Pedagogical stance in mentalization-based treatment

Pedagogical stance in mentalization-based treatment investigated the role of pedagogical interventions, or the act of transferring defined learning objectives to demarcated groups, in mentalization-based therapy (MBT) for individuals with borderline personality disorder (BPD). The authors suggest that the development of epistemic trust, or the trust necessary for social communication, is crucial to the effectiveness of MBT and that the integration of a pedagogical therapeutic stance, or an explicit attempt to share knowledge, may be a way to actively promote clinical change in MBT. The study analyzed the use of pedagogical interventions in a sample of 346 individual MBT sessions using quantitative methods and explored the therapeutic stance in 33 sessions using qualitative methods. The results of the study suggest that there is a pervasive, but hidden or implicit, psychopedagogical agenda in MBT and that psychopedagogical content is valuable to patients. The authors suggest that the development and clarification of the pedagogical stance in MBT could improve the quality of therapists' interventions.


  1. What is the primary goal of pedagogy?
    a) To transfer defined learning objectives to demarcated groups
    b) To increase patient understanding of core aspects of personality disorder
    c) To facilitate accurate and flexible mentalizing
    d) To promote clinical change in mentalization-based therapy

  2. What is the term "epistemic" used to denote in mentalization-based therapy?
    a) The act of transferring defined learning objectives to demarcated groups
    b) The trust necessary for social communication
    c) The process of developing reflective practice
    d) The ability to accurately and flexibly mentalize

  3. What is the goal of a pedagogical therapeutic stance in mentalization-based therapy?
    a) To actively promote clinical change
    b) To open the "epistemic highway"
    c) To increase patient understanding of core aspects of personality disorder
    d) To facilitate accurate and flexible mentalizing

  4. Which of the following is NOT one of the four tentative strategies for pedagogical interventions in mentalization-based therapy identified in the study?
    a) Independent reasoning
    b) Epistemic trust
    c) Mental flexibility
    d) Physical therapy

  5. What is the goal of increasing reflective practice in pedagogy?
    a) To facilitate accurate and flexible mentalizing
    b) To open the "epistemic highway"
    c) To increase patient understanding of core aspects of personality disorder
    d) To promote clinical change in mentalization-based therapy

  6. What is the term "epistemic vigilance" used to refer to in mentalization-based therapy?
    a) A protective mechanism against misinformation
    b) The trust necessary for social communication
    c) The process of developing reflective practice
    d) The ability to accurately and flexibly mentalize

  7. What is the most common intervention type in MBT?
    a) Epistemic trust
    b) Independent reasoning
    c) MBT Item 16—therapist checking own understanding
    d) Mental flexibility

Correct answers

  1. To transfer defined learning objectives to demarcated groups
  2. The trust necessary for social communication
  3. To actively promote clinical change
  4. Physical therapy
  5. To facilitate accurate and flexible mentalizing
  6. A protective mechanism against misinformation
  7. MBT Item 16—therapist checking own understanding

Pedagogical stance in mentalization-based treatment

Goldfried (1980) suggested two principles common to all therapies—providing the client new and corrective experiences and offering the client direct feedback. This is in line with the finding in "Pedagogical stance in mentalization-based treatment" that the highly rated therapists challenged the patients’ comfort zones, which seemed to foster epistemic trust. All evidence-based treatments for BPD contain strong elements of pedagogy and strategies to achieve epistemic trust. For instance, ST utilizes cognitive, experiential, and behavioral interventions and focuses heavily on the provision of a strong, quasi-parental relationship between patient and therapist (Ellison, 2020). However, as we have seen in "Pedagogical stance in mentalization-based treatment", in highly rated MBT this is exemplified by balancing a curious “not-knowing stance” with a communication of central psychological building blocks (or challenges):

To be a teacher is not to say: This is the way it is, nor is it to assign lessons and the like. No, to be a teacher is truly to be the learner. Instruction begins with this, that you, the teacher, learn from the learner, place yourself in what he has understood and how he has understood it, if you yourself have not understood it previously, or that you, if you have understood it, then let him examine you, as it were, so that he can be sure that you know your lesson. (Kierkegaard, 1998, pp. 46–47)


Importantly, in conjoint therapies such as MBT an essential aspect is that other patients can communicate knowledge, demonstrate their own epistemic trust in the therapists, and “intervene” when therapists miss opportunities. Karterud (2015) has suggested that borderline patients will be more open to confrontations with their fellow patients than with an authoritative therapist, a tendency that may reflect difficulties with authority in general (e.g., low epistemic trust). To hopefully increase this effect, reading the case formulations to each other in MBT groups has been introduced as part of the treatment program in MBT (Karterud, 2018).


When entering therapy, the patient is at some level open to receiving help and gaining new knowledge about the world. The teaching aspect of the therapy is highlighted in the focus on epistemic trust. This term addresses the ability of some therapeutic “potions” to open the patient to a necessary trust in someone else’s knowledge about the world. Thus, epistemic trust is an essential part of the “strong alliance” and is the element that defines the therapeutic relationship as something other than a normal, safe relationship. Paradoxically, however, as Plato teaches us (Hamilton et al., 1961), the most powerful and likely lasting way to teach is to allow for a not-knowing exploration (because the patient then learns how to learn and can trust his new knowledge at a deeper level). If a patient displays too much trust in the therapist, this would be a collapse in mentalizing, and the patient would need to integrate the tool of mentalizing by practicing together with the therapist.


The two low-rated MBT sessions in "Pedagogical stance in mentalization-based treatment" seemed to demonstrate that the countertransference of being useless, judged, not knowing enough, or not being liked, which resulted in attempts to establish a “normal bond” with reciprocal positive feelings was perhaps the most important factor making the therapists stray from the manual. The highly rated MBT therapists seemed to tolerate the patient’s anger, irritation, not knowing, and stubbornness in a steadfast way, while the more poorly rated MBT sessions were characterized by therapists wanting to deliver solutions, trying to please, offering extra sessions, or avoiding difficult feelings and thoughts. We have learned from the MBT manual (e.g., Karterud & Bateman, 2010) that the ability to withhold one’s own opinions/knowledge/answers is essential for the patient’s understanding and change. The therapist must have a plan for their questions (some Socratic method perhaps or whatever other pedagogic school one adheres to). This means that the therapist has in mind what the patient needs to understand but withholds answers as long as the patient is heading in the “right” direction (but not eternally withholding answers). Within the MBT model, the therapist might, however, give hints or tell the patient how they would have reasoned if in the patient’s shoes (e.g., Item 15 “Use of countertransference”).


In terms of epistemic trust, the difficulty in therapist training is twofold: 1) It is very difficult to imagine what it is like not to know something when you know it. However, the willingness to enter not-knowing with the patient is crucial because the patient typically needs to discover for themselves in order to fully trust their understanding and to change their maladaptive patterns. 2) It can be difficult to trust that someone actually is able to discover (learn) by themselves when they move slowly, that is, the therapist thinks their function is to mentalize for the patient. Perhaps the most important thing patients learn in MBT is to refine the tool with which they need to find answers by themselves (improved mentalizing and epistemic trust). This then clarifies that MBT therapists are teachers of a sort who teach people how to learn. One illuminating finding by Rønnestad and Skovholt (2003), who interviewed expert therapists, is therapists’ ability and willingness to learn from their patients. The patients in MBT are ideally engaged in a mentalizing discourse where beliefs, feelings, and interpersonal transactions are challenged in order to bring about changes in perspective, while solutions and answers play subordinate roles (Karterud and Bateman, 2010). There is a significant difference between openly exploring what goes on in another’s mind and evaluating statements about the world that can be tested. Therefore, the therapist needs to challenge unwarranted beliefs (Item 3). Psychic equivalence is a state in which the patient’s thoughts become too real. This is also a state that needs to be challenged; however, it will often be necessary for the therapist to validate the patient’s emotions first (Item 13 “Validation of emotional reactions”) and then attempt to untangle the patient’s view (Item 9 “Psychic equivalence”).


As we have seen, Item 16 (“Monitoring own understanding and correcting misunderstanding”) is the most frequent intervention in MBT-I and therefore deserves attention. It also works in symphony with most other items and is often closely related to Item 2 (“Exploration, curiosity, and a not-knowing stance”). Still, checking one’s own understanding is not quite the same as pure curiosity, so the distinction is necessary. Changing one’s worldview is considered a challenging process, not to mention amending one’s personality, as most of us tend to believe what we believe. In trying to define insight in therapy, Hobbes stated that “The best definition I have been able to come up with is this: Insight is manifested when a client makes a statement about himself that agrees with the therapist’s notions of what is the matter with him” (1962, p. 742). In such instances, Item 7 becomes particularly relevant.


Every teacher knows that pupils must be rewarded and encouraged on the way to increased knowledge. In "Pedagogical stance in mentalization-based treatment", we saw several examples of the excellent use of Item 7 (“Acknowledging positive mentalizing”). This intervention seems crucial in building a strong alliance (epistemic trust), as it directly points to the therapist’s approval of the patient’s endeavor to learn mentalizing. The essence here is that the therapist remembers what the patient does not know and steps out of their own understanding without forgetting what the patient is looking for. And when the patient finally achieves understanding, the therapist joins the (tea) party. Item 7 is not only linked to Item 2, but in some cases the acknowledgment could be directed towards the patient’s willingness to mentalize or to tolerate feelings. Improved functioning is also an expression of mentalizing that should be acknowledged. We saw no concrete examples of this in our four sessions. This absence was “penalized” in the competence ratings of the low-rated session, but the absence of Item 7 was not seen as a mistake in the highly rated session. This may be due to a halo effect, incompleteness in the manual, or simply that the acknowledgement comes across even though it is not explicitly verbalized. One example might be the therapist smiling in session B as the patients says she is angry with her.


All evidence-based psychotherapies provide patients with a model of the mind and an understanding of their disorder and then treatment actions consistent with that explanation. However, any therapeutic model—that is, understanding the causes of the problem and their possible resolution—can be effective only insofar as it results in the patients’ feeling of being mirrored in a way that leads to the feeling of being understood as an agent. In our view, this is one of the most powerful human experiences leading to the restoration of feelings of agency and selfhood (Fonagy et al., 2019). However mysterious (e.g., an expression of the universal will; Hegel, 2018, p. 234) our personalities may be, a Danish study has concluded that the development of agency through the reconstruction of personal life stories may be a crucial mechanism in psychotherapy with BPD patients (Lind et al., 2019). In line with this, another Dane has brilliantly written:

If One Is Truly to Succeed in Leading a Person to a Specific Place, One Must First and Foremost Take Care to Find Him Where He Is and Begin There. This is the secret in the entire art of helping. Anyone who cannot do this is himself under a delusion if he thinks he is able to help someone else. In order truly to help someone else, I must understand more than he—but certainly first and foremost understand what he understands. (Kierkegaard, 1998, p. 45)

There are seemingly (at least) two important aspects here. First,

If I do not do that, then my greater understanding does not help him at all. If I nevertheless want to assert my greater understanding, then it is because I am vain or proud, then basically instead of benefiting him I really want to be admired by him. (Kierkegaard, 1998, p. 45)

As “to help is a willingness for the time being to put up with being in the wrong and not understanding what the other understands” (ibid.), then not-knowing is essential in a treatment. Curiosity is an essential component of this process; we have termed this the not‐knowing or inquisitive stance (Fonagy et al., 2020, p. 1). In terms of pedagogic stance, which has recently been suggested as an MBT intervention (Karterud et al., 2020), the overarching strategy will be in accordance with the patients’ level of insight into their inner reality. For example, congruent with Kierkegaard (1998), Kohut (1984) states that the healing aspect of the analyst’s interpretation is that the patient feels understood. To battle comfort zones in a tailored fashion, the therapist first and foremost needs to listen (e.g., inhabit the presented narrative).

In the end, we would think of only one universal therapist stance: it seems to be important with all clients to be a good listener. Listening includes a focus on the client and communicating a sense of respect and interest in what the client has to say. Such therapist behavior can help to enhance the client’s sense that he or she has been understood. (Dolan et al., 1993, p. 408)


The second crucial aspect is that the helper must indeed have more knowledge than the person they are trying to help (in that domain); that is, “I must understand more than he” (Kierkegaard, 1998, p. 45). The fact that appreciation and empathy are crucial in all helping endeavors—for example, “My love, if anything will help him to become another person” (Kierkegaard, 1995, p. 172)—does not exclude the fact that true knowledge also has great importance and value; for example, “[t]he Sophist demonstrates that everything is true” (Kierkegaard, 2013, p. 205). “Truth—or, more precisely, an accurate understanding of reality—is the essential foundation for any good outcome” (Dalio, 2017, p. 135). Therefore, one should not recommend the frequent use of myths (adhering to the Sophists) in therapy but rather the best and most relevant (tailored) pieces of knowledge available. Wittgenstein summarized this well, stating “[t]o convince someone of the truth, it is not enough to state it, but rather one must find the path from error to truth” (Wittgenstein et al., 1993, p. 119). “If you can do it, if you can very accurately find the place where the other person is and begin there, then you can perhaps have the good fortune of leading him to the place where you are” (Kierkegaard, 1998, p. 46). Importantly, as the concept of pretend mode in the framework of MBT highlights, a mere mental understanding is not enough, as “[h]aving to exist with the help of the guidance of pure thinking is like having to travel in Denmark with a small map of Europe on which Denmark is no larger than a steel pen-point, indeed, even more impossible” (Kierkegaard, 1992, p. 275). Apparently, even wizards have no potion against emotional suffering, and at the affected end of the novel Harry Potter and the Goblet of Fire, Professor Albus Dumbledore provides us with a plausible psychoeducational model of how the mind works: “He will stay, Minerva, because he needs to understand. Understanding is the first step to acceptance, and only with acceptance can there be recovery. He needs to know who has put him through the ordeal he has suffered tonight, and why” (Rowling, 2000, p. 680). This kind of (grand)fatherly intervention is in line with what we found in the highly rated MBT sessions ("Pedagogical stance in mentalization-based treatment"), and the emotional content and sincerity of the therapist combined with the bond made the interventions potent. Importantly, “[i]f what the therapist offers in this respect is not felt to be true, the channel for knowledge transmission will remain closed, and the patient will be unable to learn from the experience of therapy (Allison & Fonagy, 2016, p. 298). Therefore, one potential pitfall in the focus on epistemic trust or natural pedagogy (Csibra & Gergely, 2006; Csibra & Gergely, 2009, 2011) is that it presumes that epistemic trust is a biological feature (upper-right quadrant; Karterud et al., 2020) and that as long as therapists succeed in activating the epistemic highway all is well. One may perhaps suggest that it is more important to investigate how and in which setting what content should be provided to the patient instead of focusing solely on such explanations and suggestions as ostensive cues (Sperber et al., 2010) that signal to patients the relevance to them of the information being conveyed (i.e., ostensive cues can be seen as signals designed to trigger epistemic trust; Csibra & Gergely, 2009). Examples of content that could be transmitted from therapist to patient in an adaptive, timely, and pedagogic manner is such information that “[s]ecure dependence and autonomy are two sides of the same coin, rather than dichotomies […]. The more securely connected we are, the more separate and different we can be” Diana (Fosha et al., 2009, p. 263), or that we humans can change attachment patterns, e.g., “earned-secure attachment” (Dimaggio et al., 2007). The first one would fit well with a typical intervention addressing the second prototypical version of targeting impaired epistemic trust (Mistaking or confusing others’ dependency, gratitude, or relational valence with reality). However, as such a pedagogic stance can color and be part of all other interventions, an empirical recognition of effective pedagogic strategies may necessitate the study of expert therapists. As discussed above and exemplified in "Pedagogical stance in mentalization-based treatment", both Folmo et al. (2021) and Karterud et al. (2020) reported a frequent use of Item 16. As 32% of the interventions in 327 MBT-I sessions were of this type, we get an empirical signal that there is something here in need of further investigation. One should be careful not to suggest an increased pretend mode in therapy; but based on the current study it seems that opening the door to a pedagogic stance in MBT is indicated. For those who believe in another myth, namely in worldly success (of which Ray Dalio, legendary founder of Bridgewater Associates is an example), for some patients in a suitable setting (etc.) such interventions could be carefully administering the content in principles like “Don’t confuse what you wish were true with what is really true” or “Don’t worry about looking good – worry instead about achieving your goals” (Dalio, 2017, p. 162).


As we have seen, the term specific factors is generally meant to refer to the core, theory-specified techniques or methods prescribed for a given treatment modality (Holtforth & Castonguay, 2005). While the MBT therapist tries to regulate feelings through the mentalizing discourse, when emotions reach the boiling point, the skills manual for DBT (Linehan, 2014) advises as follows: “Suppressing emotion increases suffering. Mindfulness of current emotions is the path to emotional freedom” (p. 403). However, if the emotional pain reaches dangerous/extreme levels, one should “[s]ay: ‘Splash your face with cold water or put your face in a bowl of ice water or cold water on your eyes and upper face (this will reduce arousal for a brief time)’” (p. 402). Linehan reported that this surprisingly simple but effective technique will calm you down immediately. The theory here “might seem counterintuitive, but research has shown that immersing your face in very cold water while holding your breath causes your body to turn on the nervous system’s relaxation response and slow your heart rate” (McKay et al., 2019, p. 110). However, when emotions are not at the boiling point, we could perhaps remind the patient that “you’re looking for the best answer, not simply the best answer that you can come up with yourself” (Dalio, 2017, p. 189) or to recognize the idea “that to gain the perspective that comes from seeing things through another’s eyes, you must suspend judgment for a time—only by empathizing can you properly evaluate another point of view” (Dalio, 2017, p. 189). Importantly, “some skills might not be appropriate in every situation even if they do work. For example, it might not be practical – or safe – to use the diving technique while you are driving a car” (McKay et al., 2019, p. 132). In an integrative contribution to the understanding of mechanisms of change in BPD, Euler et al. (2019) reported that overall defense function (measured by the Defense Mechanism Rating Scale) in an RCT with 32 patients (16 of 31 outpatients received DBT skills training in addition to individual treatment as usual) improved significantly due to skills training in DBT. However, in line with Hoffart and Johnson (2017), caution in interpreting such studies is advised. Decreases in the defense mechanism targeted by many psychodynamic treatments may not add empirical support to DBT, not only because such concepts are suggested to be unmeasurable but also because DBT is “not explicitly designed to target defense mechanisms” (Euler et al., 2019, p. 1074). However, despite such warnings it seems that such findings point us towards a common ground for evidence-based treatments for PDs.


In terms of transmitting skills or other wisdom, there has been a recent surge in interest in the Eastern philosophies in Western mental health care. For example, Falkenström (2010) reported an increase in mindfulness was associated with an increase in well-being with the successful incorporation of Buddhist principles into DBT and the increased psychotherapeutic application of mindfulness (Bhatia et al., 2013). A recent pilot study by Schanche et al. (2020) concluded that “it may be beneficial to introduce personal mindfulness practice as a way of preparing novice therapists for their future profession” (p. 311). Such mergers of old philosophical and psychological teachings from Buddhism with Western psychology has been fruitful (e.g., Falkenstrom, 2003; Safran, 2003). This is not only important in terms of implementing knowledge but also in terms of the cross-cultural perspective whenever we try to investigate universal psychological principles. The Bhagavad Gita can serve as another example worthy of attention in relation to the current thesis. The Bhagavad Gita is an ancient collection of writings that can best be compared to the Bible or the Quran (except that the Hindus also include such works as the Relativity Theory by Einstein, The Holy Bible, and Shakespeare’s writings among their holy scriptures). This work serves as the primary spiritual guide for the vast majority of Hindus worldwide (Bhatia et al., 2013). Numerous eminent Indian psychiatrists have recommended the use of the principles in the Bhagavad Gita for psychotherapy and healing (Venkoba & Parvathi, 1974). In fact, it is considered the first “psychotherapeutic manual” by some, as researchers have identified most Western psychotherapeutic approaches (e.g., grief emancipation therapy, mindfulness, psychotherapy, psychodynamic psychotherapy, and supportive psychotherapy) embedded in this work produced around 2500 to 5000 BC (Bhatia et al., 2013). Throughout the work, the therapist (Lord Krishna) is a trusted friend, philosopher, and guide—one who certainly instills hope and utilizes ostensive cues as he says to his patient (Arjun) “Leave everything and trust me, I will rescue you from all the problems, do not worry” (Reddy, 2012, p. 102). A Western psychotherapist should most likely refrain from instilling so much hope and dependency (despite the patient [Arjun] being considered as having satisfactory premorbid personality with adequate coping skills; ibid.), but the point here is to see the cross-cultural aspects of communicating as a treatment method and identify epistemic trust (knowledge) (culturally embedded but still valid as recognized, tried, and true principles) within a trustful relationship (i.e., the working alliance).

As is the case with any successful model of therapeutic intervention, which needs to be individualized for maximum benefit, the psychotherapeutic approach practiced in the Bhagavad Gita also will have its place in the repertoire of psychotherapeutic models and remains a useful tool in the hands of an experienced therapist when applied judiciously for some patients with specific problems of distress. (Reddy, 2012, p. 104)

At this point, it seems clear that

[T]here is no such thing as a single true theory of psychotherapy and its active ingredients, nor is there one superior technique that can be applied to all forms of pathology, although specific techniques and curative factors may be particularly important in working with certain types of pathology. (Jørgensen, 2004, p. 534)




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