In a live Q&A clinical psychologists Apoorva Shetty and Prateek Sharma spoke to Dr Ashlesha Bagadia, a psychiatrist, psychotherapist and MBT practitioner about Mentalization Based Treatment and how it helps practising mental health experts. Edited excerpts.
Apporva: Tell us a bit about your own journey with Mentalization Based Treatment
Ashlesha: I remember when I first started seeing psychotherapy patients, one of the things I used to think that I don’t want to work with personality disorders But when I started training in MBT and other therapies that helped me with personality disorders, I found it a lot more rewarding to work with than many of the other mental health issues. And there are so many misconceptions and misunderstandings, which for me got clarified with the kind of training I had. I think India is at the right place now to take up skills that have been evidenced all over the world and adapt it to our setting because we are different culturally. I have tried to adapt skills and some have worked, some haven’t. So I’m hoping as more people get trained and try the learning in different settings we will get more evidence coming out of our Indian settings.
Apoorva: How is it different from all the therapies that we come across?
Ashlesha: Mentalization essentially is really looking at being reflective, a reasonable awareness of our own mental functioning, and a reasonable awareness or attunement to someone else’s mental functioning as well.
So for example, you and I are talking now, and I might be aware of what’s going on in my mind. I might have some thoughts about what I need to cover, I might have a little anxiety if I am gonna run out of time, and a little excitement to know how many people are going to join this live chat. So there are a few things happening in my mind. I also need to keep in mind that you have some questions, so I can’t just keep talking all the time. So that attunement, and being able continue to regulate my emotions and respond to you while having some kind of attunement to you and respond to that. That is a mentalizing process where we’re being reflective and are carrying on with a task. So mentalizing really is being aware of your emotions, being able to regulate them, and being reflective about what’s going on in your mind and being sort of reflective about what’s going on in someone else’s mind. So all of us are more or less mentalizing most of the time. We are losing our mentalizing capacity every now and then when something happens, but we regain it.
Apoorva: How is mentalizing for individuals with different disorders or mental health conditions?
Ashlesha: We are all on a spectrum. I mean, at the moment, you and I are having a fairly good conversation. We are regulated. But if for example, the electricity goes now, or if the live session stops, I might get upset, and how upset I might get is really dependent on what might have happened at the beginning of the day, what my mood might have been, before I started this, you know, how much rides on this. So there’s so many factors that impact on how upset I get and how much I lose my capacity to mentalize. So for any individual, all these factors come into play.
That said, attachment insecurity tends to affect our capacity to mentalize the most. We are more likely to get upset with our family members or lose our mentalizing capacity with people we are closer to than the people who we might have a professional or business-like relationship with. We might get upset, but we are going to get less upset, or we will regain our mentalizing a lot faster. Or we will be able to sort of put it aside and say, you know, that doesn’t matter so much. So it’s really a range of things that makes us lose our mentalizing capacity. Now, the level to which it can be affected is also our underlying vulnerability. So someone, for example, who has a history of trauma, or has a history of depression, or abuse, their underlying vulnerability is more than someone who’s not. Their ability to be reflective gets compromised and their ability to regain and come back also gets compromised.
But even when awareness is there, there might not be action. I don’t know if you had this experience, but say we’re having a fight with a loved one you can sense that what you’re saying is not right. Maybe I am shouting a little too loud, I can sense it, but I can’t stop myself. So for many of us, awareness might be different but that doesn’t mean that action takes place in stopping ourselves. You know, it’s only later on to say that you’re sorry that you lost control or your temper.
People with severe trauma who dissociate may not have full awareness that they’ve lost their mentalizing in that moment. But remember, mentalizing is not lost for a long time. It’s an episodic thing when we feel triggered and lose the capacity to mentalize in those moments, and then it comes back and then it goes again.
Apoorva: So we are all ultimately on the spectrum. And some of us have had more difficult experiences, and these experiences might eventually be tied with our mentalizing capacity.
Prateek: I think this gives us a good start on the phenomenology of mentalizing. I would also like to know about its history. Mentalization is not new. It has now been operationalized but Freud himself has written a paper, Two Principles of Mental Functioning, in which he talks about thinking itself, how we start thinking and what it means to us in relational contexts. So maybe we talk a little bit about how it grew.
Ashlesha: So mentalizing is, is a little bit like how Freud described it, thinking about thinking. It’s being aware of what’s going on in our mind, a meta awareness where we are a fly on the wall and looking down and saying, okay, you know, she looks comfortable, she looks uncomfortable. I’m doing all right, I’m not doing alright. So thinking about thinking is one of the functions of mentalizing. And it’s been described in different ways, by different people along the way. But Peter Fonagy is the one who first described it in the context of personality disorder and in the context of using it in therapy specifically targeted to improve mental health.
See, all forms of therapy are technically geared towards reducing emotional distress and dysfunction, becoming more aware of our mental processes and functioning in a better capacity. CBT and DBT both improve mentalizing but nobody said it in that context. So Peter Fonagy, a psychologist and Professor Anthony Bateman who’s a British psychiatrist included concepts from psychodynamic and psycho-analytical frameworks to develop MBT. They were studying and practising traditional forms of psychotherapy when they realised that there is something that’s missing in the traditional forms of psychotherapy, especially when it comes to personality disorders.
They’ve taken some principles from mindfulness and a huge body of work from the attachment based framework because mentalizing capacity really begins when attachment security starts developing. They used this information to put together this operational system of Mentalization Based Treatment. Their strongest body of work is in borderline personality disorder and antisocial personality disorder. But it has a lot of different applications for working with adolescents with a range of mental health conditions, families, and even with the perinatal population.
There have been studies to show that it even works with mental health conditions like depression and anxiety.
Apoorva: What would be some of the gaps in the current training in India? Let’s talk about adapting this to the India context.
Ashlesha: Previous evidence showed that persons with personality disorders need to be engaged in therapy for long periods of time, and they need to be in therapy with psychodynamic therapists or psychoanalysts. That kind of training is really not easily available in India. Long term therapy and long term training also is not something that’s easily available. MBT meets that gap because it’s a three day course for the basic and two-day advanced course. Therapists can actually learn and then start putting it to practise.
Another gap is that theoretically, we might have a lot of exposure. And of course now you know, the world is at our fingertips, we can access any kind of theory from anywhere, but actually being able to put in their practice and have supervised practice and learning is rare. Additionally you can also start seeing changes with brief focused engagement as well.
My personal style is more aligned to MBT rather than very behaviour focused therapy. And reflective based therapy can be adapted to any culture. Also, attachment issues are universal, a baby is a baby, and a baby is going to be insecure if there is a breakdown in attachment, no matter what the cultural framework is. That cultural understanding and correcting cultural connection happens much later for the baby. And so I feel like the framework is quite easily adaptable and it crosses cultural barriers.
Anecdotally, from my experience, it applies well, but I’m just one right, so we all start applying this to what is an emerging problem in India of personality difficulty, then we may be able to answer that question of universal adaptability.
Prateek: We see that therapy from across modalities has facilitated mentalizing capacity for patients. And that brings us to like a question that I was wondering about, who is this for? We sort of develop our own niches across time, but what we know about mentalization is present across different kinds of issues and different kinds of modalities. So, who can benefit from a training like this?
Ashlesha: Therapy skills in general should be learned by anyone working in the field of mental health, because you may need to apply them even for people who are not in contracted therapy for. So this course is definitely suitable for psychiatrists who are working with personality disorders, patients with reduced reflective capacity or working with complex families. I know that a lot of psychiatrists end up seeing a person who’s reflective capacity may be okay, but there’s someone in the family who’s not mentalizing and then that makes a difference to how their patient gets better. So definitely for psychiatrists, social workers, clinical psychologists, counsellors, therapists, and anyone who is doing either brief or long term work with mental health conditions. It need not be severe clinical conditions. If you’re working with anxiety, depression, or just stress related disorders, it can be helpful.
What I would say though, is that if someone is very new to therapy, maybe they’ve just finished their masters or they’ve not had a lot of clinical experience, then it may be that they may need to wait a little bit. There needs to be a little bit more understanding of all the different ways in which people can present before you can actually make good use of this course.
To fully take advantage of the course you need to be in clinical practice and have at least a few years of exposure to people with mental health conditions of different kinds, not necessarily complex clinical cases. But those two years will put you in the right place to understand what’s happening in the mentalizing world ,what the therapy is all about and the more effective and applying the skills is.
Apoorva: When we talk to people who’ve been through trauma, they are often very factual and don’t go very deep into it. So I wonder what your understanding is and how would you or the framework look at such individuals?
Ashlesha: MBT looks at how all of us work on different poles. We either might be very emotional at some point, or we might be very cognitive, you know, so that’s two opposite poles. We might be very self-focused or we might be very other- focused. As a therapist, one of the skills we learn is to identify which pole our client is at. So in the example you gave, they could be very much in the cognitive mode and they’re not at that moment aware of the emotions that are going on for them.
Ideally, someone who’s being reflective will be able to have a thought, link an emotion to that, regulate and come back to the fact. They will be able to move between these two poles as the narrative is going but if they’re stuck in one pole, they’re either very emotional and over distressed, or they’re completely detached and very cognitive. This being stuck can reduce reflective capacity. They may look like they’re doing okay, but they’re actually not able to resolve and are stuck in that space.
There is also a phenomenon described in MBT where it looks like connections have been made. For example, they may say, my senior once bullied me and now I have a boss who is a bully, and that’s why I get upset. So it’s a very nice explanation of the connection that has been made, and that’s the explanation that they will stay with. With this they stay in the cognitive space and are not able to recover from it.
In therapy we identify and teach them to move between the poles. The client might lose their mentalizing capacity and we help them bring it back, we as therapists might lose our mentalizing capacity and we bring ourselves back.
Prateek: There are patients who are receiving a lot of therapy but a pattern of change is not to be seen and I found that mentalization is an answer to that and certain concepts associated with mentalization help in making progress. And like you just said, it also informs our countertransference because we also have to keep a check on our mentalizing capacity based on how the other person is interacting and reacting to us.
Apoorva : Can we go into what the course offers.
Yeah. So we are quite excited to bring Professor Bateman, one of the founders and developers of this course to India. He has half a century of experience, maybe even more, with not just MBT but with psychotherapy and working with this kind of framework and applying it to different countries across the world. So, he is coming to India in February and the basic course is going to be a three-day course in Bangalore. It will be three full days where you’ll learn the history of mentalizing, how mentalizing is different from other therapies and how it’s similar. We’re also going to learn skills through role plays, and by applying them to cases. There will also be many group discussions.
Once you complete the initial three days of basic training you have to be in supervised practice. We run a supervision once a month, and you can be part of that supervision group. The next level is the advanced course and that happens whenever he comes again. But there are advanced courses in other countries that happen more frequently. So once you have done at least six to eight sessions of supervised practice, you can do the advanced course which is a two day course. Those who have completed their requirements from previous batches will be doing advanced training this February. Once you finish the advanced course you’re an MBT practitioner. You can also go on to do a next level of course, which allows you to become an MBT supervisor.
The course is accredited by the Anna Freud Centre, UK. So if you did the basic course here, you could advance anywhere across the world. There’s also a whole range of supervisors listed on the Anna Freud Centre website whom you can access. There are also other MBT courses that can be done after the basic course: MBT with adolescents and with families, with children. So lots of different next level MBT courses can be done, after you do the basic course and make the supervision requirements.
Apoorva: Any additional thoughts?
Yes. What MBT really talks about is shifting some of the things that are not working very well in traditional psychodynamic psychotherapy. And one of the main things that really appealed to me is to be genuine in the room, you know that we are not sort of this neutral, stoic, serious looking therapist, who is just going to let the patient talk. It’s actually a genuine, safe engagement, while being a professional relationship. You know, so to maintain that balance between being genuine and being professional is quite tricky. And I think that is what this brings to the table. A lot of people with borderline personality disorder respond really well because they’ve had enough experiences of people brushing them aside and not taking them seriously.
You can sign up for the MBT course here: https://theparc.in/mentalization-based-treatment/
Artwork by Enway
Radha Ramaswamy is a practitioner and trainer of Theatre of the Oppressed (TO), a participatory theatre pedagogy widely used across the world for social and personal change. Following her training in Theatre of the Oppressed at the Seattle-based Mandala Center for Change, Radha founded the Centre for Community Dialogue and Change (CCDC) in Bangalore in 2011. CCDC is committed to making this powerful and versatile tool for creative change accessible to individuals and communities everywhere. To this end Radha offers workshops and trainings across different cities in India and abroad, working with students, teachers, health professionals, women’s groups, senior citizens, and other communities of people. She has collaborated with many institutions of higher learning on theatre-based projects, and presented papers and conducted workshops in several conferences on education, teacher training, and mental health.
Dr Prabha Chandra is senior professor of psychiatry and dean of faculty of behavioural sciences, at the The National Institute of Mental Health and Neuro-Sciences (NIMHANS), Bangalore. She is the president elect of the International Association for Women’s Mental Health, a past executive member of the Marce International Society and co-author of the World Psychiatric Association (WPA) curriculum on intimate partner and sexual violence, as well as the WPA Position statements on perinatal psychiatry and violence against women. She is also a co-author of the recent Lancet Commission for mental health and violence against women.
An active researcher with 17 funded grants as principal investigator, she has also edited several books on women’s mental health and palliative care. Dr Chandra was heralded as a champion for women’s mental health by Lancet Psychiatry. She started the first dedicated perinatal psychiatry service and Mother Baby Unit in Asia and also organised the first ever Marce International conference in a low and middle income country ( LAMIC), in Bangalore, India. She is also a consultant to the World Health Organisation and The United States Agency for International Development for implementation of perinatal mental health programmes in LAMIC.
Dr Ashlesha Bagadia is a perinatal psychiatrist and family psychotherapist with over two decades of experience in mental health. She has completed higher training in Perinatal and Women’s Mental Health, Family Systems Psychotherapy and Mentalisation Based Treatment.
She has a keen interest in bringing advanced psychotherapy skills to India and making it accessible to areas with limited resources. She hopes to make clinical skills that may originate from western theories, more culturally relevant and adaptable to local settings. She has been conducting workshops and courses with a view to help clinicians make meaningful connections, grow through stronger peer interactions and better collaborative care.
Poornima Mahindru is a clinical psychologist and psychotherapist in the field of mental health for over a decade. In the course of her professional journey she has experienced a dearth of opportunities to upskill herself. She strongly believes that mental health professionals need constant training and learning to provide quality care to their clients.
At The PARC, she will design workshops and training programs – in collaboration with national and international experts – to increase the Indian mental health community’s access to high quality training.
She carries vast experience of working in premier organisations like Manipal University and NIMHANS and has been in the leadership roles in private neuropsychiatric hospitals. She currently practices with The Green Oak Initiative where she specialises in perinatal mental health and personality disorders and provides clinical and professional supervision for mental health professionals
Dr Shaibya Saldanha is practising gynaecologist and co-founder of Enfold Proactive Health Trust, an orgnisation that addresses gender and sexuality with a special emphasis on child sexual abuse, through education, training, research, advocacy, and tangible support.
Dr Saldanha was formerly associate professor at the department of obstetrics at St John’s Medical College, Bangalore. At present she is a training consultant to the state government of Meghalaya on maternal and child health.
Dr. Anthony W. Bateman is a psychiatrist and psychotherapist. He is consultant to the Anna Freud Centre, London, Visiting Professor at University College, London and Honorary Professor in
Psychotherapy at University of Copenhagen.
He developed Mentalization Based Treatment ( MBT ) for borderline personality disorder and
studied its effectiveness in research trials. Adapted versions are now being used in multi-centre trials for antisocial personality disorder, eating disorders, and drug addiction. He was an expert member of National Institute for Clinical Excellence (NICE) development group for treatment guidelines for Borderline Personality Disorder in UK and was Chair of the National Guideline Development Group for Eating Disorders.
He has authored 16 books including Psychotherapy for Borderline Personality Disorder: mentalization based treatment and Mentalization Based Treatment for Personality Disorder: a practical guide (2016) (with Peter Fonagy), numerous book chapters, and over 150 peer reviewed research articles on personality disorder and the use of psychotherapy in psychiatric practice.
Pavitra Jayaraman believes that mental health belongs in all conversations and even more so in clinical settings. She is building The PARC to ensure that mental health is an important aspect in all health experiences through training, communication and community engagement.
In her previous role she built the content operations for White Swan Foundation for Mental Health – a knowledge centred non-profit – that curated complex information on mental health for workplaces, adolescents, parents, teachers and the elderly in six Indian languages through several offline and digitals platforms. Pavitra is also an independent journalist and communications consultant. She has worked with NDTV where she reported on politics and health and with Mint as a long form features writer.