This article is a spiritual version of our article "Metaphors in Mentalization-Based Treatment: Reintroducing the Language of Change in 'Plain Old Therapy'" published in Journal of Contemporary Psychotherapy.
The use of metaphors and teaching stories in Mentalization-Based Treatment (MBT) has been largely avoided, despite their potential usefulness in psychotherapy. MBT, a treatment for Borderline Personality Disorder, is based on traditional psychoanalysis and research on attachment and social cognition. However, the MBT manual advises against the use of metaphors and teaching stories. This article argues that, in the hands of a responsive therapist, metaphors and teaching stories can be a powerful tool to open social trust and stimulate growth within the window of tolerance, without being too confrontational. They can translate understanding from one arena to another and make unconscious patterns conscious, and may also be used to challenge patients and avoid direct confrontation. The article suggests that metaphors and teaching stories can be successfully implemented in MBT when they are responsively tailored and explained to the patient, and suggests ways to overcome common obstacles to their use in MBT.
Before you read the article, we advice you to challenge yourself on the following questions:
What is Mentalization-Based Treatment (MBT)?
A. A treatment for depression
B. A treatment for anxiety disorders
C. A treatment for Borderline Personality Disorder
D. A treatment for eating disorders
What is the basis of MBT?
A. Traditional psychoanalysis
B. Cognitive-behavioral therapy
C. Dialectical behavior therapy
D. Psychoanalytic object relations
What are metaphors and teaching stories used for in psychotherapy?
A. To challenge patients and avoid direct confrontation
B. To make unconscious patterns conscious
C. To translate understanding from one arena to another
D. All of the above
How can metaphors and teaching stories be beneficial in MBT?
A. By avoiding direct confrontation
B. By making unconscious patterns conscious
C. By translating understanding from one arena to another
D. All of the above
When can metaphors and teaching stories be successfully implemented in MBT?
A. When they are responsively tailored and explained to the patient
B. When the patient is highly mentallyizing
C. When the patient is highly confrontational
D. When the patient is in a state of high emotional arousal
How can obstacles to the use of metaphors in MBT be overcome?
A. By avoiding them altogether
B. By using them only with highly mentallyizing patients
C. By using them responsively and explaining them to the patient
D. By using them only in highly confrontational situations
What is the metaphorical nature of our ordinary conceptual system?
A. It is based on literal, factual thinking
B. It is based on abstract, theoretical thinking
C. It is fundamentally metaphorical in nature
D. It is based on sensory experience
How do metaphors and teaching stories communicate "timeless truths"?
A. By connecting with archetypical versions of our own narratives
B. By reaching towards concepts beyond our normal reasoning
C. By communicating across epochs and cultures
D. All of the above
How can metaphors and teaching stories be used to challenge patients and avoid direct confrontation?
A. By using them only in highly confrontational situations
B. By avoiding them altogether
C. By using them responsively and explaining them to the patient
D. By using them only with highly mentallyizing patients
How can metaphors and teaching stories translate understanding from one arena to another?
A. By avoiding them altogether
B. By using them only in highly confrontational situations
C. By using them only with highly mentallyizing patients
D. By using them responsively and explaining them to the patient
Answers are provided below the article. Remember, the text below is an alternative (more spiritual) version, and the published article may be found here: https://link.springer.com/article/10.1007/s10879-021-09512-9
This theoretical article investigates the possible role of metaphors and teaching stories in Mentalization-based treatment (MBT). Despite stemming from the psychoanalytic realm, the use of metaphors has hitherto been proscribed in MBT, thus impeding the publication of an empirical article at the present time. However, given that a pedagogic stance has recently been proposed as an MBT intervention, this article investigates the possible role of metaphors and teaching stories in light of epistemic trust, alliance, and narrative identity and exemplifies different metaphors and teaching stories from various cultures. Metaphors seem to be a useful tool to challenge patients, avoid direct confrontation, make unconscious patterns conscious, and teach or translate concepts from one arena to another. Hence, metaphors and wisdom stories, along with the use of case formulations focused on narrative identity, may help foster an alliance with MBT and, consequently, promote clinical change for patients with borderline personality disorder.
The use of metaphors and teaching stories in psychotherapy
Metaphors are pervasive in everyday language and thought (Lakoff & Johnson, 2008). The stories we tell ourselves, how we tell them, and how we understand them are a central part of our identity and our wisdom (Glück & Bluck, 2013). Wisdom can be defined as a personal resource that is used to negotiate fundamental life changes (Bluck & Glück, 2004, p. 545). As the narrative identities of patients with borderline personality disorder (BPD) display disruptions in the themes of agency, communion fulfillment, and overall coherence (p. 510), addressing concepts, narratives, and metaphors in effective BPD treatments could be crucial. The use of metaphors has been well-established in the field of psychotherapy (Berlin, Olson, Cano, & Engel, 1991; Kopp, 1995; Muran & DiGiuseppe, 1990; Råbu, Halvorsen, & Haavind, 2011; Tay, 2013). For example, Råbu et al. (2011) found that, “in the course of therapy, the therapist introduce[s] a literary metaphor that seemed to further consolidate the alliance” (p. 23).
A positive development in patient-rated working alliance has been found to characterize Mentalization-based treatment (MBT) with good outcomes (Folmo, Stänicke, Johansen, Pedersen, & Kvarstein, 2020). The role of social learning (epistemic trust) has been proposed as the core of BPD and is considered a central component ensuring the effectiveness of BPD treatment (Luyten, Campbell, & Fonagy, 2020; Sharp et al., 2020). Moreover, increased epistemic trust has been found to be associated with alliance strength (Folmo, Karterud, Kongerslev, Kvarstein, & Stänicke, 2019). Hence, in order to promote alliance and epistemic trust, the “pedagogic stance” has been proposed as an intervention in MBT (Karterud, Folmo, & Kongerslev, 2020). A recent study investigated 33 MBT sessions qualitatively and another 327 sessions quantitatively (Folmo, Langjord, Stänicke, & Kvarstein, 2021), concluding that MBT therapies seemed pervaded by an indirect form of pedagogic intervention. In particular, “Monitoring own understanding and correcting misunderstanding” (i.e., MBT Item 16; Karterud et al., 2013) accounted for 32% of the identified interventions. This was considered as a means for the therapist to present his/her own understanding, typically with a little question mark at the end of the statement. Importantly, in contrast to the more skills-based BPD treatments (Ellison, 2020), little guidance exists on how to perform such pedagogic interventions in MBT. In reality, MBT has been criticized for being too abstract and difficult to learn (Hutsebaut, Bales, Busschbach, & Verheul, 2012; Sharp et al., 2020). As the pedagogic stance is a now promoted in MBT (Karterud et al., 2020), such a theoretical framework is essential. MBT has been reported to challenge the patients’ comfort zone (Folmo et al., 2019). In line with such a carefrontational style, the current theoretical article explores the use of metaphors in MBT, which has been done for many centuries “as a method of teaching and communicating in many fields” (Muran & DiGiuseppe, 1990, p. 70). These metaphors also seem to be a useful tool to challenge patients, avoid direct confrontation, make unconscious patterns conscious, and teach or translate concepts from one arena to another (Muran & DiGiuseppe, 1990).
The current article investigates the role of metaphors and teaching stories as a potential way to strengthen and negotiate the alliance in MBT. This article takes on a theoretical approach, as the previous MBT manuals (Karterud & Bateman, 2010) prescribe the use of metaphors and stories, but also because “there exist certain ‘timeless truths,’ consisting of common observations of how people change. These observations date back to early philosophers and are reflected in great works of literature” Goldfried (1980, p. 996). As the central topic consists of metaphors and teaching tales, many of these wisdom stories lend structure to some parts of this text.
“Metaphor is pervasive in everyday life, not just in language but in thought and action. Our ordinary conceptual system, in terms of which we both think and act, is fundamentally metaphorical in nature. The concepts that govern our thought are not just matters of the intellect. They also govern our everyday functioning, down to the most mundane details. Our concepts structure what we perceive, how we get around in the world, and how we relate to other people” (Lakoff & Johnson, 2008, p. 3). Wittgenstein (1975) stated at the opening of his first lecture on the foundations of mathematics at Cambridge in 1939 that, “[W]hen we learn spelling, we learn the spelling of the word ‘spelling’ but we do not call that ‘spelling of the second order’” (p. 14). Hence, as there is no language of the second order reserved for thoughts, “communication is based on the same conceptual system that we use in thinking and acting, language is an important source of evidence for what that system is like” (Lakoff & Johnson, 2008, p. 3). In order to appreciate the influence of language or metaphor on cognition, we do not need to adhere to the hypothesis of linguistic relativity, which posits that language, or the logos, we operate within is a large contributor to how we view our reality (Passer & Smith, 2008, p. 305). There is a popular expression stating that, “The Greeks had a word for it,” and typically “the literal truth is that they did!” (Benjamin & Karpiak, 2001, p. 1). This is very much the case in terms of the concept of time, which the Greeks divided into Chronos (Newtonian clocktime) and Kairos (“the depth of time”). Wittgenstein famously stated that, “The limits of my language mean the limits of my world” (Wittgenstein, 2001§ 5.6), and even if one would disagree, our concepts—including musical pitch or sensory input/memory—form the very building blocks of what is possible to think (Almaas, 2004). Let us consider the common use of war metaphors in terms of arguments in the English language: “We can actually win or lose arguments. We see the person we are arguing with as an opponent. We attack his positions and we defend our own. We gain and lose ground. We plan and use strategies” (Lakoff & Johnson, 2008, p. 4).
The use of metaphors, characterized by many as the language of change, has been used for many centuries “as a method of teaching and communicating in many fields” (Muran & DiGiuseppe, 1990, p. 70). “Metaphors are mirrors that reflect our inner images of self, life, and others. Like Alice, we can go through the looking glass and journey beyond the mirror’s image, entering the domain of creative imagination wherein metaphoric imagery can become a key that unlocks new possibilities for self-created ‘in-sight’ and therapeutic change” (Kopp, 1995, pp. xiii–xiv). The parables of the Bible, the teachings of Kabbalah, the koans of Zen Buddhism, the allegories of literature, the images of poetry, modern TV series, movies, and the myths and fairy tales of storytellers all make use of metaphors to convey ideas in an indirect way. The use of metaphors has pervaded the field of psychotherapy since Freud first introduced them (Freud, 1900). In fact, MBT was originally termed “psychoanalytically oriented partial hospitalization” (Bateman & Fonagy, 1999). Within the psychoanalytic tradition, Jung’s (1989) concept of the archetype or “metaphorical prototypes” (Mills & Crowley, 2014), which are commonly portrayed in fantasies, dreams, myths, and fairy tales, are expressed through metaphors that are only understood on an unconscious level. Archetypal ideas, such as the hero, involve basic attitudes or reaction patterns imagined to be universal for all humans. In line with such a view, Milton Erickson created wisdom stories based on personal life experiences in an attempt to communicate both with the conscious and the unconscious minds of the patient (Erickson & Rossi, 1976).
However, the potential harm of using metaphors has also been identified (Muran & DiGiuseppe, 1990). It has been argued that the application of such tools in evidence-based treatments for BPD must be tailored to each patient, just as with all psychotherapeutic techniques (Muran & Barber, 2011). Wampold and Imel (2015) proposed five elements of effective psychotherapy change: (1) an entrusting curative setting in which treatment takes place; (2) the therapist provides a rationale for the therapy, which is accepted by the patient; (3) a culturally embedded explanation for the psychological disorder or psychic distress; (4) an emotional bond between the therapist and patient (alliance); and (5) a therapeutic ritual/procedure that promotes positive and progressive behavior. Hence, the use of metaphors in psychotherapy should include informing the patient of the rationale for doing so and ensure that it is related to the therapeutic setting. In order to imagine how such use of metaphors can be performed, within cognitive therapy, the patients may be asked to restate the metaphor stated by the therapist in their own words, after which they should try to improve or replace it, if possible. The therapist may directly question the patients’ “understanding of the metaphor, and how it relates to desired behaviour and emotional well-being, and on the range of situations where they see it as applicable. Often, it is necessary that the therapist explain the meaning, the value, and the applicability of the metaphor, and then model its use in various stressful situations” (Muran & DiGiuseppe, 1990, p. 79). As it is suggested that, “Our conceptual system is largely metaphorical” and that “The way we think, what we experience, and what we do every day is very much a matter of metaphor” (Lakoff & Johnson, 2008, p. 3), bringing this to awareness through treatment may be inherently valuable.
Further, as many artists have tried to master their internal struggles during their creative productions, some stories also allow for comfort and company even in suboptimal conditions. For example, Kafka’s description of transforming into a disgusting, monstrous insect certainly did not result from empathic parenting, and his letter to his father detailed the perceived terrors he suffered during childhood (de Vries, 2010). Similarly, in “Ferdydurke” by Witold Gombrowicz (2012), an author Milan Kundera describes as one of the great novelists of our century (Gombrowicz, 2004), tells the bitterly funny story of a writer (adult) who finds himself tossed into a chaotic world of schoolboys by a diabolical professor who wishes to reduce him to childishness. The therapeutic use of metaphors typically involves abstracting or translating a concept from a topic that the client knows well into another with the aim of explaining or constructing an experience in a different arena. In terms of finding appropriate metaphors, the rules in selecting a metaphor for use in cognitive therapy are as follows: “(a) clearly define the concept that you wish to communicate or teach; (b) attend to the client’s language and search for an arena which he/she understands and has comfortably mastered; (c) search for an analogue construct in the client’s arena of knowledge that includes the core elements of the concept that you wish to teach; and (d) if none exists or comes to mind, start over with a new arena about which the client has knowledge” (Muran & DiGiuseppe, 1990, p. 79).
As we all know, there are many ways to digest the same thing, e.g., “When venomous snakes drink water, it becomes poison—when cows drink water it becomes milk” (Zen proverb), and different techniques demand different alliances (Spinhoven, Giesen-Bloo, van Dyck, Kooiman, & Arntz, 2007). In 1951, Rogers (2012) suggested that the three effective components of psychotherapy are empathy, unconditional positive regard, and congruence. Luborsky (1976) applied 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 another “based on a sense of working together in a joint struggle” (p. 94). Bordin (1979) redefined the working alliance in terms of a bond between a therapist and patient while engaged in a series of tasks tailored to lead toward agreed upon goals. According to Bordin (1979), different types of psychotherapy would need various 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).
Although BPD has been traditionally considered to be chronic, several evidence-based treatments have been developed recently (Ellison, 2020). Investigating these treatments may be especially interesting in terms of discerning the effective components of psychotherapy. For example, Falkenström, Granström, and Holmqvist (2013) have reported an alliance effect that is six times stronger among PD patients, whereas Spinhoven et al. (2007) indicated that different treatments have varying levels of alliance strength, i.e., “the overall quality of experiences and feelings during a large number of therapy sessions clearly differs between treatment conditions” (p. 112). Importantly, in the realm of psychotherapy research, the strength of the alliance is the only robust mechanism of change that has been identified in the literature (Wampold & Imel, 2015). Outstandingly, within the field of BPD, there is solid evidence indicating that various specific therapies are superior to the usual form of treatment (Ellison, 2020). Hence, the treatment of BPD patients provides a unique laboratory in which to investigate what makes a therapeutic relationship a healing one. In BPD treatment, “[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). Meanwhile, Fonagy, Luyten, Allison, and Campbell (2019) highlighted 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). Consequently, the therapeutic relationship should enable a patient to develop other learning relationships with an acquired sense of how to trust another person as a source of significant social information. Interestingly, we know little about how this process is done, and the current narrative in psychotherapy research is that the best predictor of outcome is the therapist’s ability to foster a strong working alliance, that is, “talented” therapists will more skilfully provide “magic potions” (Fonagy, 2010): “Templar Knights of psychotherapy, who were both fearsome warriors and devout monks, could righteously believe that the people they cured recovered because of their magic spells and carefully measured potions, which often took decades of apprenticeship to learn to brew with confidence” (p. 22).
Importantly, the mean alliance level for therapists has been reported to have a stronger predictor of outcome than differences in alliance between patients (Baldwin, Wampold, & Imel, 2007). In other words, some therapists are more helpful than others regardless of what the alliance is at a given instance. A systematic review of therapist effects (Johns, Barkham, Kellett, & Saxon, 2019) reported a weighted average of 5% (8.2% in RCTs), with values ranging between 0.2% to 29%. Manual treatments can be viewed as attempts to provide aspiring clinicians with some guidelines from expert therapists on what kinds of strategies or interventions are considered to be helpful, or how to nurture an alliance related to certain problems or types of patients (e.g., Lemma, Target, & Fonagy, 2011). Hence, while introducing the use of metaphors in MBT may be too advanced for some therapists, it could be considered a productive tool for others.
Recently, Luyten et al. (2020) have “redefined personality disorder as a disorder of social communication resulting in marked impairments in the sense of self‐coherence and self‐continuity because the individual is unable to benefit from the organizing influence of social communication and social recalibration of the mind in particular” (p. 91). Fonagy and his colleagues (2015) have borrowed the term “epistemic” from Aristoteles (epistémé; Schwartz, 2011) to denote the trust necessary for social communication. When the epistemic highway is opened, it allows “for accurate and flexible mentalizing to become fully available to an individual” (Luyten et al., 2020, p. 91). Epistemic vigilance, freezing, or petrification, is considered an evolutionary protection from misinformation, whether motivated by ignorance or the intention to deceive (Sperber et al., 2010). BPD is often considered the very prototype of personality pathology (Kernberg & Caligor, 2005; Sharp et al., 2015), i.e., relational pathology, and trust issues, at core. Hence, epistemic petrification is typical for BPD patients (Luyten et al., 2020, p. 91), and increased epistemic trust seems to be linked to alliance strength (Folmo et al., 2019). According to Luyten et al. (2020), their concept of “epistemic trust” is “closest to those of Kruglanski and colleagues,” who view epistemic freezing as “a tendency to defend existing knowledge structures even when they are incorrect or misleading” (p. 91). This is interesting in terms of “talking cures” (Freud, Breuer, & Strachey, 1895), because according to Kruglanski (2013), the “major contemporary schools of cognitive therapy assume that dysfunctional thought is characterized by remediable biases and distortions in clients’ inference processes,” and the present analysis suggests that biases (e.g., of a motivational or a cognitive nature) are an inseparable aspect of all inference processes both “normal” and “neurotic” (p. 6). Consequently, “what sets adaptive and maladaptive thoughts apart is their content rather than the process whereby they have been reached” (Kruglanski, 2013, p. 6). This may seem somewhat contrary to the idea that a mentalizing discourse is healing for BPD patients, as the content rather than the process, is advocated as the maladaptive core. However, this notion has important implications for the reeducation that is considered an integral aspect of effective BPD treatments (Spinhoven et al., 2007). Specifically, according to the theory of mentalization, for communication to be accepted as meaningful and relevant, epistemic trust between the teacher and the learner must first be established (Luyten et al., 2020; Wilson & Sperber, 2012). If the content rather than the process is the maladaptive core, this could be good news, as under “the appropriate conditions, many kinds of knowledge could be revised, modified, or abandoned. Thus, one could presumably change one’s knowledge of basic values (i.e., one’s knowledge of good and bad), one’s views of physics (Kuhn, 1962), one’s fundamental likes and dislikes, or one’s self-identity. Furthermore, to the extent that our personalities are largely composed of preferences, values or ideologies, they, too, can change in significant ways” (Kruglanski, 2013, p. 11). Consequently, in terms of treatment, “the epistemic process has implications for ‘unfreezing’ the maladaptive thought patterns and ‘refreezing’ in their stead alternative, more adaptive notions” (Kruglanski, 2013, p. 6).
Identity disturbance has long been considered one of the defining features of BPD (Jørgensen, 2010; Leichsenring, Leibing, Kruse, New, & Leweke, 2011). Within the field of psychotherapy research, “narrative identity” is considered a central concept in understanding how the “self” is built, and maintained. For example, 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 borderline patients (Lind et al., 2019). Hence, which stories we tell ourselves about ourselves—and how we tell them—seem to influence our ability to mentalize (reflective functioning) and (probably) vice versa. Investigating 40 BPD patients, Adler, Chin, Kolisetty, and Oltmanns (2012) reported that, “[The] narrative identity of people with features of BPD show unique disruptions in the themes of agency, communion fulfillment (but not communion), and overall coherence” (p. 510). The thematic integration of a life narrative relies on the development of three simpler abilities: the ability to summarize multi-episode stories, the ability to interpret stories, and an awareness that inferential processes are employed in autobiographical remembering and reasoning (Habermas & Bluck, 2000, p. 759). Levy et al. (2005) found that low reflective function, i.e., the operationalization of mentalizing (Fonagy, 2002) in BPD patients, predicted greater levels of impulsivity on the Continuous Performance Task and deficits in concept formation on the Wisconsin Card Sorting Test. Such impulsivity and vacillations in mental states “also lead to wavering on commitment to goals and in-session collaboration and demands from the patient for help followed by evasive maneuvers” (Levy, Beeney, Wasserman, & Clarkin, 2010, p. 415). Hence, BPD patients may need extra attention in order to understand and focus on their life stories and those of others (e.g., in group therapy settings).
There is no disputing the sociocultural importance of the image of the wise individuals, such as Cleopatra or the Buddha (Bluck & Glück, 2004, p. 544). However, in considering individual-level personal identity, it is important to ascertain whether an individual has some sense of a self who is capable of wise thoughts and actions, and if so, how such a view of the self is embedded in his/her life story (Habermas & Bluck, 2000). Importantly, even if this view of the self as a wise person does not appear as a trait-like semantic self-representation, it may contribute to one's identity formation through autobiographical memory. In the field of psychotherapy, it is widely accepted that wisdom “is an adaptive form of life judgment that involves not what but how one thinks. It refers to a combination of experiential knowledge, cognition, affect, and action that sometimes occurs in social context” (Bluck & Glück, 2004, p. 545). Consequently, wisdom is defined as a personal resource that is used to negotiate fundamental life changes and challenges and is often directed toward the goals of living a good life or striving for the common good. Assuming that anyone can be wise given the right knowledge, the correct use of knowledge, or through the right person–environment fit, Bluck and Glück (2004) applied a “wisdom of experience” procedure, which has been shown to be a valid means of studying experienced wisdom in everyday lives across the life span. By investigating narratives concerning times in which individuals said, thought, or did something wise, Bluck and Glück (2004) showed that all age groups use experienced wisdom to transform negative life situations to positive ones; furthermore, they are equally likely to link these experienced wisdom events to larger temporal life periods.
Young and older adults also relate wisdom experiences to their life stories by explaining how they are connected to later life consequences or to the direction that their lives had taken. An important part of psychotherapy could be seen as helping patients make sense of their life stories as they strive to take agency in them, understand them, learn from them, tell them to others, and relate them to others’ stories. In MBT, the therapists facilitate such a process by actively using a case formulation in both group (Karterud, 2018) and individual therapies (Karterud et al., 2020). Hence, the use of metaphors or teaching/wisdom stories may be an important element to consider in MBT, given the importance of working with one’s personal narrative, narrative identity, and a(n unconscious) route to access what is often denoted the perennial wisdom in ancient and current cultures. Indeed, “Research on process in psychotherapy could benefit from more specific methods for identifying processes that may involve autobiographical reasoning, such as insight” (Habermas & Bluck, 2000, p. 762).
Further, in terms of wisdom/teaching stories, it is interesting to note that the Berlin wisdom model considers knowledge as the core of wisdom (Kunzmann & Baltes, 2003). In this view, there are three main factors that contribute to the development of wisdom: 1) general personal attributes, such as intelligence and personality; 2) expertise-specific factors, such as experience with life problems, availability of mentors, and motivation; and 3) facilitative experiential contexts, such as age, parenthood, or work contexts (Baltes & Staudinger, 2000). Hence, to a certain extent, internalized teaching stories could be seen as a parallel to the availability of mentors.
The combination of group and individual therapy in MBT has been proven to be an efficient strategy (Antonsen et al., 2017). Thus, having an alliance with the group and epistemic trust in other patients are crucial elements for successful healing. Within wisdom research, Ardelt (2004) argued that wisdom goes beyond deep and complex knowledge and requires the transcendence of one’s subjectivity and self-centeredness. This process, which she views as essential for wisdom, leads to greater feelings of connectedness to others and the world. This is in line with the finding that high-rated MBT focuses on integrating the patient in the group therapy component. Interestingly, Cologon et al. (2017) reported 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, Ogrodniczuk, Joyce, Weideman, & Rosie, 2007, p. 116). The use of wisdom/teaching stories may be one way of introducing a greater understanding of experiences in a shared cultural context of social healing. Relating to other patients’ life stories becomes especially relevant, and currently, typical interventions are of this kind:
Therapist: When it concerns the right treatment, I think in the same way as you describe, Anita, that when it comes to oneself and feelings, which we should focus on in the treatment here, it is important that you verbalize how you experience things, and how other may experience things, so it is very good that you (to the group) tell Monica what happened, and that I don’t do that, so that you can hear it directly from each other, but that can also become very challenging and vulnerable
Anita: Yes, but she admitted that resigning was her problem, wasn’t it, at that is one of the reasons we are here, not to resign (Clinical excerpt from a previous publication by Folmo et al. (2017)).
Such a “carefrontational” style, referring to the “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), has been advocated in MBT (Folmo et al., 2019). In the same study, the skillful challenging of maladaptive patterns seemed to increase epistemic trust in individual MBT (ibid.). This is in line with the idea of therapy as a “joint struggle” (Luborsky, 1976, p. 94) and Davanloo’s (1990) notion that adequate confrontations are necessary in forging an unconscious alliance with the patient, and this may be one reason why skilled MBT therapists challenge the patients’ comfort zone (Folmo et al., 2019). Importantly, the therapeutic relationship should also enable each patient to develop other learning relationships, with an acquired sense of how to trust another person as a source of significant social information (Fonagy et al., 2019). This may be challenging to attain, as there are things that a person may be afraid to divulge even to him/herself, and every decent individual has a number of such things stored away in his/her mind (Dostoevsky, 1999), e.g., individuals stand in their own shadow and wonder why it’s dark (Zen proverb). In both dialectical behavior therapy (DBT) and MBT, the individual therapy largely has the effect of preventing drop-outs (Andersen, Poulsen, Fog-Petersen, Jørgensen, & Simonsen, 2020). The act of telling stories, which tends to evoke the child in us, may have the effect of making “dangerous” content more general (indirect validation); such an act can also make challenging interventions less confrontational in that, “[A] metaphor avoids direct confrontation and communicates ideas that may be unacceptable to clients at the conscious level” (Muran & DiGiuseppe, 1990, p. 75). For instance, addressing patients’ eagerness to change quickly or their restlessness with others’ slow progress could be playfully addressed by telling the following Zen story about a student who went to his teacher and said, “I have committed myself to your system. How long will it take me to succeed?” The teacher’s response was, “Ten years.” Impatiently, the student countered, “But if I work extremely hard, and do dedicate myself to practicing however many hours it takes each day, how long will mastery take then? The teacher though for a moment, and then replied “Twenty years” (de Vries, 2010, pp. xiii–xiv).
However, like skillful challenging (Folmo et al., 2019; Rønnestad, 2016; Råbu et al., 2011), another possible mechanism of using metaphors and teaching stories is as a means to develop an unconscious alliance (Davanloo, 1990): “How to choose the most forceful strategy for challenging any particular dysfunctional thought in a given clinical context often involves a creative search for metaphors that seem to have symbolic significance or personal meaning for the client and, therefore, high persuasive impact. This search may sometimes simply involve joining a client’s own use of metaphor and reframing it according to a particular disputational strategy” (Muran & DiGiuseppe, 1990, p. 79).
For some patients, Zen proverbs may open the epistemic highway, while for others, Ray Dalio, legendary founder of Bridgewater Associates, could be the source of valid information: “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). However, despite cultural differences, some stories seem to incorporate some kind of innate Esperanto, easily making them accessible for patients, e.g., “unfreezing’ the maladaptive thought patterns” (Kruglanski, 2013, p. 6). Naturally, people have epistemic trust in a variety of sources: “A cultist, for example, might believe that a statement is worth believing only if endorsed by the guru, and an experimental scientist might believe that hypothesis x is true only if an empirical outcome y was observed in a controlled experiment” (Kruglanski, 2013, p. 23). Teaching stories try to reach behind epistemic defenses by employing a slightly different ostensive cue (i.e., clearly marking that the therapist is performing a teaching tale), whose signal is designed to trigger epistemic trust (Csibra & Gergely, 2011). This may also allow the therapist to address unconscious belief systems that the patient would not normally become aware of, as “persons may not be conscious of the reasons for their behavior, which (if pushed a bit) could be taken to mean that some of our actions may have unconscious determinants” (Kruglanski, 2013, p. 24).
As there are several ways by which beliefs could be disconnected from “evidence,” the use of teaching stories has three advantages above normal reasoning: 1) patients may forget why they concluded as they did (once a given proposition was accepted as true, a person may forget its evidential basis); 2) many assumptions are not derived from evidence, but rather from strong intuitions, or other inferences; and 3) patients may lack the capability to come up with alternatives to a given belief, e.g., unable to imagine that things could be other than what they presently seem. Consequently, “positive proof may enhance our confidence in a proposition, not every confidently held proposition needs to have been systematically proven” (Kruglanski, 2013, p. 24). Thus, addressing the unconscious (showing not telling), the teaching stories may reach beyond such idiosyncrasies by talking a more universal language than the conscious mind.
According to the poet, T.S. Eliot, Latin served as a cultural Esperanto for medieval Europe: “Dante’s universality is not solely a personal matter. The Italian language, and especially the Italian language in Dante’s age, gains much by being the immediate product of universal Latin. … [T]he Italian vernacular of the late middle ages was still very close to Latin [, which] had the quality of a highly developed and literary Esperanto” (Eliot, 2014, pp. 200–201). In terms of psychotherapy, it may be difficult to identify such an Esperanto, as the “putatively unbridled nature of conceptual configurations in which persons may have faith implies the considerable relativity of human knowledge. Different cultures may subscribe to divergent belief systems, and the potential heterogeneity in what different persons ‘know for a fact’ may be considerable” (Kruglanski, 2013, p. 11). Hence, for the therapist to be an effective teacher, s/he should open the epistemic highway (Fonagy, Luyten, & Allison, 2015) and address the maladaptive knowledge or belief-systems, which are typically culturally embedded. This may seem like a tough challenge. However, as any child can inform us, the inherent meta-language of archetypical stories or fables may be able to somewhat transcend both the specific language barrier and the inherent idiosyncrasy of psychopathology, as long as it is culturally and socially relevant, or at least applicable to their own life stories. In fact, throughout time and across cultures, people have made sense of their lives in story form (Bruner, 1990; Polkinghorne, 1988).
For some reason, certain stories become part of us, influencing how we view ourselves and the world. For example, there is a reason why we all remember that Alan Turing ended his life by taking a bite out of a poisoned apple. Typically, such images, stories, or metaphors make us understand a deeper reality or tell us something about reality that is not easily understood. Addressing this kind of resonance, George Eliot (i.e., Mary Anne Evans) thus preludes Chapter 31 of Middlemarch as follows: “How will you know the pitch of that great bell Too large for you to stir? Let but a flute Play ‘neath the fine-mixed metal listen close Till the right note flows forth, a silvery rill. Then shall the huge bell tremble—then the mass With myriad waves concurrent shall respond In low soft unison” (Eliot, 2005, p. 568). Hence, Eliot may have indicated that, through resonance, we may grasp concepts beyond our normal reasoning, and the wonderful “lines telling of the great bell stirred by the note of a flute played at the proper pitch suggest the moving power that lies in sympathetic vibration. The first time a military body crossed the Brooklyn Bridge, the spectators were surprised to hear the order given for the soldiers to march out of step” (Miller, 2020, p. 34) describe how the force of sympathetic vibration might have destroyed the suspension bridge. In other words, while sympathetic vibration may destroy a bridge, it may in fact be an essential part of human healing, just as the telling of a healing myth is at the core of social healing (Wampold & Imel, 2015).
The best effect of writing often depends on circumstances (Eliot & Cross, 1885), and similar to therapeutic interventions, the effect of such stories depends on the specific situation. However, John Keats claimed that beauty is truth, which may explain why some things resonate deeply with us, even if we have never experienced the content being elaborated. In terms of these powers to transcend our idiosyncrasies, such resonance is often created by being personal, and it is almost paradoxical that clinical experience informs us that the more detailed and particular the emotions each patient dares to enter, the more others will recognize similar structures in themselves. Hegel (2010) denied the notion that thoughts could refer to unique individuals, i.e., it is exclusively concerned with universals. Addressing the universality of human experience, T.S. Eliot wrote that, “the business of the poet is not to find new emotions, but to use the ordinary ones” (Kermode & Kermode, 1975, p. 43).
Further, Buddhist philosophy (Brown, 2006) and even modern leadership theory seem to indicate that universal principles may appear if one dives deep inside the self/particular: “Look, if this really is your ‘one-big-thing,’ if you've really dug deep enough, if you've really gotten personal, everybody already knows. I know. Others know. So, there’s this sort of illusion out there that you are sharing something so private, that nobody knows. Trust me, they know!” (Kegan & Lahey, 2009, p. 81). In terms of psychotherapy, this may have two implications. First, the therapist does not need fear to be personal (not private); second, there are universal principles, emotions, and archetypical patterns in the individual that can be transposed as wisdom from one person to another, especially in a healing relationship that fosters growth. Hence, it becomes of interest to investigate the maps and personal growth kit/toolbox available as prototypical teaching stories.
The Sufi tradition is famous, both through the exceptional poets Rumi and Hafiz as well as Shah (2000), for using “stories as vehicles for psychological action or knowledge” (p. 105). In terms of teaching stories designed to induce psychological understanding and foster a deepening of our understanding, we need some kind of key to unlock our unconscious selves and such stories are not easily produced. Still, one can find them everywhere, e.g., the idea of the glass being half full or half empty. Similarly, the Bible contains jewels, such as the fool who “built his house on the sand” (Matthew 7:26), “turn to them the other cheek” (Matthew 5:39), and “now these three remain: faith, hope and love, but the greatest of these is love” (Corinthians 13:13). The idea of walking on water, or “being in the world but not of it” as some would perhaps rather reframe it (Almaas, 2004), is the central metaphor in the story of “The Three Hermits” by Leo Tolstoy (1886): A bishop teaches three old hermits the words of The Lord’s Prayer, and when they forget the words, they come running on the water after his boat. “I was twelve years old the first time I walked on water” is the first line in Paul Auster’s (2017) novel, “Mr. Vertigo.” Such ideas are so embedded in our culture, language, and concepts (Lakoff & Johnson, 2008)—and even in certain individuals—that they may even need to be adjusted or challenged in certain situations. For example, turning the other cheek is good, but not every time and under all circumstances. Telling a story in order to amend such maladaptive patterns “provides the conscious mind with one denotative message which keeps it occupied, while another therapeutic message can then be slipped to the unconscious mind via implication and connotation” (Muran & DiGiuseppe, 1990, p. 75). In terms of addressing hypermentalization in the context of MBT, one could, for instance, tell a short story about a man whose car broke down in a desert. The man driving the car realizes that he needs to walk to the closest house to borrow an adjusting wrench. After walking for an hour and reaching the house, a young woman opens the door for our hero, who shouts at her: “You can just keep your bloody adjusting wrench, I can do without it!” before he leaves.
As we see the importance of the transmission of social knowledge in BPD treatments, it would be unwise to dismiss one of the biggest bites out of the fruit of the Tree of Knowledge that mankind has taken in recorded history: the invention of stories (Harari, 2014), while also allowing for shared intentionality (Tomasello, 2010). One typically finds that culturally embedded metaphors and teaching narratives are part of healing myths across time and space, and we see no reason why MBT therapists should not embody (and skillfully transmit) the wisdom contained in such traditions. This could be as simple as sharing the comfort of not being alone in the feeling expressed as follows: “I like not only to be loved, but also to be told that I am loved. I am not sure that you are of the same kind. But the realm of silence is large enough beyond the grave” (Eliot & Haight, 1955, p. 142).
However, the therapist should probably follow the advice Shah (1997a) provides along these lines: “A man travels in India. The train is very slow, and has just stopped; allegedly for the hundredth time, at a wayside station. The man jumps out of his carriage, runs up to the driver and roars at him: ‘Can’t you move any faster than this?!’ The train driver replies: ‘Of course I can move faster than this—but, you see, unfortunately, I am not allowed to leave the train.’” Coming from a tradition where he is in “respectable company” (Shah, 2000, p. 105) in terms of promoting teaching stories as a prime promotor of psychoeducation, Shah (1997b) reasons: “Nowadays, few people contest the importance of knowing about conditioning in order to examine belief-systems” (p. 240). Consequently, he wonders why it is difficult to communicate along these lines. Shah (1997b) offers a very simple answer: “We are at a stage in understanding human behavior analogous to that which was obtained when people began to try to talk of chemistry to those who were fixated upon the hope of untold wealth (or, sometimes, spiritual enlightenment) through alchemy. Like the alchemist or those who want easy riches, people want dramatic inputs (emotional stimuli, excitement, reassurance, authority figures and the rest) rather than knowledge. It is only when the desire for knowledge and understanding becomes as effective as the craving for emotional stimulus that the individual becomes accessible to change, to knowledge, to more than a very little understanding. So learning must be preceded by the capacity to learn.” (p. 240).
Nevertheless, we do not wish to promote exercises or teachings for their own sake only. Addressing this, Shah (2000) informs us: “[There] was once a man about who agreed to train a fish who begged him for help to live out of the water, being desperate to take up a life on land. Little by little, a few seconds and then a few minutes, then hours at a time, he managed to get the fish accustomed to the open air. In fact, the fish went to live near him, with its own damp but open-air palace in a flower-bed near in the man’s garden. It was delighted with its new life and often used to say to him: ‘This is what I call a real living!’ Then, one day, there was a very heavy downpour of rain, which flooded the garden, thus drowning the fish” (p. 107). However, various teachings (or systems for self-development) are deeply embedded in all cultures and archetypical stories.
Addressing his young student, the Magister Musicae in Hesse’s novel, The Glass Bead Game, (Hesse, 2002) said: “You will soon be entering another stage…There you will learn all sorts of new things, some of them very pleasant. Probably you’ll also begin dabbling in the Glass Bead Game before long. All this is very fine and important, but one thing is more important than anything else: you are going to learn meditation there” (p. 77). We see meditation practices echoed in this cornerstone of Western literature, and this notion was central to Hesse being awarded the Nobel Prize in 1946 ("The Nobel Prize in Literature 1946 – Hermann Hesse: Award Ceremony Speech,"). The merger of Western psychology and Zen Buddhism has proven to be a productive precedent for dialectical behavior therapy (Ellison, 2020). In relation to this, there are probably similar reasons why there is a long tradition for performing cross-cultural studies when investigating proposed universal principles in psychology (e.g., epistemic trust) (Passer & Smith, 2004).
While the MBT therapist tries to regulate feelings through the mentalizing discourse, when the emotions reach the boiling point, the skills manual for DBT (Linehan, 2014) reads 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, Wood, & Brantley, 2019, p. 110). However, when the 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).
Within the Indian tradition, the extensive use of parables is no better illustrated than by Ramakrishna telling a story of a student who has just learned from his guru that every being and event is simply God. While he walks home meditating on this truth, he encounters a mad elephant. The elephant driver has completely lost control of the animal and warns everyone to flee. However, the disciple sees no reason to move as he continues his contemplative exercise, now regarding both himself and the elephant as God. Consequently, the crazed beast picks up the disciple with its trunk and dashes him to the earth. The Guru, who is also famous for his healing powers, is called to revive the unconscious victim. After certain healing rituals are performed, the young man regains consciousness. “He is surprised to find his guru gazing at him. When asked why he did not run from such evident danger, he replies: ‘Why should I run? My guru, you taught me that all beings and events are God. I have implicit faith in your inspired words.’ The venerable master then addresses his immature disciple: ‘But my child, why did you fail to heed the inspired words of the elephant driver, who is also God?’” (Hixon, 1992, p. 228). Similarly, we all remember the “Borges fable in which the cartographers of the Empire draw up a map so detailed that it ends up covering the territory exactly” (Baudrillard, 1994, p. 1); however, avoiding such a “desert of the real”, the map should never be considered more real than the terrain (ibid.).
In terms of encouraging a humble attitude, Tzu (2003) reminds us that the ocean is the king of all streams, because it lies lower than them. However, we do not need ancient China to gain such wisdom, as we are pervaded by insights into psychological patterns. For example, even a modern electric circuit informs us that there will always be some electrons trying to move in the opposite direction of the current (i.e., Ohm’s law Penrose, 2006)—a perplexing phenomenon causing electric cables to heat up. Hence, resistance to change almost seems part of the universal design, and the means to turn such tides obviously need to be stronger than the normal conditions, as rivers rarely run backwards. As we would expect from any basic economic theory, setting up the right conditions for relational healing likely includes some magic stemming from the scarcity of potion brewers. Seemingly addressing the Templar Knights of psychotherapy, having earned the right to brew their magic potions (Fonagy, 2010), or in this case ignite fire, Shah (1991) writes: “If—stretching credulity to its limits and producing, as a purely hypothetical exercise, a nonsense situation—the warmth of fire were to be available to all, how could its nurturing aesthetic, its divinely benevolent mercy, be valued for its scarcity? Today, people win and earn the right to fire. They are given it, from the temples, as a reward” (p. 126). Eliot and other modernists have pointed out that, “there is nothing more out-of-date than yesterday’s news” (Smith, 1994, p. 7). However, concerning some scarcity, a reader of the Daily Mail 48 years ago (Hendry, 1972), learned an ineffective method to get people into a jewelry shop: The owner handed out 3,000 diamonds to people on the streets. They all looked real, but only four of them were. Each recipient was informed that there were real diamonds among the give-away stones and that they could visit his store in order to find out if they had been lucky. Only one of the 3,000 recipients turned up at the shop. Shah (2000) does not fail to relate this gem of a story to his teaching tales, as it points out the need to explore further in order to benefit from them: “The analogy includes the minus factors that people can call us fakes for peddling silly old stories and refuse to seek further” (p. 105).
The Bhagavad Gita is an ancient collection of writings that can best be compared to the Bible or the Quran (except that the Hindis also define such works as the Relativity Theory by Einstein, The Holy Bible, and Shakespeare’s writing among their holy scriptures). This work serves as the primary spiritual guide to the vast majority of Hindus around the globe (Bhatia, Madabushi, Kolli, Bhatia, & Madaan, 2013). Numerous eminent Indian psychiatrists have recommended the use of the principles of 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 years BC (Bhatia et al., 2013). Throughout the work, the therapist (Lord Krishna) is a trusted friend, philosopher, and guide—one who certainly installs 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 installing 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).
Importantly, one does not need to be a literary, scientific, or cultural titan to find appropriate teaching narratives. Plato’s myth of the cave (Hamilton, Cairns, & Cooper, 1961) provides us with an excellent image of how limited our understanding of the world may be. Quantum theory informs us that even “physical matter” must be interpreted and that “there is no such thing as matter an sich” (Penrose, 2006). The Eye of Sauron in Tolkien’s Lord of the Rings trilogy reminds us all of a devilish superego (antilibidinal ego), and perhaps the Mithril that saves Frodo in the Lord of the Rings is what is needed in order to protect the self from such a force (e.g., Mithril, in the shape of heightened awareness of, and ready countermoves for, the antilibidinal ego’s workings). Who cannot somehow relate to the archetypical story of Calypso in the Odyssey, who was willing to offer Odysseus eternal life, but only if he would love her? In the Bhagavad Gita, Arjun is told that he must fight, even though he recognizes his family among his enemies. The imaginative therapist will have no problems adapting such an ancient insight to the right patient at an appropriate time. In terms of recognizing misunderstandings, or even poor mentalizing, the literary canon contains various examples. For example, de Montaigne (1811) asks: “Who will think better of me for their not understanding what I say” (p. 268) and claims that “Aristotle boasts somewhere in his writings that he affected it: a vicious affectation” (p. 269), i.e., that the Greek philosopher purposefully expressed himself unclearly. Dante seems to believe that the Sirens led Odysseus astray: “The apparent deviation from the Odyssey story is not surprising and can easily be ascribed either to Dante’s ignorance or to a conflation of Circe and the Sirens, but it may equally be understood as creative distortion of the original situation for dramatic effect” (Lamberton, 1989, p. 295). However, metaphorical interventions do not need to be related to culture, but could be as simple as providing the patient with the knowledge that when they tell others “what is wrong with them” (in group therapy, or outside therapy), if they wish their gift of insight to be received, they should tailor the message to the recipient in order to maximize the corrective mirroring, thus allowing the recipient to benefit from it.
Imagine a patient who claims that “Nobody cares about me!” The therapist could easily address this by making an extremely simple case around putting a number from 0 to 10 on how much different people they know care about them. Such tools provide a different framework through which thoughts can operate, and this is the very essence of therapy according to MBT theory. It seems premature to suggest that changing the content of the mind (Kruglanski, 2013, p. 6) would, in itself, be sufficient for helpful BPD therapy. However, this may be an essential element.
As the role of social learning (epistemic trust) has been launched as the core of BPD and is considered central in ensuring the effectiveness of MBT (Sharp et al., 2020), teaching stories and metaphors deserve more attention, as they could address the unconscious parts of patients’ belief systems in different ways than what can easily be accomplished without such tools. In terms of epistemic trust, Fonagy and colleagues (Luyten et al., 2020) agree with Kruglanski (2013), who argued that, “What sets adaptive and maladaptive thoughts apart is their contents rather than the process whereby they have been reached” (Kruglanski, 2013, p. 6). If the content rather than the process is the maladaptive core, this can be considered good news, as knowledge can be revised, modified, or abandoned, thereby making it possible to change “one’s self-identity” (Kruglanski, 2013, p. 6).
Importantly, there seems to be an innate process in which people prove their views: “Thus, people’s premises may vary as may the evidence they consider relevant or legitimate. However, the logical process of proving one’s ideas seems uniform across disparate instances of inference” (Kruglanski, 2013, p. 23). For this reason, there may be some kind of (unconscious) Esperanto available through such narratives. Furthermore, teaching tales and metaphors are, in themselves, part of the culture. Hence, to the extent that evidence-based treatments can be considered a form of reeducation (Spinhoven et al., 2007), introducing patients to central concepts in culture, which are relevant to their current situation, seems logical: We do not need to reinvent the wheel, we just need to find new ways to use it.
Compliance with Ethical Standards
The authors have no conflict of interest. As this is a theoretical article, no informed consent was needed. No research on humans and/or animals was performed.
What is Mentalization-Based Treatment (MBT)? A. A treatment for depression B. A treatment for anxiety disorders C. A treatment for Borderline Personality Disorder D. A treatment for eating disorders Correct answer: C. A treatment for Borderline Personality Disorder
What is the basis of MBT? A. Traditional psychoanalysis B. Cognitive-behavioral therapy C. Dialectical behavior therapy D. Psychoanalytic object relations Correct answer: A. Traditional psychoanalysis
What are metaphors and teaching stories used for in psychotherapy? A. To challenge patients and avoid direct confrontation B. To make unconscious patterns conscious C. To translate understanding from one arena to another D. All of the above Correct answer: D. All of the above
How can metaphors and teaching stories be beneficial in MBT? A. By avoiding direct confrontation B. By making unconscious patterns conscious C. By translating understanding from one arena to another D. All of the above Correct answer: D. All of the above
When can metaphors and teaching stories be successfully implemented in MBT? A. When they are responsively tailored and explained to the patient B. When the patient is highly mentallyizing C. When the patient is highly confrontational D. When the patient is in a state of high emotional arousal Correct answer: A. When they are responsively tailored and explained to the patient
How can obstacles to the use of metaphors in MBT be overcome? A. By avoiding them altogether B. By using them only with highly mentallyizing patients C. By using them responsively and explaining them to the patient D. By using them only in highly confrontational situations Correct answer: C. By using them responsively and explaining them to the patient
What is the metaphorical nature of our ordinary conceptual system? A. It is based on literal, factual thinking B. It is based on abstract, theoretical thinking C. It is fundamentally metaphorical in nature D. It is based on sensory experience Correct answer: C. It is fundamentally metaphorical in nature
How do metaphors and teaching stories communicate "timeless truths"? A. By connecting with archetypical versions of our own narratives B. By reaching towards concepts beyond our normal reasoning C. By communicating across epochs and cultures D. All of the above Correct answer: D. All of the above
How can metaphors and teaching stories be used to challenge patients and avoid direct confrontation in MBT? A. By using them only in highly confrontational situations B. By avoiding them altogether C. By using them responsively and explaining them to the patient D. By using them only with highly mentallyizing patients Correct answer: C. By using them responsively and explaining them to the patient
How can metaphors and teaching stories translate understanding from one arena to another in MBT? A. By avoiding them altogether B. By using them only in highly confrontational situations C. By using them only with highly mentallyizing patients D. By using them responsively and explaining them to the patient Correct answer: D. By using them responsively and explaining them to the patient
Adler, J. M., Chin, E. D., Kolisetty, A. P., & Oltmanns, T. F. (2012). The distinguishing characteristics of narrative identity in adults with features of borderline personality disorder: An empirical investigation. Journal of personality disorders, 26(4), 498-512.
Almaas, A. (2004). The inner journey home: The soul's realization of the unity of reality: Shambhala Publications.
Andersen, C. F., Poulsen, S., Fog-Petersen, C., Jørgensen, M. S., & Simonsen, E. (2020). Dropout from mentalization-based group treatment for adolescents with borderline personality features: A qualitative study. Psychotherapy research, 1-13.
Antonsen, B. T., Kvarstein, E. H., Urnes, Ø., Hummelen, B., Karterud, S., & Wilberg, T. (2017). Favourable outcome of long-term combined psychotherapy for patients with borderline personality disorder: six-year follow-up of a randomized study. Psychotherapy research, 27(1), 51-63.
Auster, P. (2017). Mr. Vertigo: Leya.
Baldwin, S. A., Wampold, B. E., & Imel, Z. E. (2007). Untangling the alliance-outcome correlation: Exploring the relative importance of therapist and patient variability in the alliance. Journal of Consulting and Clinical Psychology, 75(6), 842.
Baltes, P. B., & Staudinger, U. M. (2000). Wisdom: A metaheuristic (pragmatic) to orchestrate mind and virtue toward excellence. American Psychologist, 55(1), 122.
Bateman, A., & Fonagy, P. (1999). Effectiveness of partial hospitalization in the treatment of borderline personality disorder: a randomized controlled trial. American Journal of Psychiatry, 156(10), 1563-1569.
Baudrillard, J. (1994). Simulacra and simulation: University of Michigan press.
Benjamin, L. S., & Karpiak, C. P. (2001). Personality disorders. Psychotherapy: Theory, Research, Practice, Training, 38(4), 487–491.
Berlin, R. M., Olson, M. E., Cano, C. E., & Engel, S. (1991). Metaphor and psychotherapy. American Journal of Psychotherapy, 45(3), 359-367.
Bhatia, S. C., Madabushi, J., Kolli, V., Bhatia, S. K., & Madaan, V. (2013). The Bhagavad Gita and contemporary psychotherapies. Indian journal of psychiatry, 55(Suppl 2), S315.
Bluck, S., & Glück, J. (2004). Making things better and learning a lesson: Experiencing wisdom across the lifespan. Journal of personality, 72(3), 543-572.
Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, research & practice, 16(3), 252.
Brown, D. P. (2006). Pointing out the great way: The stages of meditation in the Mahamudra tradition: Simon and Schuster.
Bruner, J. S. (1990). Acts of meaning (Vol. 3): Harvard university press.
Csibra, G., & Gergely, G. (2011). Natural pedagogy as evolutionary adaptation. Philosophical Transactions of the Royal Society B: Biological Sciences, 366(1567), 1149-1157.
Dalio, R. (2017). Principles: Life and work: Simon and Schuster.
Davanloo, H. (1990). Unlocking the unconscious. Chichester: Wiley.
de Montaigne, M. (1811). The essays of Michael de Montaigne: Printed for W. Miller [etc.] by C. Baldwin.
de Vries, M. F. K. (2010). Reflections on character and leadership: on the couch with Manfred Kets de Vries: John Wiley & Sons.
Dostoevsky, F. (1999). Notes from the Underground, and The Gambler: OUP Oxford.
Eliot, G. (2005). Selected Novels of George Eliot: Wordsworth Editions.
Eliot, G., & Cross, J. W. (1885). George Eliot's Life as Related in Her Letters and Journals: As Related in Her Letters and Journals.
Eliot, G., & Haight, G. S. (1955). The George Eliot Letters: 1874-1877: Yale University Press.
Eliot, T. S. (2014). Selected Essays, 1917–1932: Houghton Mifflin Harcourt.
Ellison, W. D. (2020). Psychotherapy for Borderline Personality Disorder: Does the Type of Treatment Make a Difference? Current Treatment Options in Psychiatry, 1-13.
Erickson, M. H., & Rossi, E. L. (1976). Two level communication and the microdynamics of trance and suggestion. American Journal of Clinical Hypnosis, 18(3), 153-171.
Falkenström, F., Granström, F., & Holmqvist, R. (2013). Therapeutic alliance predicts symptomatic improvement session by session. Journal of counseling psychology, 60(3), 317–328.
Falkenström, F., & Larsson, M. H. (2017). The working alliance: From global outcome prediction to micro-analyses of within-session fluctuations. Psychoanalytic Inquiry, 37(3), 167-178.
Folmo, E., Karterud, S., Kongerslev, M., Kvarstein, E., & Stänicke, E. (2019). Battles of the comfort zone: modelling therapeutic strategy, alliance, and epistemic trust—a qualitative study of mentalization-based therapy for borderline personality disorder. Journal of Contemporary Psychotherapy, 49(3), 141-151.
Folmo, E., Stänicke, E., Johansen, M., Pedersen, G., & Kvarstein, E. (2020). Development of therapeutic alliance in Mentalization-based treatment. Manuscript submitted for publication.
Folmo, E. J., Karterud, S. W., Bremer, K., Walther, K. L., Kvarstein, E. H., & Pedersen, G. A. (2017). The design of the MBT‐G adherence and quality scale. Scandinavian journal of psychology, 58(4), 341-349.
Folmo, E. J., Langjord, T., Stänicke, E., & Kvarstein, E. H. (2021). Pedagogic stance in Mentalization-based treatment. Manuscript in preparation.
Fonagy, P. (2002). Affect Regulation, Mentalization, and the Development of the Self. New York (Other Press) 2002.
Fonagy, P. (2010). The changing shape of clinical practice: Driven by science or by pragmatics? Psychoanalytic Psychotherapy, 24(1), 22-43.
Fonagy, P., Luyten, P., & Allison, E. (2015). Epistemic petrification and the restoration of epistemic trust: A new conceptualization of borderline personality disorder and its psychosocial treatment. Journal of personality disorders, 29(5), 575-609.
Fonagy, P., Luyten, P., Allison, E., & Campbell, C. (2019). Mentalizing, epistemic trust and the phenomenology of psychotherapy. Psychopathology, 52(2), 94-103.
Freud, S. (1900). Interpretation of dreams (J. Strachey, Trans.) New York: Avon. Original work published.
Freud, S., Breuer, J., & Strachey, J. (1895). The standard edition of the complete psychological works of Sigmund Freud, Volume II (1893-1895): Studies on hysteria: J. Strachey, Trans.) London: The Hogarth Press.
Glück, J., & Bluck, S. (2013). The MORE life experience model: A theory of the development of personal wisdom. In The scientific study of personal wisdom (pp. 75-97): Springer.
Goldfried, M. R. (1980). Toward the delineation of therapeutic change principles. American Psychologist, 35(11), 991.
Gombrowicz, W. (2004). A guide to philosophy in six hours and fifteen minutes: Yale University Press.
Gombrowicz, W. (2012). Ferdydurke: Yale University Press.
Habermas, T., & Bluck, S. (2000). Getting a life: the emergence of the life story in adolescence. Psychological bulletin, 126(5), 748.
Hamilton, E., Cairns, H., & Cooper, L. (1961). The collected dialogues of Plato: Princeton University Press.
Harari, Y. N. (2014). Sapiens: A brief history of humankind: Random House.
Hegel, G. W. F. (2010). Georg Wilhelm Friedrich Hegel: the science of logic: Cambridge University Press.
Hendry, T. (1972, July 20). Giveaway Diamonds. Daily Mail.
Hesse, H. (2002). The Glass Bead Game (Magister Ludi). trans. Winston, R. and C. Picador USA.
Hixon, L. (1992). Great Swan: Meetings with Ramakrishna: Motilal Banarsidass Publishers Pvt. Limited.
Hutsebaut, J., Bales, D. L., Busschbach, J. J., & Verheul, R. (2012). The implementation of mentalization-based treatment for adolescents: a case study from an organizational, team and therapist perspective. International Journal of Mental Health Systems, 6(1), 1-11.
Johns, R. G., Barkham, M., Kellett, S., & Saxon, D. (2019). A systematic review of therapist effects: A critical narrative update and refinement to review. Clinical Psychology Review, 67, 78-93.
Jung, C. G. (1989). Memories, dreams, reflections: Vintage.
Jørgensen, C. R. (2004). Active Ingredients in Individual Psychotherapy: Searching for Common Factors. Psychoanalytic psychology, 21(4), 516–540.
Jørgensen, C. R. (2010). Invited essay: Identity and borderline personality disorder. Journal of personality disorders, 24(3), 344-364.
Karterud, S. (2018). Case formulations in mentalization-based group therapy. Research in Psychotherapy: Psychopathology, Process and Outcome, 21(3).
Karterud, S., & Bateman, A. (2010). Manual for mentaliseringsbasert terapi (MBT) og MBT vurderingsskala. Versjon individualterapi: Oslo: Gyldendal akademisk.
Karterud, S., Folmo, E., & Kongerslev, M. (2020). Mentaliseringsbasert terapi MBT. Oslo, Norway: Gyldendal Akademisk.
Karterud, S., Pedersen, G., Engen, M., Johansen, M. S., Johansson, P. N., Schlüter, C., . . . Bateman, A. W. (2013). The MBT Adherence and Competence Scale (MBT-ACS): development, structure and reliability. Psychotherapy research, 23(6), 705-717.
Kegan, R., & Lahey, L. L. (2009). Immunity to Change: How to Overcome it and Unlock Potential in Yourself and Your Organization: Harvard Business Press.
Kermode, F., & Kermode, J. F. (1975). Selected prose of TS Eliot: London: Faber.
Kernberg, O. F., & Caligor, E. (2005). A psychoanalytic theory of personality disorders. Major theories of personality disorder, 2, 114-156.
Kopp, R. R. (1995). Metaphor therapy: Using client-generated metaphors in psychotherapy: Psychology Press.
Kruglanski, A. W. (2013). Lay epistemics and human knowledge: Cognitive and motivational bases: Springer Science & Business Media.
Kunzmann, U., & Baltes, P. B. (2003). Beyond the traditional scope of intelligence: Wisdom in action: American Psychological Association.
Lakoff, G., & Johnson, M. (2008). Metaphors we live by: University of Chicago press.
Lamberton, R. (1989). Homer the theologian: Neoplatonist allegorical reading and the growth of the epic tradition (Vol. 9): Univ of California Press.
Leichsenring, F., Leibing, E., Kruse, J., New, A. S., & Leweke, F. (2011). Borderline personality disorder. The Lancet, 377(9759), 74-84.
Lemma, A., Target, M., & Fonagy, P. (2011). Brief dynamic interpersonal therapy: A clinician's guide: Oxford University Press.
Levy, K., N, Meehan, K., B, Reynoso, J., S, Lenzenweger, M., F, Clarkin, J., F, & Kernberg, O., F. (2005). Abstracts of the 2005 Poster Session of the American Psychoanalytic Association Winter Meeting: The Relation of Reflective Funct. Journal of the American Psychoanalytic Association, 53(4), 1305-1308.
Levy, K. N., Beeney, J. E., Wasserman, R. H., & Clarkin, J. F. (2010). Conflict begets conflict: Executive control, mental state vacillations, and the therapeutic alliance in treatment of borderline personality disorder. Psychotherapy research, 20(4), 413-422.
Lind, M., Thomsen, D. K., Bøye, R., Heinskou, T., Simonsen, S., & Jørgensen, C. R. (2019). Personal and parents’ life stories in patients with borderline personality disorder. Scandinavian journal of psychology, 60(3), 231-242.
Linehan, M. (2014). DBT? Skills training manual: Guilford Publications.
Luborsky, L. (1976). Helping alliances in psychotherapy: The groundwork for a study of their relationship to its outcome. In J. L. Cleghhorn (Ed.), Successful psychotherapy (pp. 92–116). New York, NY: Brunner/Mazel.
Luyten, P., Campbell, C., & Fonagy, P. (2020). Borderline personality disorder, complex trauma, and problems with self and identity: A social‐communicative approach. Journal of personality, 88(1), 88–105.
McKay, M., Wood, J. C., & Brantley, J. (2019). The dialectical behavior therapy skills workbook: Practical DBT exercises for learning mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance: New Harbinger Publications.
Miller, F. E. (2020). The Voice: Outlook Verlag.
Mills, J. C., & Crowley, R. J. (2014). Therapeutic metaphors for children and the child within: Routledge.
Muran, J. C., & Barber, J. P. (2011). The therapeutic alliance: An evidence-based guide to practice: Guilford Press.
Muran, J. C., & DiGiuseppe, R. A. (1990). Towards a cognitive formulation of metaphor use in psychotherapy. Clinical Psychology Review, 10(1), 69-85.
The Nobel Prize in Literature 1946 – Hermann Hesse: Award Ceremony Speech. Retrieved from https://www.nobelprize.org/prizes/literature/1946/ceremony-speech/
Passer, M. W., & Smith, R. E. (2004). Psychology: The science of mind and behavior: McGraw-Hill.
Penrose, R. (2006). The road to reality: A complete guide to the laws of the universe: Random house.
Piper, W. E., Ogrodniczuk, J. S., Joyce, A. S., Weideman, R., & Rosie, J. S. (2007). Group composition and group therapy for complicated grief. Journal of Consulting and Clinical Psychology, 75(1), 116–125.
Polkinghorne, D. E. (1988). Narrative knowing and the human sciences: Suny Press.
Reddy, M. (2012). Psychotherapy-insights from bhagavad gita. Indian journal of psychological medicine, 34(1), 100.
Rogers, C. (2012). Client Centered Therapy (New Ed): Hachette UK.
Rønnestad, M. H. (2016). Is expertise in psychotherapy a useful construct. Psychotherapy Bulletin, 51(1), 11-13.
Råbu, M., Halvorsen, M. S., & Haavind, H. (2011). Early relationship struggles: A case study of alliance formation and reparation. Counselling and Psychotherapy Research, 11(1), 23-33.
Shah, I. (1991). The Magic Monastery: Analogical and Action Philosophy of the Middle East and Central Asia: Octagon Press.
(1997a). An Advanced Psychology of the East Audio Cassette – Audiobook, September 1, 1997 [
Shah, I. (1997b). The Commanding Self: Octagon.
Shah, I. (2000). A perfumed scorpion: Octagon Press Ltd.
Sharp, C., Shohet, C., Givon, D., Penner, F., Marais, L., & Fonagy, P. (2020). Learning to mentalize: A mediational approach for caregivers and therapists. Clinical Psychology: Science and Practice, 27(3), Article e12334.
Sharp, C., Wright, A. G., Fowler, J. C., Frueh, B. C., Allen, J. G., Oldham, J., & Clark, L. A. (2015). The structure of personality pathology: Both general (‘g’) and specific (‘s’) factors? Journal of abnormal psychology, 124(2), 387.
Smith, S. (1994). The Origins of Modernism: Eliot, Pound, Yeats and the Rhetorics of Renewal: Harvester/Wheatsheaf.
Sperber, D., Clément, F., Heintz, C., Mascaro, O., Mercier, H., Origgi, G., & Wilson, D. (2010). Epistemic vigilance. Mind & Language, 25(4), 359-393.
Spinhoven, P., Giesen-Bloo, J., van Dyck, R., Kooiman, K., & Arntz, A. (2007). The therapeutic alliance in schema-focused therapy and transference-focused psychotherapy for borderline personality disorder. Journal of Consulting and Clinical Psychology, 75(1), 104.
Tay, D. (2013). Metaphor in psychotherapy: A descriptive and prescriptive analysis (Vol. 1): John Benjamins Publishing.
Tolstoy, L. (1886). THREE HERMITS: OTBEBOOKPUBLISHING.
Tomasello, M. (2010). Origins of human communication: MIT press.
Tzu, L. (2003). Tao Te Ching: The New Translation from Tao Te Ching: The Definitive Edition: Penguin Publishing Group.
Venkoba, R. A., & Parvathi, D. (1974). The Bhagvad Gita treats body and mind. Ind J Hist Med, 19, 35-44.
Wampold, B. E., & Imel, Z. E. (2015). The great psychotherapy debate: The evidence for what makes psychotherapy work: Routledge.
Wilson, D., & Sperber, D. (2012). Meaning and relevance: Cambridge University Press.
Wittgenstein, L. (1975). Wittgenstein's Lectures on the Foundations of Mathematics, Cambridge, 1939: From the Notes of R.G. Bosanquet, Norman Malcolm, Rush Rhees, and Yorick Smythies: University of Chicago Press.
Wittgenstein, L. (2001). Tractatus Logico-Philosophicus , trans. Pears, D. and McGuinness, B. London: Routledge, 2001.