Mentalizing and Group Psychotherapy: A Novel Treatment for Antisocial Personality Disorder

Antisocial personality disorder (ASPD) is characterized by failure to conform to social norms with respect to lawful behavior; irritability and aggressiveness, indicated by repeated physical fights or assaults; impulsiveness; disregard for the feelings and safety of others; and disregard for self-safety and the consequences of one’s behavior (1). The condition is common in the United Kingdom, with prevalence rates of about 0.6%–1.0% in the general population and higher in prison populations; just under two-thirds of male remanded prisoners, half of male sentenced prisoners, and one-third of female prisoners meet diagnostic criteria (2). ASPD is highly predictive of future violence and future reconviction or reincarceration after release (3). Thus, finding an effective treatment is a social and health priority, but no intervention has been established as the treatment of choice for addressing ASPD symptoms (4–6). The high risk of harm to others associated with the condition suggests that treatment by sole practitioners in private practice is unwise and that sharing risk between the health and criminal justice systems is more appropriate. Recently, mentalization-based treatment (MBT), an evidence-based treatment for borderline personality disorder (7, 8), has been adapted for treatment of people with ASPD (MBT-ASPD) who live in the community and have repeatedly enacted violent crimes. The treatment has shown promising outcomes (9). This article discusses the mentalizing model of ASPD and outlines key strategies for implementation of MBT-ASPD in group therapy through a clinical case presentation from a treatment group in Great Britain.

Mentalizing and ASPD

Mentalizing facilitates effective responses to life challenges by generating a psychological understanding of an individual’s own actions and those of others in terms of underlying thoughts and feelings. It involves a blend of cognitive and emotional responses to a challenge, awareness of one’s own current experience alongside the experiences of others, and attention to both externally observable and internally subjective aspects of interpersonal interaction (10). Mentalizing involves both the process of arriving at this psychological knowledge and the process of responding to such knowledge by designating it as “just thoughts or feelings” not requiring further consideration or, by contrast, something worthy of serious reflection and purposeful action. Thus, mentalizing operates as an interpersonally contextualized meta-reflective process that includes cognitive appraisal and emotional identification, experiencing, and regulation. This mental process is out of balance and easily disrupted at all levels of abstraction among people with ASPD, who show evidence of a range of mentalizing problems, especially in social interactions.

Mentalizing is a multifaceted process (11), where psychopathology arises from an over- or under-use or imbalance of the poles of the four main dimensions of mentalizing: self and other, cognitive and affective, automatic and controlled, and external and internal. In ASPD, antisocial behavior and violence occur through a number of imbalances. First, this behavior may be triggered when understanding of others’ mental states is compromised and self-states are given priority. Such imbalance occurs rapidly if the attachment system is activated by perceived threats to self-esteem, such as interpersonal rejection or disrespect (12). Second, the behavior may occur when increasing affect overwhelms cognitive appraisal and situations are interpreted according to affective rather than cognitive or rational processing (e.g., “I think you are against me, so you are”). Balanced cognitive-affective mentalizing and discrete recognition of self-states that are well-differentiated from the experience of others’ mental states (e.g., envisioning the subjective state of the victim) prevent interpersonal violence (13). Third, such behavior may occur when excessive external focus and hypervigilance with constant monitoring of the environment for threat (e.g., “the look in the eye”) are used to understand mental states without considering the internal state of the other. This external focus can lead to excessive use of automatic mentalizing (e.g., “He looked at me, and I knew he thought I was a piece of rubbish. I am not having that.”). Fourth, such behavior may occur in the context of reliance on automatic, reflexive processing without stopping and thinking with controlled mentalizing (e.g., “Am I right here? Let me think about it. What is it that is causing me such annoyance?”).

These imbalances may become fixed, forming persistent mental modes of function known as psychic equivalence, teleological mode, and pretend mode. In psychic equivalence, thoughts are seen as facts, thinking is concrete, and experience is intense. In teleological mode, interpretations about others’ motivations and mind states are based on what the other people do (e.g., “actions speak louder than words.”). In pretend mode, the mind is isolated from the external world. The person becomes detached and may show dissociation, or depersonalization in extreme cases.

Mentalizing interfaces developmentally with attachment, and the two are loosely interacting psychological and biological systems. The development of effective, robust, and balanced mentalizing requires a secure attachment environment. In an insecure, dismissive, or disorganized attachment environment, commonly generated in the context of adverse early experiences, mentalizing becomes distorted, unstable, and oversensitive to emotional and interactional stressors. Dismissing attachment styles are overrepresented among people with ASPD and among violent offenders. The early life of individuals who later develop ASPD is characterized by adverse environmental threats to the developing attachment system in terms of loss, separation, neglect, and physical and sexual abuse (14). Many of these children develop preadolescent conduct problems that carry a high risk of subsequent development of adult antisocial behavior and violent offending (15). From this perspective, ASPD can be understood as a disorder of mentalizing and attachment in which genetic precursors interacting with early environmental adversity result in abnormal personality development, particularly in areas of affect regulation, impulse control, and ability to mentalize. In summary, the mentalizing model of antisocial behavior suggests that the behavior arises out of a dysfunction of the attachment system, which, when activated, temporarily inhibits affect regulation and mentalizing abilities (16).

Given the attachment sensitivities and mentalizing problems associated with ASPD, helping these patients to develop and maintain mentalizing capacities to consider other’s perspectives, identify others’ emotions, be compassionate toward others within relationships, accurately read other’s intentions, and differentiate their own experiences of others motives from others’ actual motives (i.e., self-other mentalizing) may not only assist in social functioning but also may reduce the risk of antisocial behavior. Indeed, mentalizing has been shown to be a protective factor against aggression among people with violent traits (17), and encouraging mentalizing has been shown to reduce school violence (18). Most importantly, people with ASPD need to be supported to develop a capacity to relate with others in “we mode,” in which sharing and understanding of the mind states of the self and others result in prosocial behavior.

Mentalizing and Joint Intentionality: Significance of “We-ness”

Loss of integrated and balanced mentalizing results in a reduction in joint intentionality and togetherness, which leaves people with ASPD isolated from others and unable to engage in and feel part of everyday social interactions through which personal learning and change can occur. Joint intentionality is a specific mentalizing mindset proposed to account for the human capacity to participate in shared collaborative activity between two or more people. The key to constructive prosocial interaction is the capacity to coordinate perspectives and thus appreciate the distinction between the subjective (one’s own view) and the objective (actual physical reality “out there”), and then to coordinate these with knowledge of another individual’s mental state (19). The joining of minds is the crucial ingredient of social mentalizing. Joint attention defines a common object at the same time, acknowledging that people have different perspectives on it. This shared process leading to collaboration with others requires a high level of mentalizing and is singularly absent in the daily lives of people with ASPD.

MBT-ASPD Group: Developing Joint Intentionality and Facilitating Self-Other Mentalizing

Two central group processes, the development of shared values by the group and a focus on relational mentalizing, are harnessed at the start of an MBT-ASPD group to reduce a sense of isolation, signify the importance of “we-ness,” and generate self-other compassion and sensitivity; both are at the core of mentalizing and prosocial behaviors and attitudes. The implementation of these processes will be discussed by using a clinical illustration. MBT clinicians lay the foundations of individual and joint intentionality at the beginning of the treatment. First, the patient and clinician work on an individual-level formulation of problems, using the patient’s history and experiences to agree upon the patient’s aims of treatment. Second, patients present their formulation to others in their group to see what aspects of their own problems overlap with those of others. Third, the patients create a shared area of problems in a new joint synthesis. Fourth, a group formulation is generated, including group values, to facilitate an experience of being part of something that is beyond the sum of its parts (the individual patients).

MBT-ASPD is organized as a group psychotherapy to promote an experience of working together with a common aim. Every group develops its own “microculture,” which is based on agreed upon customs or traditions. In MBT-ASPD, the group has to agree on its own values from the start. This is the first step toward building an experience of we-ness.

Clinical Process

Values-Driven Group Discussion and Formulation of the Group by the Group

Defining and agreeing on the values within which the group operates is not the same as making practical arrangements. Values are related to higher-level processes that determine the interactional culture of the group—respect, tolerance, mutuality, and independence, for example. A list of potential values is given to the patients for discussion, and the group creates a list of agreed on values, which are then written down and available to the group at each meeting. The most popular value chosen by people with ASPD is respect. The clinician asks the group members to each define their version of respect and to provide examples of how they assess respect from others and how they show respect to others. In addition, the group members formulate the work they are to do within the value system they devise (e.g., showing respect for each other, listening without judgment to each other, hearing each other out). If the group agrees to a value labeled “tolerance of different perspectives,” then they are agreeing to disagree; the group members accept that they each have different opinions but that they can express what they think and be who they are as long as they do not hurt one another.

Working on values is in itself a we-ness process because it necessitates that everyone join together to decide what sort of group they are and what sort of social agreements they have. Values underpin we-ness within the group and give some authority to the clinician who, as part of the group, can ask to revisit the values when they are breached. The participants can also insist on revisiting the values, and the group must revisit and redefine values when a new member joins, as part of the process of group engagement and inclusion.

Relational Mentalizing to Promote Self-Other Mentalizing in the Context of We-ness

Several structured elements in MBT-ASPD groups underpin relational mentalizing. First, at the beginning of each group, the patients are given time to chat about their week. This is explicitly a social time. The structured process of sharing about their week allows patients to complain, ask for and receive advice from others in the group, and talk about important events that have happened. Next, the clinician summarizes the work that was done in the previous session. This summary specifically identifies relational interactions that have been noted in the group: “Mark, you were very supportive of John last week in terms of agreeing with him about being suspicious of people, and that is something worth continuing to discuss between you.” Finally, the clinician is instructed to ask each person if there is anything he or she wants to talk about with everyone in the group and with whom in particular he or she would like to discuss it: “Who would you like to talk to in the group about this?” The aim of this initial structured process is to stimulate prosocial interpersonal interaction and decision making. It is followed by detailed exploration of the participants’ personal interactions at home and in daily life, as well as those in the group.

Clinical Illustration

In this case illustration, John wanted to talk in the therapy group about an incident that led to his arrest. He gave a brief summary of having insulted and threatened someone, which led to an argument and to the police being called.

The clinician is trying to deescalate and to change the focus temporarily by engaging in an “MBT loop”—a temporary detour from the affective content creating low mentalizing, with a graded return to exploration when mentalizing is stable—by asking John to consider his self-states when he was on his way to the clothing sale in more detail, rather than focus on the tension of the here and now. The clinician also partially sides with John, because the group response has so far been negative and invalidating. The aim is to reduce interpersonal tension and to create conditions in which mentalizing is more likely to occur. Only once these conditions are established can the current interaction in the group be explored. John’s description of his state of mind at the time of the incident suggests low mentalizing, and his and Peter’s current mental states show hallmarks of psychic equivalence, imposing their own perspective with a threat of impending action.

The next step is to ask patients other than Peter to join the conversation, a process known as triangulation of perspective. On this occasion, another patient joined in:

The clinician continues the triangulation and attempts to bring in another viewpoint while avoiding discussion about whether John’s judgment of the assistant as a trickster was accurate, thereby keeping the group in an MBT loop away from the current tension between John and Peter.

Here, the clinician presents his experience of the interaction and asks the participants to take it into account with the aim of stimulating balance in self-other mentalizing. This intervention contrasts with psychodynamic therapy, in which openly presenting the clinician’s mental states through disclosure of counter-responsiveness is generally not recommended. But the embryonic capacities for affective empathy found in clients with ASPD can be nurtured only if they explicitly learn about the effects they have on others’ minds in the context of trusting relationships. Here, Peter shows a low level of emotional empathy for others by saying, “It is your problem if you get anxious.” This callous disregard of the clinician’s state of mind, a dismissal of the other, cannot go unaddressed. Prosocial relationships require recognition of and sensitivity to the effects of one’s actions on others. Self-disclosure of clinician mind states, including countertransference experience, is therefore used in MBT-ASPD to establish a platform on which to explore these issues.

Having reduced the tension and rekindled a mentalizing atmosphere, the clinician can return from the MBT loop to the starting point and ask the protagonists in this argument to revisit their interaction further and to rework their understanding of what was being said and what they were reacting to. In addition, the incident itself can be explored to identify and empathize with John’s experience at the time and to explore his distrust in others:

The detailed exploration of a nonmentalizing interaction occurring within the group, with a focus on self-other affective mentalizing, reduces the toxicity of the process and allows learning from the present to occur in future social interactions.

Conclusions

Participating in mentalizing interactions within a values-based system that encourages we-ness in a group environment that is more regulated and protected than the patient’s natural social environment is important for patient learning and change (see Box 1 for recommendations for conducting MBT-ASPD). As the group develops, there will be other, more complex and subtle, disruptions of the group’s interactions, emotionally and relationally, in the atmosphere of the group, in the position of authority figures, and in attitudes of deference or antagonism toward the group leader. The experience of being a part of, being challenged by, and contributing to the culture of the group is a fundamental aspect of MBT. The therapy introduces and regulates the experience of making a cultural contribution that enables the patients to begin to experience their agency within a group. Experiencing recognition of one’s subjectivity within a group setting is a powerful social experience that can create a virtuous circle, as mentalizing of self and other becomes cooperatively reinforced and supported. Violence then becomes less and less tenable as a way of interacting with others and the world.