3). In the example above (Table 11), the therapist achieves both of these aims at the same time, as he does inquire about the patient’s absence from the group in a transparent way. This makes his own mind accessible to the patient (Item 1), and she learns that he pays attention to her and that her actions have an impact on him (Items 14 and 15). Such strategic competence gave the therapists a broader roadmap of how to navigate, adjust, and tailor the MBT technique to the unique patient, relationship, and situation. This strategy is again rooted in the MBT theory, which in this case points towards epistemic trust and towards a recognition of how important it is for Elsa (Session A) to attend the group session (especially as there has recently been a rupture in the alliance with the group). A good working alliance makes the patient able to learn from the therapist at a significant level (necessitates that the patient feels understood). This alliance can be used to foster a good working alliance with the group, which is considered essential in MBT. To learn from the therapist, the patient first needs to be open to the therapist’s knowledge about the inner and outer world. This ability is captured in the term epistemic trust (Fonagy et al., 2015). By developing epistemic trust, the patient’s ability to learn from the therapist (and consequently from others’ minds in general) increases, and by learning mentalizing from the therapist the patient gradually learns how to learn on their own. Therefore, mentalizing is both a key to unlocking the patient’s epistemic trust (its not-knowing stance applies for permission to enter the patient’s inner chamber and turn up the light to increase understanding and clarity vis-à-vis the patient’s inner processes) and the very process the patient needs to assimilate in order to improve (Fonagy et al., 2002). To be included and accepted by a group, one needs to master the implicit rules of conduct and manners. The more competent one is at this, the higher social rank one has the potential to achieve.

In fact, being a competent member of a particular cultural or subcultural group means having at hand the implicit cultural meanings shared by members of that group. When a set of implicit cultural meanings has been shared over time, people do not have to refer explicitly to a particular meaning for it to be invoked. (Magnusson & Marecek, 2015, p. 143)

Patients with BPD are aware of this social game but are unable to master its rules. By chasing this enigmatic code, they lose sight of themselves and are mesmerized by the image they construct from the puzzle pieces of what they believe others need or want them to be. The paradoxical result of misunderstanding the group norms is that BPD patients become even more bound by these rules or rather by their private version of these rules. BPD patients frequently have the same ingredients, but something does not quite add up for them. They often realize that their version of these norms is different than the consensus. When BPD patients are emotionally calm, they typically have an adequate ability to play the social game. This is one of many possible examples of how theory, knowledge about the patient, and the alliance work in concert to orchestrate such a display of strategic competence and battling. As BPD pathology often involves rigid thought processes. Skillful challenging of such ideas was found crucial in "Battles of the comfort zone". Next, we turn our attention to the two MBT items especially designed for this purpose.

 

Items 3 and 9: Challenging maladaptive patterns of thinking

In session C, the therapist attempted several interventions targeting the patient’s psychic equivalence, but he does not follow them up and may have failed in validating the patient’s feelings before challenging them, which seemingly cements the non-mentalizing position. Importantly, in the low-rated MBT sessions Item 3 (“Challenging unwarranted beliefs”) was absent, while in the good sessions, Item 3 averaged 6.5. In Session A, the patient’s willingness to explore her own patterns and reactions is a result of an adequate working alliance carefully constructed over 14 months. Based on this solid ground, the therapist moves on to several “high-risk interventions” (Item 3: “Challenging unwarranted beliefs”; Item 9: “Psychic equivalence”; Item 14: “Transference and the relation to the therapist”; and Item 15: “Use of countertransference”) during the session. Perhaps the most striking watershed between highly rated and low-rated MBT is the degree to which the curious, open, and not-knowing position becomes a vehicle for questioning, challenging, investigating, and identifying different perspectives in the patient’s experiences. The more the relationship allows for contrasting views, confrontations, tolerating feelings, humor, self-disclosure, and curiosity, the more likely it is the patient will improve their mentalizing capacity. This session contains significant amounts of all these ingredients, and the therapy has evidently been important and helpful for the patient. As mentioned earlier, at the beginning of the session Elsa states “Oh, damn, what a skillful therapist you are! Thanks.” As outlined above, session A revolves around three major themes: (i) false humility for having arranged a funeral, which turns into healthy pride, (ii) reluctance to be part of the group, and (iii) fear of not being able to shield her son from her own feelings (rather than providing comfort) as he threatened to commit suicide. The therapist arrests the patient’s unquestioned beliefs across all three topics and directs the mentalizing discourse to facilitate changes in perspective but not to present solutions or conclusions (as recommended by the manual; Karterud & Bateman, 2010). In the middle of the session, Elsa’s therapist makes use of his own countertransference and challenges the patient’s resistance against the group in a transparent way (see Table 11).

Items 16 and 2: Where pedagogy and curiousness intersect

It is important for us to note that although all the 17 items are distinct, some overlap considerably. Item 2 colors many other interventions in the MBT spectrum. Low-rated MBT seems to be characterized more by the use of Item 16 than Item 2, which then implies that the therapist follows and tries to understand the patient instead of being a not-knowing (curious) door to new knowledge. However, Item 16 can also be used in a more pedagogical manner, which has a different character we will return to in the Discussion section.

 
Discussion

The following four major findings from "Battles of the comfort zone" will be discussed in more detail below:

 

• The variation between highly rated and low-rated MBT can be investigated in terms of CF concepts.
• Highly rated MBT was characterized by a carefrontational style, where therapists battled the patients’ comfort zones in a tailored fashion, while displaying faith in their own method (e.g., Falkenström et al., 2013, p. 10).
• Avoid being overwhelmed by countertransferences.
• Reintroduce “embedded alliance”.

 

Individual MBT already had reliable fidelity measures for both adherence and competence (Karterud et al., 2013). The Quality Lab for Psychotherapy at Oslo University Hospital applied this scale and rated 108 individual sessions over a 3-year period, with at least two raters per session. Having established and implemented a reliable scale, our next question was what characterized sessions with different levels of ratings. However, the answer to what characterizes good MBT could not simply be that it was “good MBT”, that is, displaying many MBT interventions of high quality. Such an article would provide a list of effective strategies in MBT or goods examples of MBT interventions and would be valuable in clinical practice but would not expand our understanding much. As the answer in this case is (part of) its own definition, we would expect such a path to process research, similar to mathematics trying to explain itself through mathematics: “no more than a mathematician can show by way of mathematics – by means of his science, that is, and ultimately by mathematical formulae – what mathematics is” (Heidegger, 1976, p. 33). That is, such tautological logic would be empty of explanatory power. Therefore, when contemplating the arena of current psychotherapy research, the domain of PDs is one of the few demonstrating the superiority of certain treatment programs/methods despite the Dodo bird verdict being alive in terms of no reported difference between the evidence-based treatments for BPD (Ellison, 2020). Our main question was how therapists in an evidence-based treatment for patients with relational pathology and low epistemic trust (BPD) tailored their technique to the unique patient. Therapists seeking greater efficiency learn that for unknown reasons some therapists excel in manifesting strong working alliances, no matter what method they employ (Lemma et al., 2011). Falkenstrom et al. (2013) reinforced the conclusions of Baldwin et al. (2007), which showed that only the mean level of alliance for each therapist was important for outcome. “The within-patient effect of alliance on symptom level varied significantly between patients, but not between therapists” (p. 326). Therefore, we saw a need to investigate how such skilled therapists fostered the therapeutic alliance. Manualized treatments can be viewed as attempts to provide aspiring clinicians with some guidelines from expert therapists on what kind of strategies or interventions are considered to be helpful or to nurture the alliance for certain problems or types of patients (e.g., Lemma et al., 2011). However, the manual (treatment approach) must be adapted to the specific patient, and this merger of the working alliance and the specific technique(s) was the topic of our IPA.

 

One of the first observations in our IPA was that highly rated MBT, not only includes, but transcends the manual. These therapists seemed to possess some sort of inner map, knowledge, or understanding of the patient and the present situation that made them navigate the interpersonal terrain in a flexible way without losing track of their long-term goal(s). The interventions built logically on each other and seemed guided by an overarching strategy: “If one intervention failed, the therapists pursued the same goal by another route. In the low-rated sessions, interventions were infrequent, and often lacked a clearly detectable plan or overarching pattern” ("Battles of the comfort zone"). One central question then emerges: What does skillful MBT look like without primarily using the language of MBT? Can the CFs explain the difference between highly rated and poorly rated sessions? Our results indicated that one can indeed explain MBT in terms of the CFs but also that the therapy was focused on an increase in mentalization. The overarching strategy or strategic competence was closely linked to the working alliance and epistemic trust. It could be seen as the best attempt to address the challenge: Given the patient, goal, situation, and relationship, how do we best bring about change? Strategic competence may provide the therapists with a broader roadmap of how to navigate, adjust, and tailor the MBT technique to the unique patient, relationship, and situation. Strategic competence partially overlaps with the quality score of MBT; it includes the timing, precision, and relevance of the interventions. Consequently, a skillful application of MBT includes an overarching ability to navigate without being defined by the MBT manuals. Therefore, one problem with manuals (attempts to transmit knowledge from expert therapists) for the average therapist is that they do not teach such overarching strategies, something MBT has been criticized for in terms of being difficult to learn and operationalize (Hutsebaut et al., 2012; Sharp et al., 2020).

 

The first of the four major findings in "Battles of the comfort zone" was that we seemed able to denote differences between highly rated and poorly rated MBT in terms of CF concepts (the observed variation between highly rated and poorly rated MBT could be investigated in terms of CFs). Highly rated MBT contained overarching strategies to systematically challenge the patients’ world view that are not defined by the manual. As the alliance can be seen as looking at the relationship in terms of meaningful work (Hatcher, 2010, p. 25), this may signal that the rated competence/quality of MBT was associated with alliance strength and that the observed quality of a treatment is some sort of measure of the “embedded alliance” (Hatcher, 2010). As we have seen, in Bordin’s view (1979) different types of psychotherapy need different types of alliances. For example,

a treatment geared toward changing deep personality structures would depend much more on a strong emotional bond between therapist and patient for the patient to feel secure enough to engage in the emotionally painful therapy work than exposure therapy for a simple phobia, which probably depends more on agreement on tasks. (Falkenström & Larsson, 2017, p. 167).

 

It seems likely that every type of therapy will promote/foster somewhat different alliances (Bordin, 1979). Bordin also highlights the importance of the bond when working with difficult material: “Some basic level of trust surely mark all varieties of therapeutic relationships, but when attention is directed toward the more protected recesses of inner experience, deeper bonds of trust and attachment are required and developed” (Bordin, 1979, p. 254). With BPD patients, different techniques are demonstrated to produce different alliances; for example, the results reported by Spinhoven et al. (2007) “indicate that the rating of the alliance reflecting the overall quality of experiences and feelings during a large number of therapy sessions clearly differs between treatment conditions” (p. 112). The battling style found in highly rated MBT in "Battles of the comfort zone" indicates that a focus on tasks and goals may be particularly important in treatments of BPD. This is not in disagreement with the point made by (Falkenström & Larsson, 2017) but could simply indicate that to foster a strong bond, one would need to focus strictly on the tasks and goals of therapy and that the bond part is strongly connected to (patients’) epistemic trust acquired from previous challenges in terms of a mentalizing discourse. The findings in "Battles of the comfort zone" are in line with such reasoning. Such a process seemed to create a positive feedback loop between the bond (relationship) and the ability to focus on tasks and goals. "Battles of the comfort zone" also indicated that the bond was an important asset for the therapist to be able to challenge adequately by focusing on the tasks and goals of therapy. In fact, this seems to be in line with Falkenstrom et al. (2015), who suggest that tasks and goals are one factor and not two. Wampold and Imel (2015) highlight the importance of a healing ritual, agreement on the explanation of the problems, and a cure congruent with this conceptualization. This indicates the need for a strong agreement and focus on tasks and goals in therapy. "Battles of the comfort zone" signaled that maintaining a positive personal bond seemed less important than using that bond for meaningful work, such that the bond part of alliance in the low-rated sessions was also partly positive but lacked meaning, purpose, and direction. Epistemic trust seemed like the asset that was built from alliance ruptures and repairs and adequate battles of the comfort zone. Therefore, the current investigation of MBT highlights that therapy is not about simply being supportive, having a “tea party”, avoiding difficulties, or being uninvolved in the relationship. Importantly, "Battles of the comfort zone" proposes that the part of the bond that grows in time seems to be epistemic trust, which seemed associated with a strong focus on tasks and goals in MBT. The development of embedded alliance measures may prove pivotal for the further integration of the common and specific factors in psychotherapy research, which is likely necessary for the increased understanding and measurement of specialized treatments (e.g., MBT). We will return to this later in the discussion.

 

The second finding worthy of special attention was that highly rated MBT was characterized by a carefrontational style, where therapists battled the patients’ comfort zones in a tailored fashion. This is not only in line with the importance of “psychotherapists’ deep engagement in the client’s welfare, willingness and capacity to confront the client’s dysfunctional behavior, maintenance of optimism and a resource-focus while also being playful” (Rønnestad, 2016, p. 12; Råbu et al., 2011) but also underscores what Fonagy et al. (2019) denote the “re-emergence of social learning”, which they claim is “the way in which any effective treatment is embedded in metacognitive processes about the self in relation to perceptual social reality” (p. 94). The therapeutic relationship should enable the patient to develop other learning relationships based on an acquired sense of how to trust another person as a source of significant social information. Consequently, one central outcome from studying MBT in detail is that a steady mentalizing approach seems like a close “technical approximation” of optimal reparenting; we see more clearly how the specific technique influences alliance building and epistemic trust. It is possible to argue that to achieve an attachment with a BPD patient (alliance) who will largely be healed by that corrective experience itself (Fonagy & Bateman, 2006), epistemic trust can be attained by attending to and caring so deeply for the patient that the therapist challenges the patient’s deepest belief systems in a way that makes it safe to trust a new way of experiencing reality. In treating BPD, “[m]uch of the therapist’s role consists of a process of reeducation, and in the course of time the therapist even becomes a role model for the patient” (Spinhoven et al., 2007, p. 104). In line with this, Hoglend (2014) has shown that working with the countertransference—that is, addressing the therapeutic relationship—is an effective strategy with BPD patients. This could be seen as interpersonal psychopedagogics. "Battles of the comfort zone" demonstrates the importance of tasks and goals to achieve a strong bond (epistemic trust) when working with severe pathology and the importance of a pedagogic stance (building epistemic trust). This makes the re-educational or reparenting aspect of (BPD) treatments (Spinhoven et al., 2007) more apparent. As we will discuss later, in terms of Kierkegaard’s (1998) idea of helpful relations, such tailored battles seem to necessitate that the therapist listens deeply to the content and nature of the narrative (e.g., narrative identity;  Lind et al., 2019a; Lind et al., 2019b), implied worldview, and mentalizing process. In other words, the therapist must strongly empathize but not identify with the patients’ narrative, while being able to challenge them and alter the discourse. For this reason and because a “pedagogic stance” has recently been prescribed by the MBT manual (Karterud et al., 2020), the article will return to a more in-depth examination of pedagogics in MBT.

 

Importantly, one “of the sacrosanct assumptions of a client is that their therapist believes in the treatment being delivered” (Falkenström et al., 2013, p. 10; Wampold & Imel, 2015, p. 120). This is a topic that will be discussed in depth later, for example, when the placebo effect is addressed. The second major finding in "Battles of the comfort zone", coinciding with the CF approach, is that the therapist staying on course and battling the comfort zones of the patient is a way to communicate trust in their own treatment method and thus instill hope. This again fostered epistemic trust and increased alliance. The literature supports this view and typically reports that the very administration of the “magic potion” may be as important as the active ingredients. Kaptchuk et al. (2008) reported that factors contributing to the placebo effect and non-specific effects can produce both statistically and clinically significant outcomes and that the patient–practitioner relationship is the most robust component. The authors concluded that “warmth, empathy, duration of interaction, and the communication of positive expectation might indeed significantly affect clinical outcome” (p. 7). The positive expectations instilled in the highly rated sessions were connected to the tasks and goals of therapy and seemed particularly important in MBT; this is further investigated in «Battles of the comfort zone». The bond was an asset that the therapists could use to advocate the importance of the tasks and goals, and it also seemed crucial that the challenges—in line with the theory of an unconscious alliance by (Davanloo, 1990a, 1990b)—fostered epistemic trust. Such a theory would also highlight the importance of focusing on tasks and goals and the development of epistemic trust.

 

"Battles of the comfort zone" found that the bond part of the alliance in MBT seemed like an asset that could be used to promote focus on goals and tasks. The therapeutic process was some sort of battle, and in the low-rated sessions the therapists certainly were brought out of their comfort zone, to the degree that they abandoned the therapeutic project (temporarily). Luborsky (1976) brilliantly employed a counting signs method of assessing alliance and described two types of alliance, one “based on the patient’s experiencing the therapist as supportive and helpful” and one “based on a sense of working together in a joint struggle” (p. 94); the “joint struggle” inspired us to title “Battles of the comfort zone”. As Morken et al. (2019) state, “After all, therapy is not supposed to be a tea party” (Morken et al., 2019, p. 11). In "Battles of the comfort zone", higher quality implied more battles, and therapists seemed to nurture the alliance through battles of the comfort zone.

 

In BPD treatments, “a sudden shift from idealizing to derogating the therapist can disrupt the patient’s capacity to work with therapist comments and may result in unilateral termination on the part of the patient” (Levy et al., 2010, p. 414). Consequently, dealing with alliance ruptures becomes crucial in effective BPD treatments (Morken et al., 2019). In line with the findings presented in "Battles of the comfort zone", Boswell et al. (2013)’s study on CBT found that higher levels of interpersonal aggression were associated with lower adherence and competence ratings and that both adherence and competence ratings deteriorated over the course of treatment. Anger and hostility are widely recognized as difficult emotions to work with in therapy (Mayne & Ambrose, 1999) and are central features of BPD patients. As emphasized by Sharp et al. (2020), effective MBT presupposes an ability to not be overly involved in the content of the patients’ narrative but rather to focus on the (mentalizing) process itself, something that is not easy, as borderline pathology is typically characterized by intense emotions and a tendency to trigger tough transferences (Colli et al., 2014). BPD “symptoms frequently interfere with the development of the therapeutic alliance and make treatment a long and difficult endeavor, fraught with recurrent ruptures, perceived empathic failures, chronic evasiveness, angry outbursts, and premature termination” (Levy et al., 2010, p. 413). As the MBT therapist needs to be an attachment figure for the patient (Karterud & Bateman, 2010), the ability to maintain high RF and relationally navigate the relational landscape in a manner allowing the patient to gain corrective emotional experiences will most often include patients testing whether the therapist can be trusted. Resulting battles of the comfort zone may (temporarily) weaken the alliance. According to Safran and Muran (2000), such alliance ruptures can be seen as a royal road to identifying and addressing the transference/countertransference. The results in "Battles of the comfort zone" indicated that high levels of epistemic trust seemed to be a product of previous alliance (rupture) processes. Observing these findings, one could wonder whether epistemic trust is a crucial factor for therapeutic relationships to foster healing effects. Relational healing is hard to imagine in the absence of epistemic trust. Consequently, as epistemic trust is considered lacking in BPD patients (Fonagy et al., 2015), it would resonate with MBT theory if acquired epistemic trust could be of special importance for borderline patients, often considered the very prototype of personality pathology (Kernberg & Caligor, 1996; Sharp et al., 2015), that is, relational pathology, and trust issues, at core.

 

The third major finding in "Battles of the comfort zone" was to avoid being outplayed by one’s own countertransferences. Another related relational reeducation (i.e., pedagogic stance) aspect is that the therapist needs to both avoid being handicapped by countertransference(s) and simultaneously allow for relational growth by addressing ruptures in the alliance (building a strong emotional bond and gaining epistemic trust). Therefore, one would expect that an effective therapist would need to adequately mentalize the patient’s epistemic trust and alliance, allowing for such relationship building. One imaginative method to indicate therapists’ ability to mentalize (i.e., RF) might be whether or rather to what degree they are able to identify and evaluate the therapeutic alliance as experienced by the patient. Therefore, despite therapist- and patient-rated alliances being equally good predictors of outcome (Fluckiger et al., 2018), it would be interesting to investigate whether therapies with good outcome are characterized by high congruence between patient-rated and therapist-rated alliance. Cologon et al. (2017) report that therapists’ RF predicted therapist effectiveness. In their study, “secure attachment compensated somewhat for low reflective functioning and high reflective functioning compensated for insecure attachment” (p. 614).

 

Being aware of the different countertransferences typical for meetings with BPD patients should be facilitated by examples and case studies, preferably in the manuals but also from theory. According to Masterson (1988), the “borderline patient defines love as a relationship with a partner who will offer approval and support for regressive behavior” (p. 110).

 

Transactional models inform us that individuals impact their environment such that the characteristics of both the person and the environment change in ways that will alter the relationship (e.g., the nature of future interactions) between the two (Cicchetti & Rogosch, 2002; Steinberg & Avenevoli, 2000). For example, “disorganisation of the attachment system may cause a child to be increasingly manipulative and controlling over their environment, but such controlling actions may undermine the caregiver’s capacity to provide a normative playful environment to his or her toddler” (Fonagy & Bateman, 2007, p. 84). The resulting lack of epistemic trust (Luyten et al., 2020b) needs to be addressed in BPD treatments, something that can be done using the three different communication systems proposed by Bateman et al. (2018). Importantly, an “[a]typical personality development can only be identified by considering the difficulties in negotiating developmentally appropriate, normative tasks that have relevance for the particular disorder of interest” (Fonagy & Bateman, 2007, p. 84). Due to social deviations from normative relational expectations (social norms) and low epistemic trust, such relational patterns tend to play out frequently in therapy with BPD patients (Morken et al., 2019). Therefore, the therapeutic relationship and focusing on repairing alliance ruptures seem central for positive outcomes for BPD patients («Battles of the comfort zone» explored this further). In the course of treatment, the BPD patient will typically test whether the therapist can be trusted, for example, whether the therapist is willing to challenge them if they try to avoid painful content in what they describe. Therefore, becoming an attachment figure for patients implies tolerating the multiple relational tests while keeping a steadfast focus on the tasks and goals of treatment. However, this may induce difficult (counter)transferences and involve projective identification, for example, in terms of feeling a wish to abandon the patient or feeling invaded.

 

Being aware of such patterns may prepare the therapist for such emotional challenges in therapy. A somewhat parallel finding to that of Cologon et al. (2017) is that the

higher the percentage of patients in a therapy group who had a history of relatively mature relationships, the better the outcome for all patients in the group, regardless of the form of therapy or the individual patient’s quality of object relations score. (Piper et al., 2007, p. 116)

This also seems to signal that a sufficient ability to mentalize (RF) allows others (e.g., group members and therapists) to create a relational environment encouraging new emotional and interpersonal learning to happen. Therefore, it seems crucial for therapists working with BPD patients that they do some kind of self-developmental work to maintain their own RF when presented with poor mentalizing and prepare to tolerate the strong (negative) transferences typically involved in such treatments. A well-functioning (MBT) team is also necessary for such a process and for the carefrontational style allowing for successful battles of the comfort zone. Further, the merger of Zen Buddhism and cognitive therapy (CT) has proven useful for BPD treatments (Ellison, 2020). The integrating of such realms in therapy will be elaborated below.

 

The fourth major finding was that therapeutic alliance was associated with adherence and quality. The findings in "Battles of the comfort zone" suggest that quality/competence in reality (or at least in practical terms) is a measure of the specific alliance fostered by a focus on mentalizing (a specific alliance for MBT). As will be argued later, this could mean that future measurement of MBT and other psychotherapies should really be (or is) a specific measure of the working alliance promoted by the treatment approach. When rating CT, the mean correlation between adherence and competence has shown to be .96 (Barber et al., 2003, p. 214). This may signal that there is no significant difference between adherence and competence in CT. Further, it has been demonstrated that many raters struggle to distinguish between the two concepts (Perepletchikova, 2007; Perepletchikova, 2009). However, in the MBT-I-ACS no such confusion was reported (Karterud et al., 2013), and it seems that in MBT, perhaps because it is a relationally oriented psychotherapy, it becomes quite apparent to the observer/rater whether the interventions are successful in targeting the aim of the treatment in a way tailored to the patient. For example, as the manual states, the quality of the therapy reveals itself either as an attuned presence or as an absence in cases when, for example, the therapist is mistuned to the RF of the patient or when the therapist is not sufficiently challenging (Karterud et al., 2020).

 

Any clinical intervention is inextricably bound to the relational context in which it is applied (Strupp, 1986). Therefore, slavish adherence to treatment protocols appears to result in deterioration of the therapeutic relationship (e.g., Henry et al., 1993). Such inflexibility has been related to a negative outcome (e.g., Castonguay et al., 1996; Hoglend et al., 2006) in that the therapist may try to fit the patient into a model instead of adjusting the model to the patient (Roth & Fonagy, 2006). Consequently, Owen and Hilsenroth (2014) emphasize the importance of therapist flexibility in relation to therapy outcomes. Contemplating the four sessions in "Battles of the comfort zone", some may argue that the patients’ contribution to the observed competence of the therapist is substantial. When Waltz et al. (1993) rigorously defined adherence and competence, they realized that the context of therapy characteristics of the client and what was happening in therapy were important. “When clients like their therapist and improve substantially, it is easier for therapists to look competent” (p. 624). Therefore, adherence and competence appear, in part, to be a function of the characteristics of the patient (Boswell et al., 2013; Imel et al., 2011). In fact, moderate adherence may imply therapist flexibility or responsiveness (Stiles et al., 1998), and it could therefore be viewed as a limitation that "Battles of the comfort zone" chose to investigate four sessions rated 2/2 and 7/7. However, as will be elaborated later, competence/quality may be seen as a (partial) measure of the working alliance (therapeutic alliance), and the two highly rated sessions in "Battles of the comfort zone" should not be seen as displaying rigid adherence but rather as examples of two therapists tailoring their method to the unique relationship. “In principle, each individual patient needs a unique form of treatment, adapted to her individual problems, needs, and style. This demands a high level of therapeutic flexibility, which most competent therapists are, however, able to offer” (Jørgensen, 2004, p. 519).

 

There have been some attempts at investigating the relationship between alliance and the specific technique. Gaston et al. (1998) found that the interaction between alliance and technique differentially predicted outcome between therapies. In short-term psychotherapy, 15% of the variance in outcome (measured as interpersonal problems) was explained by the interaction between alliance and exploratory techniques (not significant). In long-term psychotherapy, both supportive and exploratory therapist techniques interacted significantly with alliance to predict outcome. Further analyses indicated that supportive interventions were more helpful for patients with low levels of alliance, while exploratory interventions were more effective for patients with high levels. Further research in such directions may provide more clarity on how good execution of MBT and other psychodynamic therapies includes but transcends the manual guidelines, which may in turn help improve future manual(s). Investigating 646 patients (9.5% PDs), Falkenstrom et al. (2013) reported their “findings indicate that when the alliance is worse than usual for a given patient, symptoms are likely to get worse to the next session” (p. 326). As will be argued later, the finding in "Battles of the comfort zone" that the strategic competence and working alliance indicates the quality of the therapy and the importance for a constant “battle” in such challenging therapies may indicate a need for close monitoring of the alliance, session to session. This topic will be further addressed when debating how to teach, monitor, and manualize MBT. However, as the working alliance and strategic competence (not defined by the manual) seemed to explain the rated differences in MBT, one may wish to investigate the impact of the different aspects of the alliance in MBT therapies with different outcomes, which was the topic of «Battles of the comfort zone».

 

Tables

Table 1: Frequency/number (adherence) of specific MBT interventions in sessions with various overall ratings (1–2; 3–5; 6–7)

MBT Item	Average MBT	MBT sessions rated 6–7	MBT sessions rated 3–5	MBT sessions rated 1–2
2. Exploration, curiosity, and a not-knowing stance	12.4	16	14	3
3. Challenging	1.6	2.5	1	2
7. Acknowledging positive mentalizing	1.9	5	0.5	1
9. Psychic equivalence	0.4	1.5	0	0
10. Affect focus	9.5	11.5	9	8
11. Affect and interpersonal events	4.0	3	5	3
12. Stop and rewind	0.4	0.5	0	1
13. Validating feelings	4.3	9.5	2.5	1
14. Relation to therapist	5.3	11	2	5
15. Counter-transference	1.4	1.5	1.5	1
16. Validating understanding	19.9	21.5	23	10
17. Integrating group experiences	1.6	2.5	0.5	3
Number of interventions	62.8	86	59	38
N (number of MBT sessions)	327	97	164	66

Table 2: The nine prototypical versions of interventions targeting impaired epistemic trust (including missed opportunities)

1: Mistaking or confusing the recipe, rulebook, or “correct view” with reality

2: Mistaking or confusing others’ dependency, gratitude, or relational valence with reality

3: Mistaking or confusing achievements, actions, or superficial mirroring (e.g., looks, status, clothes) with reality

4: Mistaking or confusing one’s own inner world (typically strong emotions or looking for something that feels “right”) with reality

5: Mistaking or confusing knowledge and knowledge about knowledge with reality

6: Mistaking or confusing idealization of life project with reality

7: Mistaking or confusing (endless) possibilities and fantasies with reality

8: Mistaking or confusing strong passion or intense pain with reality

9: Mistaking or confusing love or coziness with reality

 

Table 3: Sources of variation for items with high versus low reliability on quality with 5R: Percentages of total variation

Item	T	R	S:T	TR	RS:T	Abs G
15. Pretend modus	17.1	7.1	9.3	12.6	53.9	0.64
8. Group norms	0	1.8	41.2	0	57	0.78
12. Unwarranted beliefs	24.5	7.3	23	11.2	34	0.82
18. Stop and rewind	22.1	4.2	28.2	0	45.5	0.84
14. Acknowledging	50.6	2.6	2.4	0	44.4	0.85
11. Exploration	33.6	1.8	21	10.4	33.2	0.86
16. Psychic equivalence	20.5	1.1	33.8	4.3	40.3	0.86
5. Events in the group	42.4	10.7	14.7	3.7	28.5	0.87
19. Relationship	0	0.4	59.3	0	40.3	0.88
1. Boundaries	34.3	6.2	26.4	5.5	27.6	0.89
6. Care for group	41.3	1.6	25	2.6	29.6	0.91
10. Warmth	58.1	0.8	9.9	0	31.3	0.91
4. External events	46.5	3.5	24.5	0	25.6	0.92
7. Authority	54.2	1.6	18.3	12.1	13.7	0.93
13. Emotional arousal	43.1	0	28.6	5.8	22.4	0.93
17. Affect focus	44.6	0	27.5	0	27.9	0.93
3. Turn taking	62.7	0.8	16.7	5.9	14	0.95
9. Cooperation	0	4.7	79.9	0	15.4	0.95
2. Phases	65.6	0	16.4	0	18	0.96
Overall	61.7	0	21.2	0	17.1	0.96

T: Between-therapist variation

R: Variation in how much raters observe

S:T: Therapist variation across sessions

TR: Variation in raters’ ranking of therapists

RS:T: Residual (including error) variance

Abs G: Agreement on exact scores

 

Table 4: Adherence ratings on MBT-I-ACS

Item	Session A	Session B	Session C	Session D
2. Exploration, curiosity, and a not-knowing stance	39	31	6	14
3. Challenging unwarranted beliefs	8	5	0	0
7. Acknowledging positive mentalizing	0	0	0	0
9. Psychic equivalence	1	2	3	0
10. Affect focus	16	20	6	6
11. Affect and interpersonal events	14	14	3	4
12. Stop and rewind	0	0	0	0
13. Validation of emotional reactions	12	4	0	4
14. Transference and the relation to the therapist	14	8	12	4
15. Use of countertransference	5	0	0	1
16. Monitoring own understanding and correcting misunderstanding	21	41	20	13
17. Integrating experiences from concurrent group therapy	30	68	0	6
Overall score for entire session	6	6	2	2

 

 

Table 5: Competence ratings on MBT-I-ACS

Item	Session A	Session B	Session C	Session D
1. Engagement, interest, and warmth	7	6	3	3
2. Exploration, curiosity, and a not-knowing stance	7	6	2	2
3. Challenging unwarranted beliefs	6	5	2	0
4. Adaptation to mentalizing capacity	6	6	2	2
5. Regulation of arousal	6	6	2	2
6. Stimulating mentalization through the process	7	6	2	2
7. Acknowledging positive mentalizing	0	0	2	2
8. Pretend mode	0	5	2	2
9. Psychic equivalence	6	5	2	0
10. Affect focus	5	6	3	2
11. Affect and interpersonal events	6	5	2	2
12. Stop and rewind	0	0	2	0
13. Validation of emotional reactions	5	4	2	4
14. Transference and the relation to the therapist	4	6	2	2
15. Use of countertransference	6	0	2	2
16. Monitoring own understanding and correcting misunderstanding	6	6	3	2
17. Integrating experiences from concurrent group therapy	7	7	2	2
Overall score for entire session	6	6	2	2

 

Table 6: Total number of interventions and interventions rated as MBT or not MBT

	Session A	Session B	Session C	Session D
Interventions	165	180	111	276
Not MBT	25	44	69	224
MBT	140	136	42	52
MBT ratings1	160	193	50	52
Index	85%	76%	38%	19%

¹ One intervention can have multiple MBT ratings. For example, in session A, there were 20 MBT interventions with more than one adherence rating.

Table 7: Transcript from challenging segment in session C with comments and indications of MBT-I-ACS ratings

	Verbatim material (translated from Norwegian)	Comments (item number)
Patient	No, I didn’t. More that it seemed like it was my… my poor self confidence, or my… well, my experience of how people are at University. And… that you maybe wasn’t open to see that there are more people seeing things that way… or more people experiencing it that way. That it’s not just a thing that I experience because I am the way that I am.	Patient tries to mentalize and gives an account for the view.
Therapist	Yes. Eh… Mhm.
Patient	That you tried… Well, it seemed like you were interpreting it as my individual experience, and not something to do with them. (Clears throat.)	Patient tries to mentalize the therapist.
Therapist	Mm… eh… you might be right about that, that I did it that way. Yes. Because… I think that… Because… I think like this, that because… you were saying that… because you got irritated when I said that.	14, 10. Does not facilitate mentalizing.
Patient	Angry.	Patient corrects
Therapist	Angry (laughs a little).	10
Patient	Don’t use the word irritated when I’m not irritated.	Patient corrects

 

 

Table 8: Transcript from session D with comments and indications of MBT-I-ACS ratings

	Verbatim material (translated from Norwegian)	Comments (item number)
Patient	I have been so tired.
Therapist	Yes. I understand you well, P, and I have been thinking that this… this has been a… really an intense experience for you.	Guesstimates
Patient	Mm.
Therapist	Hard… and that maybe… that what… I don’t know if you think like this, but I think that it’s got… that what you are in the middle of now has to do with that… that… rape	Guesstimates
Patient	Mm.
Therapist	What you… do you think like that too? That that is what…
Patient	Yes, I think that too.

Table 9: Transcript from session D with comments and indications of MBT-I-ACS ratings

	Verbatim material (translated from Norwegian)	Comments (item number)
Patient	I think that after Christmas and New Year it will be a new beginning.
Therapist	Yes.
Patient	And I will try to sit for an exam now.
Therapist	Yes. Quite some… quite a lot going on for you this autumn, I think.
Patient	Yes, it’s not supposed to be easy
Therapist	No.

 

 

Table 10: Transcript from challenging segment in session C with comments and indications of MBT-I-ACS ratings

	Verbatim material (translated from Norwegian)	Comments (item number)
Patient	Yes. Did you send the statement?
Therapist	I did at least send… Let me check if… If I’m sure that I’ve done it.
Patient	Yes. Because it should have been sent. I think so… I have at least told them that it is on its way, so that…
Therapist	Yes.
Patient	… now that you have postponed that deadline and all…yesterday.
Therapist	The deadline.. No, the time is up… it has been sent.
Patient	it is up, yes. Yes.
Therapist	Yes.
Patient	Then it’s ok.
Therapist	So it is… mm.
Patient	Yes. I got irritated with you last session, didn’t I, I got angry with you. You said I was irritated, but I wasn’t, I was angry.
Therapist	You were angry with me… yes… yes.. mm.	14, 10

 

Table 11: Transcript from challenging segment in session A with comments and indications of MBT-I-ACS ratings

	Verbatim material (translated from Swedish)	Comments (item number)
Therapist	It will be difficult, doesn’t?	10, 17
Patient	Yes.
Therapist	The only way to find out is to go there.	16, 17
Patient	Yes.
Therapist	But then of course you think I’m a fool telling you this for the hundredth time.	17
Patient	Yes.
Therapist	At the same time, I think like this: Now that we’re talking about it, I try in a way, well … it... it is quite difficult, because I can’t hide that I think that’s good for you to go there. Just because I happen to think so?! But at the same time, I feel that I nag you about this a lot. And then I think like this: Is it because I nag on you, that you say yes, that you want to go there, because you don’t go there. And then I feel...well, what am I doing..... and I feel disappointed in a way. We talk about it and you say you will go there and then you don’t....	14, 15, 17 Confronts at the maximum of what the patient can tolerate. Lets his own mind be transparent and uses his own feelings.
Patient	Over and over again. Over and over again.
Therapist	Yes
Patient	Yes. I understand. I understand. I understand.
Therapist	I feel something too.	15

 

Figures

MBT 80% Not MBT 20%	MBT 28% Not MBT 72%

 
Figure 1: Percentage of interventions rated for adherence to MBT in good and poor sessions (good sessions: A and B; poor sessions: C and D): Index of MBT interventions.

Figure 2: Mean MBT rating for good versus poor sessions (good sessions: A and B; poor sessions: C and D).

 

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