Treating BPD Series, Episode 4: Mentalization-Based Treatment—From Reacting to Reflecting with Carla Sharp, PhD

Dr. Carla Sharp is a leading expert in Mentalization-Based Treatment (MBT), developmental psychopathology, and the treatment of personality disorders. She is the John and Rebecca Moores Professor of Clinical Psychology at the University of Houston, where she serves as Associate Dean for Faculty and Research and directs the Developmental Psychopathology Lab and the Adolescent Diagnosis, Assessment, Prevention, and Treatment Center. A prolific scholar with more than 380 peer-reviewed publications and eight books, she has made substantial contributions to the development and dissemination of mentalization-based approaches and is a certified supervisor and licensed trainer in MBT for both adults and adolescents. In this episode, Dr. Sharp offers a comprehensive introduction to MBT as a treatment for BPD — from what mentalizing is and how it develops through early “serve-and-return” interactions, to how disruptions in this capacity contribute to the difficulties characteristic of BPD. She takes clinicians inside an MBT session, explaining experience-near exploration, empathic validation, affect elaboration, and the mentalizing loop. She also unpacks the three pre-mentalizing modes — psychic equivalence, teleological mode, and pretend mode — and discusses the therapist’s use of self, the importance of maintaining a curious “not-knowing” stance, and how clinicians can recognize when a patient’s capacity to mentalize is strengthening.

Learning Objectives

After completing this educational activity, participants should be able to:

• Define mentalizing and explain how disruptions in its development and functioning contribute to borderline personality disorder.
• Describe how MBT uses experience-near exploration, empathic validation, and the mentalizing loop to strengthen a patient’s capacity to reflect on the mental states of self and others.
• Identify the three pre-mentalizing modes — psychic equivalence, teleological mode, and pretend mode — and recognize when mentalizing has broken down in a clinical interaction.
• Apply the MBT mentalizing stance, including curiosity, uncertainty, and therapist use of self, to support reflective functioning in patients with borderline personality disorder.

Topics Covered in This Interview

• What mentalizing is and its role in psychological functioning
• How mentalizing develops throgh early “serve-and-return” interactions
• Mentalizing difficulties in borderline personality disorder
• Strengthening mentalizing as the core treatment target of MBT
• What an MBT session looks like in practice
• Experience-near exploration and the mentalizing loop
• Empathic validation and managing emotional arousal
• Affect elaboration and working with underlying emotional experience
• Mentalizing relationships with others and with oneself
• How patients and therapists determine the focus of an MBT session
• The three pre-mentalizing modes: psychic equivalence, teleological mode, and pretend mode
• Recognizing when mentalizing has gone offline
• The therapist’s use of self in MBT
• The mentalizing stance: curiosity, uncertainty, and “not knowing”
• Recognizing progress and the generalization of mentalizing outside therapy