Mentalization Based Group Therapy (MBT G) A Theoretical Clinical And Research Manual 2015

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Mentalization-Based Group
Therapy (MBT-G)

MentalizationBased Group
Therapy (MBT-G)
A theoretical, clinical,
and research manual

Sigmund Karterud

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Preface

This manual is a somewhat expanded and modified English version of a text
that was published in Norwegian in 2012 (Mentaliseringsbasert gruppeterapi;
Karterud, 2012). It is modified since the original text contained multiple references to my textbook “Group analysis and psychodynamic group therapy”
(Gruppeanalyse og psykodynamisk gruppepsykoterapi; Karterud, 1999) which
has not been translated into English. These references served to anchor
­mentalization-based group therapy (MBT-G) in the theoretical and relational
matrix of group analysis and psychodynamic group therapy. The textbook
describes the cultural, philosophical, psychoanalytic, and pragmatic roots of
group analysis through a detailed history of its founding fathers, first and foremost Siegmund Foulkes, and of its institutions. The grounding concepts of
group analysis are thoroughly explained, as well as the unresolved tensions in
theory as well as therapeutics. I argued that group analysis needs a similar modernization as that of psychoanalysis, although group analysis has always been
more relational than its individual counterpart. However, the grounding theory
of man, Homo sapiens, social to the core of its existence, had to be liberated
more profoundly from the (individual) psychoanalytic (outdated) concepts of
the psychic apparatus and the drive theory. I argued that self psychology contained resources which could vitalize group analysis, a view which I shared with
the group analytic pioneer Malcolm Pines (Pines, 1996a, 1996b). In the same
vein as Heinz Kohut regarded narcissistic personality disorder (PD) as a paradigmatic disorder for the understanding of the essence of the self and the corresponding necessities for a healing psychoanalytic practice, I shared with
Malcolm (Pines, 1990) the view that borderline personality disorder (BPD) was
a key condition for the understanding of group dynamics and its healing powers. In the United States, a similar conceptual and therapeutic development was
taking place, and I was fortunate to have Walt Stone as a companion in explorations of group dynamics and the self (Karterud & Stone, 2003; Stone & Karterud, 2006).
In this attempt to merge group analysis and self psychology, it was important
to emphasize that both disciplines contained theoretical ballast that portrayed
a polarized (and flawed) view of the nature of man. Group analysis harbored a
metaphysical drive theory while self psychology resorted to a one-sided kind of
“pure” hermeneutics, discarding any contributions to the understanding of the

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PREFACE

mind coming from the natural sciences (Kohut, 1959; Karterud, 1998). I argued
that modern hermeneutics, as construed by Paul Ricoeur (1981a), transcended
these seemingly antithetic attitudes. Hermeneutics, says Ricoeur (1981b), does
not anchor a split between the natural sciences and the humanities. There is a
certain nature behind hermeneutics, which makes it a possible enterprise, in
the same way as there is a nature behind language. Hermeneutics is the main
tool of psychoanalysis, asserted Kohut, and he was right in this first wave of hermeneutic psychotherapy. However, a next generation of researchers took a bold
step forward, by asking, with Ricoeur, what was the nature of hermeneutics
itself. What are the very elements of interpretation, how do they develop, and
when do they coalesce as true self-understanding? Ricoeur, in Oneself as
Another (1992), argued, from a philosophical stance, that self-understanding
(and thereby the “self ”) developed as the capacity to turn the look upon the
world, onto oneself, with the acquired conceptual and cultural wisdom developed by the world. In other words, the understanding of the world (others)
comes prior to understanding oneself.
In “Group analysis and psychodynamic group psychotherapy” (Gruppeanalyse og psykodynamisk gruppepsykoterapi; Karterud, 1999), I elaborate on the
implications of this view for the business of group analysis. I regret that this
theoretical-practical work is not available for the English reader, although the
English references in the preceding paragraphs contain the main ideas, scattered in different locations.
Since the time of publication of my group analytic textbook, there are signs
that indicate that group analysis has entered a phase of stagnation, although the
Scandinavian version might be more active than in the rest of Europe. When I
turned to the theory and practice of mentalization, I found, in contrast, a field
full of energy and vitality, with new and refreshing concepts, an empirical
stance, and new ways of doing therapy. And, above all, that the matter of interest
concerned the heart of hermeneutics: How does it develop, this very capacity
for interpretation, the means to understand others and oneself, and do individual differences in this capacity, which was now labeled mentalization, play a
significant role in psychopathology? These questions have been dealt with
extensively in the rich literature on mentalization during the last decades (Fonagy et al., 2002). It concerns the conception of PDs in general, but in particular
BPD (Bateman & Fonagy, 2004). By defining the capacity for mentalizing as the
key element of personality pathology, it also carries with it important implications for the practice of psychotherapy. And most important for scientific reasons, the phenomena of mentalization/interpretation (hermeneutics) were now
grounded in an evolutionary frame of reference. By that, a whole new set of

PREFACE

approaches and experiments were subsequently applied to the study of thinking
and understanding of mental phenomena, for example, comparisons of mentation among chimpanzees and children. The results have far-reaching consequences for our understanding of the individual–group relationship (Tomasello,
2014). The above mentioned developments, an evolutionary and
­mentalization-based conception of PDs, were the backdrop for our textbook of
“Personality psychiatry” (Personlighetspsykiatri; Karterud et al., 2010) which
has been significant for Scandinavian readers.
Being in charge of a unit for PDs, later expanded and titled as the Department
for Personality Psychiatry, it was natural for me to contact Anthony Bateman
who I had known since 1992. Anthony had already launched mentalizationbased treatment (MBT) at St. Ann’s Hospital, London. He was recruited as a
lecturer and supervisor at our department in Oslo, and we soon gathered
together a Nordic group for MBT.
The MBT program in Oslo was opened in August 2008. This resulted in the
former day hospital, with its roots in therapeutic community and group analytic theory and practice, being closed down and the staff had to be retrained.
At that time there existed practical guidelines for MBT (Bateman & Fonagy,
2006), but the field lacked a more comprehensive manual. Both for our local
purposes and also for the field at large we then, in cooperation with the Nordic
group, developed the “Manual for mentalization-based treatment (MBT) and
the MBT adherence and competence scale. Version individual therapy” (Manual for mentaliseringsbasert terapi (MBT) og MBT vurderingsskala. Versjon individualterapi; Karterud & Bateman, 2010). Thereafter followed the “Manual for
psychoeducational mentalization-based group therapy” (Manual for psykoedukativ mentaliseringsbasert gruppeterapi (MBT-I); Karterud & Bateman, 2011).
Unfortunately, these manuals have not been translated into English; however,
crucial parts, including the MBT adherence and competence scale (MBTACS), are available at different websites (e.g., ). A thorough description of the MBT-ACS as well as a
study of its reliability are also published in Psychotherapy Research (Karterud
et al., 2013).
This third (group) part of the manual trilogy refers extensively in its Norwegian version to the previous two manuals. Since these sources are not available
in English, I have expanded the current text somewhat.
This manual has, like most other psychotherapy manuals, three major purposes. The first is to serve as a tool for training. The second is to make possible
quality control, by assessing the degree of adherence and quality according to
the manual. The third is to promote research.

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PREFACE

A psychotherapy manual should specify guidelines for how to practice a particular type of psychotherapy aimed at a particular type of patients. Luborsky
and Barber (1993) have defined treatment manuals as a professional literature
genre that consists of the following three elements:
1 A presentation of the guiding principles which steer the therapeutic
techniques
2 The techniques themselves, illustrated by relevant examples of therapeutic
interactions
3 Scales and instruments that can identify the skills of therapists who perform
the treatment.
This manual satisfies these criteria.
A therapeutic group, as a “stranger group,” is a unique place for exploring
one’s mentalizing abilities as it unfolds in interaction with others. It is radically
different from the intimate and controlled situation of individual psychotherapy. It is also radically different from the situation of family therapy, where the
protagonists are bonded to each other through a shared past history and might
live together in daily life. A therapeutic group is closer to ordinary life than
individual therapy, and because the participants normally do not share any past
history or come into contact with each other in daily life, the therapist is freer to
construct the essence of the group. I hold the opinion that therapeutic groups
are ideal places to become aware of, understand, and transcend one’s mentalizing failures. However, I believe we have barely begun the work of cultivating
groups for these purposes.
Groups are complicated work tools. In the first chapter of this manual I
describe how group therapy with seriously disturbed patients might become a
very bad experience. In order for the mentalizing-enhancing potentials of the
group to unfold, the therapist has to construct the group in a certain manner.
This manual provides a range of recommendations for this construction. By
these measures, MBT-G stands out as being radically different from psychodynamic group therapy, from which it arose, for example, by constricting free
group associations. On the other hand, it is highly dynamic, in the sense of
taking into account multiple motivational levels both for the individuals and
for the group as a whole and the need for cultivation and development of the
group as a whole, by stimulating spontaneous interaction in the group and
utilizing here-and-now events for mentalizing purposes. By these dynamic
elements, MBT-G is radically different from dialectical behavior therapy
(DBT), skills training groups, or cognitive behavioral groups. Similarities and
differences compared to other group therapies are discussed at the end of
Chapter 2.

PREFACE

I emphasize that MBT-G is a highly flexible kind of group therapy and discuss
this aspect in Chapter 2. With poorly functioning patients in high turnover
situations, as in psychiatric inpatient units, MBT-G might be constructed quite
strictly and be imbued by psychoeducation. With highly functioning patients in
group analysis, the MBT structural elements may barely be visible, since they
will be integrated as part of the group matrix. For those for whom it is designed,
borderline patients, MBT-G should stand out as a mode of group therapy clearly
different from its psychodynamic siblings as well as its more distant relatives of
the cognitive type.
Working with this manual, I have had the privilege of having enlightening
discussions with a wide range of colleagues. First and foremost is Anthony
Bateman who has been a stimulating partner in a continuous dialogue. Then
there are members of the Nordic MBT group, such as Carsten Rene Jørgensen,
Morten Kjølbye, Sebastian Simonsen, Kirsten Aaskov Larsen, Nana Lund Nørgaard, Kraka Bjørnholm, Ann Nilsson, Kirsten Grage Rasmussen, Per Sørensen,
Fransisco Alberdi, Henning Jordet, Bjørn Philips, Anna Sten, and Niki Sundstrøm. From the MBT program of the Bergen Clinic Foundation there are Kari
Lossius, Nina Arefjord, Fredrik Sylvester Jensen, Turi Bjelkarøy, Randi Abrahamsen, Helga Mjeldheim, Brita Leivestad, and Katharina Morken. From the
Department of Personality Psychiatry, discussions involved Øyvind Urnes,
Elfrida Kvarstein, Theresa Wilberg, Christian Schlüter, Siri Johns, Bendik
Høigård, Turid Bergvik, Bendikte Steffensen, Åshild Jørstad, Jean Max Robasse,
Gunn Ingrid Ulstein, Merete Tønder, Kjetil Bremer, Kristoffer Walter, and
Espen Folmo. Participants in courses in MBT-G during the years 2011 to 2014
have contributed with demonstrations and discussions of video recordings
from their ongoing groups. Warm thanks also go to hundreds of patients who
have agreed to allow their therapy sessions to be videoed.
The clinical examples in this manual are based upon real therapies, although
they have been disguised somewhat in order to preserve anonymity. Special
thanks go to the therapists and the patients in the group who allowed publication of a full transcript of one of their sessions, which is presented in Chapter 5.
This is quite unique in the literature of group psychotherapy. The readers will
here get an undisguised explication of what MBT-G is all about and a demonstration of how the MBT-G adherence and quality scale works.
This English version of the manual has been partly translated by Paul Johanson, Elfrida Kvarstein, and Espen Folmo, and partly by me. Parts of Chapter 1
and the text on items 10–19 are written in collaboration with Anthony Bateman. Jeremy Holmes has provided useful commentaries when reviewing the
text. I have realized that writing directly in English is different than translating
a Norwegian text, even my own text. Due to economic constraints, I did not

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PREFACE

have any professional translation assistance. The language flow is not always
optimal and I hope the English-speaking audience will bear with my
“­Norwegian-English” style.
Finally, I would like to thank the Norwegian Association of Professional
Writers and Translators (NFF) who supported the Norwegian manual with a
grant and the University of Oslo and Oslo University Hospital for their general
assistance.

Contents

1 Historical and theoretical background for mentalization-based

group therapy 1
Introduction 1

Mentalizing, failures of mentalizing, and borderline personality disorder 2
Is group therapy good treatment for patients with borderline personality
disorder? 18
Group dynamics and evolution 26
Challenges with borderline patients in groups 37
2 Main principles for mentalization-based group therapy 43

Introduction 43
The group as a training ground for mentalizing 44
Focus on interpersonal transactions 50
Continuity and coherence of meaning through the therapists “minding the
group” 50
Regulation of group phases 53
Balanced (mentalizing) turntaking 55
What counts as an “event?” 56
Clarification of events 58
Identification of failures of mentalizing 60
Engaging the group members in mentalizing events 62
Identifying and working through of events in the group 64
The closing of sequences 68
Starting the group 69
The treatment course and termination 72
Coordinating and mentalizing meetings between all involved therapists 74
MBT-G in different contexts 77
Similarities and differences between MBT-G and other types of group
therapy 79
The group as a whole: Constructing and mentalizing the matrix 87
3 The mentalization-based group therapy adherence and quality

rating scale (MBT-G-AQS) 91
Introduction 91

On rating scales for group therapy 91

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CONTENTS

Selecting items for the MBT-G-AQS 93
Rating procedures for the MBT-G-AQS 95
4 The items of the MBT-G-AQS 99

Introduction: The mentalizing stance 99
Item 1: Managing group boundaries 104
Item 2: Regulating group phases 106
Item 3: Initiating and fulfilling turntaking 109
Item 4: Engaging group members in mentalizing external events 115
Item 5: Identifying and mentalizing events in the group 120
Item 6: Caring for the group and each member 123
Item 7: Managing authority 128
Item 8: Stimulating discussions about group norms 131
Item 9: Cooperation between co-therapists 133
Item 10: Engagement, interest, and warmth 136
Item 11: Exploration, curiosity, and not-knowing stance 138
Item 12: Challenging unwarranted beliefs 142
Item 13: Regulating emotional arousal 144
Item 14: Acknowledging good mentalization 149
Item 15: Handling pretend mode 151
Item 16: Handling psychic equivalence 156
Item 17: Focus on emotions 161
Item 18: Stop and rewind 166
Item 19: Focus on the relationship between therapists and patients 167
5 Transcript of a mentalization-based group therapy session 175

Introduction 175
The transcript 176
Notes on the ratings 197
Ratings of each item 199
Overall rating 205

References 207
Appendix 1 Rating scale for mentalization-based group therapy 217
Appendix 2 Rating scale for mentalization-based group therapy quality 219
Index 221

Chapter 1

Historical and theoretical
background for mentalizationbased group therapy

Introduction
In this first chapter, I provide a short account of the theoretical rationale for
defining mentalizing failures as being the pathogenic core of borderline personality disorder (BPD), and the significance of a carefully designed treatment
system that might serve as a holding environment for the kinds of interactions
and experiences that we advocate as a means to enhance mentalizing capacities.
Thereafter I sketch the historical and theoretical background for mentalizationbased group therapy (MBT-G). By that I want to highlight that we are situated
in a long professional tradition. Group psychotherapy for patients with personality disorders (PDs), and particular BPD, has been practiced for more than
50 years. There is a rich literature, while there is also an alarming lack of controlled trials that can provide evidence for beneficial effects. This state of affairs
was changed around the turn of the millennium when both mentalizationbased treatment (MBT) and dialectical behavioral therapy (DBT), which both
contain a crucial group component, were shown to be more effective than treatment as usual in several randomized trials (Linehan et al., 1991, 1993; Bateman
& Fonagy, 2001, 2009). Group therapy for patients with BPD, as part of, for
example, MBT or DBT, has therefore been recommended by health authorities
(NICE, 2009).
Thereafter, since therapists have a tendency to underestimate the mentalizing difficulties that BPD patients encounter in group situations, I discuss
group dynamics from the perspective of evolution and attachment. Being
advanced primates, we, as Homo sapiens, carry a rich genetic baggage which
helps us to instinctively follow basic group rules as well as to take on collective
emotions. Thus it is possible to be member of a group, as a more silent group
member, or as member of an engaged subgroup, without performing much
mentalization. BPD patients are likely to oscillate between excessive engagement and withdrawal.

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Historical and theoretical background for mentalization-based group therapy

Chapter 1 ends by discussing the challenges the above themes represent for
the BPD patient and for the task of developing and maintaining the group as a
good “training ground for mentalizing.”

Mentalizing, failures of mentalizing, and borderline
personality disorder
BPD is by definition a diagnostic category within the Diagnostic and Statistical
Manual of Mental Disorders, fifth edition (DSM-5) (and within the tenth revision of the International Statistical Classification of Diseases (ICD-10) under
the label emotional unstable PD). However, this category is by no means unambiguous. According to the diagnostic rules, one needs at least five (out of nine)
criteria to have the diagnosis. Since none of these criteria are either compulsory
or necessary, there are 256 different ways of being borderline (Johansen et al.,
2004)! Things are further complicated by the fact that patients diagnosed with
any PD category, have even more maladaptive personality traits located “outside” their diagnostic label. Patients with a BPD diagnosis (with any “comorbid”
PD diagnosis) have on average around 15 maladaptive personality traits, when
assessed by the Structured Clinical Interview for DSM-IV Axis II disorders
(SCID-II) (Karterud et al., 2010). This implies that as many as ten personality
traits might derive from other than the borderline dimension. If we take these
supplementary personality traits into account, the heterogeneity becomes
enormous. It becomes even more complex if we add the different symptom disorders that often accompany the disorder. We might encounter BPD patients
bordering on psychoses, with strong paranoid features and post-traumatic
stress disorder; or BPD patients with antisocial features and substance use disorder; or BPD patients with avoidant features and eating disorder. In addition,
things are further complicated by a severity dimension. Broadly speaking, the
more PD criteria that are met, the more serious is the condition (Cramer et al.,
2007). The number of criteria is linearly correlated with social dysfunction and
lower quality of life. This relation is also captured by the Global Assessment of
Functioning (GAF) scale. The more criteria fulfilled, the lower the GAF score
(Pedersen & Karterud, 2012).
When we use the term BPD in this manual, it is therefore a heterogeneous
group of patients we are referring to. And to complicate the case even further,
we will, on some occasions, refer to BPD “in a broader sense.” By this we mean
patients that do not surpass the threshold of five BPD criteria, but who can display three to four BPD criteria and exhibit other significant personality pathologies (e.g., histrionic, narcissistic, antisocial, or avoidant traits) and present
with a clinical condition of “typical borderline style” with unstable relations,

Mentalizing, failures of mentalizing, and borderline personality disorder

identity disturbance, and emotional dysregulation. Such patients may also
benefit from MBT.
“The borderline group” was first described by the American psychiatrist
Adolf Stern in 1938. Since then, the market has been filled with an enormous
clinical, theoretical, and research literature and there have been countless meetings, seminars, and conferences. Many prominent colleagues have their names
inscribed in the history of psychology and psychiatry because of their engagement in the continuous dialogue on the nature of the borderline pathology. This
strong engagement is likely to be connected to the fact that what we label borderline pathology touches something more than a delineated psychiatric disorder. It concerns fundamental questions of existence for modern humans.

Definition
MBT is grounded in the theory of mentalization. Mentalization is both
self-reflective and interpersonal (“the problem of other minds”). It refers to the
act of understanding the experiences and actions of oneself and others, in terms
of mental phenomena, for example, assumptions, feelings, attitudes, wishes,
hopes, knowledge, intentions, plans, dreams, false beliefs, deceptions, etc. The
alternative to a mentalized understanding of self and others is to conceptualize
a person as driven by outer forces, by simple stimuli–responses, by coincidences, by crude drives and instincts, by disease processes, etc. Mentalizing can be
so simple and obvious that we overlook it, but it can also be a very challenging
business. It presupposes the ability to direct one’s attention to relevant aspects
of intrapsychic and interpersonal phenomena, and for the most part it is implicit and automatic. In daily life we mentalize each other constantly by attributing
intentions to each other, consciously or unconsciously. Explicit mentalizing
means that we engage in a conscious reflection upon our own and others’
motives and self-states. Because of the very nature of our minds, it will often be
the case that our mentalizing endeavors will “fail” in the sense that we often
misunderstand ourselves and others. We can never be absolutely sure of what
other people are thinking or feeling, and our own thoughts and feelings are also
often vague and unclear. The less proficient we are in mentalizing, the more
often we misunderstand.

Historical roots
The concept of mentalization belongs to a tradition within French psychoanalysis, understood as the process whereby drives and affects are transformed into
symbols (Bouchard & Lecours, 2008). There is also an important link to the British psychoanalyst Wilfred Bion’s theory of thinking (Bion, 1970). However, the
main contributors to the modern content of the concept are Professor Peter

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Historical and theoretical background for mentalization-based group therapy

Fonagy and coworkers (Fonagy et al., 2002). The epicenter has been in London,
at the Anna Freud Centre and University College London, but the ongoing discussion about mentalization in the literature has engaged a wide range of
researchers and clinicians (Leuten et al., 2012). The concept is embedded in a
theoretical network containing elements from evolutionary theory, attachment
theory, developmental psychology, psychoanalysis, neurobiology, group dynamics, and personality pathology, to mention the most important. Historically, it is
closely connected to John Bowlby’s theories (1988) concerning “internal working models” in the mind of young children, contingent upon internal representations of their attachment experiences. Fonagy and coworkers constructed a
general theory of self-development which is rooted in the attachment relationship (Fonagy et al., 1991, 1996, 1997, 2002). The theory argues that the attachment relationship among Homo sapiens is expanded in scope and function. In
addition to providing a system for dealing with fears that can threaten the security and survival of children, it has become the most important arena for developing the self and the ability to reflect upon mental states.

Mentalizing, self-development, and attachment
The theory of self-development and mentalization is thoroughly explained in
the volume Affect Regulation, Mentalization and the Development of the Self
(Fonagy et al. 2002). Basic questions concerning self-development are discussed: How is the self—which is the prerequisite for subjectivity and self-­
reflection—constituted (e.g., the experience of being separated from other
people and things, to be the origin of one’s own actions, to be the agent and
owner of one’s own thoughts and affects, to be able to reflect upon these affects
and thoughts as one’s own)? The most important thesis is that the attachment
relationship is an arena where the child’s mental states are experienced, interpreted, and mirrored/reflected by an empathic other, and by being immersed in
a benign sociocultural culture where people are “minding” each other, the
developed mindreading capacities will eventually turn toward the self, leading
to self-understanding and self-consciousness. A considerable body of research
demonstrates that insecure attachment relationships are associated with a
diminished ability to understand the intentions of others and leads to a generally lower level of social competence (Karterud et al., 2010). In particular, disorganized attachment in childhood is associated with psychopathology in
adulthood.
The general theory of self-development is in a process of expansion. One
important contributor is the Hungarian psychologist György Gergely, who has
been particularly interested in the problem of how the core self (which is found
among other primates as well) develops into the humane reflective self (Gergely

Mentalizing, failures of mentalizing, and borderline personality disorder

& Unoka, 2008). This development is closely linked to the formation of object
representations and later to self-representations, and to the integration with
primary emotional systems. In order to be able to reflect on oneself and others
(objects), the self and other (and the relationship to important others) must be
represented in the memory system. These representations must be retrievable
in the working memory and being linked to the past, present, and future, to
feelings and relevant options. Moreover, a consistent self requires there to be a
unified agent who directs the various self-representations, object representations, and affect states. Without a reflexive distance, the individual risks being
“lost in emotions.”
Mentalization theory describes how an individual—through interaction with
a mentalizing other—achieves such a reflexive dialogue with himself/herself.
The individual learns social tools that permit him/her to transform pressures
arising from activation of the primary emotional systems into culturally sanctioned forms of understanding and expression. It is a theory that integrates
self-consciousness with temperament.
Concepts from developmental psychology that are important to be familiar
with (because they are also used in the clinical literature) include teleological
understanding, psychic equivalence thinking, pretend mode, prementalistic
thinking, and representational thinking.
Starting at the age of approximately 9 months, children develop the ability to
differentiate goals from the means to reach the goals, adapt actions to new situations, and select the means (among various options) that most effectively lead
to the goal. One can speak about the self as a goal-oriented (teleological) agent.
The capacity for goal-oriented action does not require the capacity for cause–
effect thinking or the ability to understand intention as cause, but it links the
action to a goal. The term “teleological” is also used about the mode of thinking
in regressed mental states when patients have difficulties believing anything
else than concrete goal-oriented actions: “I won’t believe it until I see it . . . ” and
“If you care about me, then you will . . . ”
From the age of about 2 years, the child develops the ability to understand
that others can have intentions (wishes, needs) that can lead to action, without
having to experience the action in real time. For example, the child is now able
to contribute in relation to others’ preferences and to comfort others. We are
now talking about the self as an intentional agent. This ability to think in mentalistic terms is also called “a naive theory of mind.” The child is now able to
attribute generalized intentions to others, but is governed by a principle of mental coherence, that is, he or she still does not grasp the concept that others can
contain contradicting intentions. At about this time the child establishes a concept of “me.” Action impulses, thoughts, and feelings become more and more

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Historical and theoretical background for mentalization-based group therapy

“mine.” However, consciousness is extroverted and “online.” It deals with targets
in the world and is bound to prevailing situations. Offline abstract thinking is
not yet possible (Bogdan, 2010).
The theory of prementalistic thinking is central to the developmental model.
Initially, thinking is assumed to be at the level of psychic equivalence, which
means that the child is unable to differentiate between the inner and outer
world (or between fantasy and reality). These perspectives are yet to be acquired.
One route is through pretend play. The nature of play is to simulate contrasting
perspectives on reality. In play, the child imagines that others are different from
what they really are. Through pretend play, the child learns to juggle between
fantasy and reality. It is most exciting when the two are quite close and when it
is difficult to differentiate fantasy from reality, for example, when daddy is
almost like the evil troll. When the ability to differentiate fantasy from reality is
not properly developed, the individual continues to alternate between psychic
equivalence thinking where the world might become “too real,” and a pretend
mode thinking which is too separated from reality.
From about the age of 4 years, there occurs a cognitive revolution (Bogdan,
2010). The child develops a more mature “theory of mind,” meaning that intentions are understood as parts of a complex network of representations of self and
other. Enhanced executive functions (among other mechanisms) allow the
child to perform metacognitive operations, that is, to understand the essence of
representations, that they represent something, for example, the aboutness of
thinking. Metacognition is thus a prerequisite for self-consciousness, for
example, by knowing that the thought (Peter is hungry) is created by me,
belongs to me, and may be false (as a representation about Peter’s mental state).
The self enters the stage as a representational actor and it is not until this stage
that children have the capacity to mentalize explicitly. Infantile amnesia (prior
to the age of 3 to 4 years) is due to the inability to code personal experiences as
uniquely personal events, that is, that happened to “me” in an autobiographical
sense. Before this age, there are only scattered episodic memories, devoid of any
narrative texture. From now on, the mentalization capacity is growing quickly.
The challenge is to be able to differentiate fantasy from reality in even more sophisticated manners and contexts, realizing that thoughts and feelings are representations of reality and not reality itself.
The autobiographical self (from around 5 to 6 years) is based on the self as a
representational agent. The transition from episodic and procedural memory to
declarative memory (“it happened to me”) expands in scope and complexity.
Now one can construct more realistic and coherent stories about one’s own
actions and experiences. This ability, however, presupposes the capacity to
maintain multiple representations of self and others so that time sequences and

Mentalizing, failures of mentalizing, and borderline personality disorder

causal and meaningful relations can be established between them. In general,
one can say that the developmental course has as its goal the establishment of
the structures and abilities that are the preconditions for a representational and
autobiographical self. The sociocultural challenges that face the child, being
thrown into a world of complex sociocultural practices, exert a constant pressure to install mentalizing capabilities in order to construe this world as meaningful and understandable. The emotional interactions between the child and
attachment figures are crucial means to reach this goal.
Mentalization theory emphasizes mentalizing ability (including metacognition) as the most important aspect of the self. It provides the self with cohesion.
Without mentalization, the individual would be subject to changing and inconsistent self-states constantly at the mercy of inner and outer events, and devoid
of self-consciousness. Mentalization provides meaning and context to these
changing self-states. It puts them in the perspective of one’s own life history and
one’s impressions of other people, ongoing interactions, and the future. The
ability to mentalize is genetically grounded, but must be realized through others in order to become manifest.

Mentalization and personality disorders
Mentalization theory is closely associated with the concept and theories of
BPD. This connection reflects the close working relationship between Peter
Fonagy and Anthony Bateman in London, both analysts and active clinicians
who treat and carry out research on difficult-to-treat borderline patients.
Together they developed MBT (Bateman and Fonagy, 2004). It is, however,
important to emphasize that impaired mentalization ability is something that
characterizes all PDs. To a certain extent this is self-evident since one of the
general criteria for a PD is that the person suffers from maladaptive thought
patterns, for example, a tendency to distort and/or interpret interpersonal
events in a rigid manner. Mentalization theory explicates what characterizes
distorted and rigid interpretational patterns. The focus is on “prementalistic”
thought patterns: psychic equivalence thinking and pretend mode. Psychic
equivalence thinking is schematic, concrete, black–white, and insisting. The
reality it refers to is “too real.” There is no room for other perspectives. In pretend mode, the relationship to reality is diffuse. Thought (and speech) is vague,
metaphoric, and emotionally flat. Cognitive theory describes distorted and
rigid interpretations as maladaptive cognitive schema. Mentalization theory
emphasizes the importance of emotions, context, and attachment more strongly and with different therapeutic consequences. But the main point is the same:
in all PDs the ability to properly interpret interpersonal events intersubjectively
is impaired to a clinically significant degree.

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An individual suffering from paranoid PD will, for example, interpret other
people as more evil than they actually are, and themself as more vulnerable to a
conspiracy than which is actually the case. This can be seen as a consequence of
the person’s impaired mentalization ability. But the theory goes even further. It
also refers to “unmentalized affects.” In the case of paranoid PD, there is a chronic
narcissistic rage, an “alien self ” and projective identification (Fonagy et al., 2002).
An individual suffering from paranoid PD is preoccupied with every manner of
humiliation without ever being able to forget them. Total irreconcilability is at its
heart and the individual’s thoughts revolve around the theme of vengeance. It is
this interwoven complex of self-representations, affects, and representations of
others which is poorly mentalized. This means that when the individual experiences new or old humiliations, he/she quickly resorts to psychic equivalence
thinking and becomes rigid, unreasonable, and insisting on his/her own version
of reality. Previous humiliating experiences and the resulting rage take center
stage and block out nuanced intersubjective thinking. Accordingly, mentalization-based treatment will necessarily also focus on affects.
Mentalization theory emphasizes the general phenomenon which the example
of paranoid PD illustrates: that thinking is influenced by one’s emotional state. If
one is interested and curious, then one is likely to have optimistic thoughts. If
one is depressed, one is likely to have sad and distressing thoughts. If one is
manic, one has lofty and unrealistic thoughts. If one is scared, one may have
­disconcerting thoughts, and if one is angry, the focus may be on revenge. Mentalization theory integrates both a “bottom-up” and a “top-down” perspective.
Emotions influence us from “below” in a way that can make us lose a more overall perspective on reality. The ability to mentalize allows us to approach emotions “from above” and put them into perspective. Mental health depends on a
balance between the two extremes: “lost in emotions” or “lost in cognition.”

Dimensions of mentalizing
Mentalizing is a multidimensional construct and breaking it down into dimensional components is helpful in understanding MBT. Broadly speaking, mentalization can be considered as four intersecting dimensions: (1) automatic
versus controlled or implicit versus explicit, (2) internal versus externally based,
(3) self- versus other-orientated, and (4) cognitive versus affective processes.
The dimensions are probably grounded in different neurobiological systems
(Luyten et al., 2012).
None of us manage to integrate all components of mentalizing all the time
and nor should we. Normal people will at times move from understanding
themselves and others according to their perceptions of what is in the mind, to
explanations based on the physical environment—“if they behave like that they

Mentalizing, failures of mentalizing, and borderline personality disorder

obviously want to spoil everything.” This is particularly the case in powerful
affective states when our cognitive processes decompose in the face of a wave of
emotion. So, personality pathology does not simply arise because of a loss of
mentalizing. It occurs for a number of reasons.
First, it matters how easily we lose it. Some individuals are sensitive and reactive, rapidly moving to non-mentalizing modes in a wide range of contexts.
Second, it matters how quickly we regain mentalizing once it has been lost.
Bateman and Fonagy (2004) suggest that a combination of frequent, rapid, and
easily provoked loss of mentalizing within interpersonal relationships with
associated difficulties in regaining mentalizing and the consequent lengthy
exposure to non-mentalizing modes of experience is characteristic of BPD.
Individuals with BPD may be “normal mentalizers” except in the context of
attachment relationships. They tend to misread minds, both their own and
those of others, when emotionally aroused. As their relationship with another
person moves into the sphere of attachment, the intensification of relationships
means that their ability to think about the mental state of another can rapidly
deteriorate. When this happens, prementalistic modes of organizing subjectivity emerge, psychic equivalence and pretend mode, which have the power to
disorganize these relationships and destroy the coherence of self-experience
that the narrative provided by normal mentalization generates.
Third, mentalizing can become rigid, lacking flexibility. People with paranoid PD often show rigid hypermentalization with regard to their own internal
mental states and lack any real understanding of others (Dimaggio et al.,
2006). At best, they are suspicious of motives and at worst, they see people as
having specific malign motives and cannot be persuaded otherwise. The mental processes of people with antisocial personality disorder (ASPD) are less
rigid than those found in paranoid people. Their mentalizing shows flexibility
at times but when uncertainty arises they resort to prementalistic ways of
organizing their mental processes and how they understand the world and
their relationships.
Finally, the balance of the components of mentalizing can be distorted.
Patients with narcissistic personality have a well-developed self-focus but a
limited understanding of others. In contrast, patients with ASPD may be experts
at reading the inner states of others, even to the point that they misuse this capacity to coerce or manipulate them, while being unable to develop any real
understanding of their own inner world. In addition, they lack abilities to accurately read certain emotions and fail to recognize fearful emotions from facial
expressions. This implicates dysfunction in neural structures such as the amygdala that subserve fearful expression processing. Marsh and Blair (2008) in a
meta-analysis of 20 studies showed a robust link between antisocial behavior

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and specific deficits in recognizing fearful expressions. This impairment was
not attributed solely to task difficulty.

Implicit versus explicit mentalizing
Among the dimensions of mentalizing, the implicit versus the explicit mode
plays a superordinate role. Most of us mentalize automatically in our everyday
lives—not to do so would be exhausting. Automatic or implicit mentalizing
allows us to rapidly form mental representations based on previous experience
and to use these as a reference point as we gather further information to confirm or disconfirm our tentative understanding of motivations. This is reflexive,
requires little attention, and is beneath the level of our awareness (Satpute &
Lieberman, 2006; Kahneman, 2011). If it does not seem to be working we move
to more explicit or controlled mentalizing which requires effort and attention.
It is therefore slower and more time-consuming and most commonly performed by inner (or outer) speech. Our capacity to manage this controlled
mentalizing varies considerably and the threshold at which we return to automatic mentalizing is, in part, determined by the response we receive to our
explicit attempts to understand someone in relation to ourselves and the secondary attachment strategies we deploy when being aroused and under stress.
Behavioral, neurobiological, and neuroimaging studies suggest that the move
from controlled to automatic mentalizing and thence to non-mentalizing modes
is determined by a “switch” between cortical and subcortical brain systems (Arnsten & Goldman-Rakic, 1998; Lieberman, 2007) and that the point at which we
switch is determined by our attachment patterns. Different attachment histories
are associated with attachment styles that differ in terms of the associated background level of activation of the attachment system, and the point at which the
switch from more prefrontal (controlled) to more automatic mentalizing occurs
(Luyten et al., 2012). Dismissing individuals tend to deny attachment needs,
asserting autonomy, independence, and strength in the face of stress, accompanied by attachment deactivation strategies. In contrast, a preoccupied attachment
classification or an anxious attachment style is generally considered as being
linked to attachment hyperactivating strategies (Mikulincer & Shaver, 2007).
Attachment hyperactivating strategies are associated with the tendency to exaggerate both the presence and seriousness of threats, and frantic efforts to find
support and relief, often expressed in demanding, clinging behavior. Both adult
attachment interviews (AAIs) and self-report studies have found a predominance of anxious-preoccupied attachment strategies in BPD patients (Fonagy
et al., 1997; Levy et al., 2006). In borderline patients, there is a characteristic pattern of fearful attachment (attachment-anxiety and relational avoidance), painful
intolerance of aloneness, hypersensitivity to social environment, expectation of

Mentalizing, failures of mentalizing, and borderline personality disorder

hostility from others, and greatly reduced positive memories of dyadic interactions (Fonagy & Bateman, 2008; Gunderson & Lyons-Ruth, 2008).
An important cause of anxious attachment in BPD patients is the commonly
observed trauma history of these individuals. Attachment theorists, in particular Mary Main and Erik Hesse, have suggested that maltreatment leads to disorganization of the child’s attachment to the caregiver because of the irresolvable
internal conflict created by the need for reassurance from the very person who
also (by association perhaps) generates an experience of lack of safety. The activation of the attachment system by the threat of maltreatment is followed by
proximity seeking, which drives the child closer to an experience of threat leading to further (hyper)activation of the attachment system (Hesse & Main, 2000).
This irresolvable conflict leaves the child with an overwhelming sense of helplessness and hopelessness. Congruent with these assumptions, there is compelling evidence for problematic family conditions in the development of BPD,
including physical and sexual abuse, prolonged separations, and neglect and
emotional abuse, although their specificity and etiological import has often
been questioned (Zweig-Frank & Paris, 1991). Probably a quarter of BPD
patients have no maltreatment histories (Goodman et al., 2003) and the majority of individuals with abuse histories show a high rate of resilience and no personality pathology (McGloin & Widom, 2001). Early neglect may be an
underestimated risk factor (Kantojarvi et al., 2008), as there is some evidence
from adoption and other studies to suggest that early neglect interferes with
emotional understanding (Shipman et al., 2005) and this plays a role in the
emergence of emotional difficulties in preschool (Vorria et al., 2006) and even
in adolescence (Colvert et al., 2008). One developmental path to impairments
in mentalizing in BPD may be a combination of early neglect, which might
undermine the infant’s developing capacity for affect regulation, with later maltreatment or other environmental circumstances, including adult experience of
verbal, emotional, physical, and sexual abuse (Zanarini et al., 2005), that are
likely to activate the attachment system chronically (Fonagy & Bateman, 2008).
BPD patients who mix deactivating and hyperactivating strategies, as is characteristic of disorganized attachment, show a tendency for both hypermentalization and a failure of mentalization. On the one hand, because attachment
deactivating strategies are typically associated with minimizing and avoiding
affective contents, BPD patients often have a tendency for hypermentalization,
that is, continuing attempts to mentalize, but without integrating cognition and
affect. At the same time, because the use of hyperactivating strategies is associated with a decoupling of controlled mentalization, this leads to failures of mentalization as a result of an overreliance on models of social cognition that
antedate full mentalizing (Bateman & Fonagy, 2006).

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This has important clinical implications for MBT. The therapist needs to
develop strategies related to excessive demand and dependent behavior as well as
ensuring an ability to manage sudden therapeutic ruptures, often characterized
by dismissive statements about the therapist’s inadequacies with the accompanying danger of leaving treatment.

Internal versus external mentalizing
The dimension of internal and external mentalizing refers to the predominant
focus of mentalizing (Lieberman, 2007). Internal mentalizing refers to a focus
on one’s own or others’ internal states, which are thoughts, feelings, and desires;
external mentalizing implies a reliance on external features such as facial
expression and behavior. This is not the same as the self/other dimension which
relates to the actual object of focus. Mentalization focused on a psychological
interior may be self or other oriented. Again, this distinction has important
consequences for MBT. Patients with BPD have a problem with internal mentalizing but they also have difficulties with externally focused mentalizing.
Inevitably both components of mentalizing inform each other, indicating that
borderline patients are doubly disadvantaged. The difficulty is not so much that
patients with BPD often misinterpret facial expression, although they might
sometimes do so, but more that they are highly sensitive to facial expressions
and so tend to react rapidly and without warning (Lynch et al., 2006). Any
movement of the therapist might trigger a response—glancing out of the window, for example, might lead to claiming that the therapist is obviously not listening and so the patient might feel compelled to leave; a nonreactive face is
equally disturbing as patients continuously attempt to deduce the therapist’s
internal state using information derived from external monitoring. Anything
that disrupts this process will create anxiety, which leads to a loss of mentalizing
and the re-emergence of developmentally earlier ways of relating to the world.
A reduced ability to arrive at an emotional understanding of others by reading their facial expressions accurately exaggerates a compromised ability in
BPD to infer mental states from focusing on internal states. To maintain or
repair cooperation during social/interpersonal exchange and interaction, we
have to understand social gestures and the likely interpersonal consequences
when shared expectations about fair exchange or social norms are violated by
accident or intent. To do this we have to integrate external mentalizing with an
assessment of the underlying internal state of mind of the other person. The
importance of this interactional process in the pathology of BPD has been creatively demonstrated experimentally. Using a multiround economic exchange
game played between patients with BPD and healthy partners, King-Casas and
colleagues (2008) have shown that behaviorally, individuals with BPD showed

Mentalizing, failures of mentalizing, and borderline personality disorder

a profound incapacity to maintain cooperation, and were impaired in their ability to repair broken cooperation on the basis of a quantitative measure of coaxing. They failed to understand the intentions of others—an internally based
task. They expected their partners to be mean to them and they were unable to
change this understanding even when evidence suggested it was incorrect, for
example, when their partner was generous. In other words, they were unable to
read the intentions of their partner and to alter their own behavior reciprocally.
This gradually led their partner in the game to become mean, suggesting that
they were provoked to become the very person they were being seen as. Analogously, therapists working with patients with BPD must bear in mind the risk of
being provoked into becoming the very therapist that their patient accuses
them of being

Self versus other mentalizing
Impairments and imbalances in the capacity to reflect about oneself and others
are common and it is only when they become more extreme that they begin to
cause problems. Some people become experts at reading other people’s minds
and if they misuse this ability or exploit it for their own gain we tend to think
they have antisocial characteristics; others focus on themselves and their own
internal states and become experts in what others can do for them to meet their
requirements and we then suggest they are narcissistic. Thus excessive concentration on either the self or other leads to one-sided relationships and distortions in social interaction. Inevitably this will be reflected in how patients
present for treatment and interact with their therapists. Patients with BPD may
be oversensitive, carefully monitoring the therapist’s mind at the expense of
their own needs and present what they think the therapist wants them to be.
They may even take on the mind of the therapist and make it their own. Therapists should be wary of patients who eagerly comply with everything said to
them. Such compliance may alternate with a tendency to become preoccupied
and overly concerned about internal states of mind, leaving the therapist feeling
left out of the relationship and unable to participate effectively.

Cognitive versus affective mentalizing
The final dimension to consider relates to cognitive and emotional ­processing—
belief, reasoning, and perspective taking on the one hand and emotional
empathy, subjective self-experience, and mentalized affectivity on the other
(Jurist, 2005). A high level of mentalizing requires integration of both cognitive
and affective processes. But some people are able to manage one aspect to a
greater degree than the other. Patients with BPD are overwhelmed by affective
processes and cannot integrate them with their cognitive understanding—they

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may understand why they do something but feel unable to use their understanding to manage their feelings; they are compelled to act because they cannot form representations integrating emotional and cognitive processes.
Others, such as people with ASPD, invest considerable time in cognitive understanding of mental states to the detriment of affective experience.

Mentalization measured as reflective functioning
An operationalized measure has been developed for mentalization: reflective
functioning (RF) (Fonagy et al., 1998). RF is scored on the basis of a transcript
of the AAI on a scale from −1 (negative or bizarre mentalization) to +9
(sophisticated mentalization). It is possible to achieve good reliability when
scoring RF, but it requires long training. Since scoring is quite time-consuming, the RF scale is primarily a research instrument and not suitable for everyday clinical use. Efforts are underway to make RF scoring easier. Based upon
the work of Perkins (2009), self-report scales have been constructed, both as
a long (RFQ-54) as well as a short version (RFQ-18). Meehan and coworkers
(2009) have tested a rating scale containing 53 items (“Reflective Function
Questionnaire”), which can be used in various contexts, such as psychotherapy sessions. Low RF has been found for a range of mental disorders, for
example, BPD, ASPD, and anorexia nervosa. Other studies have found that
low RF in young mothers predicts insecure attachment patterns for their children (Fonagy et al., 1991). Borderline patients who received transferencefocused psychotherapy were found to increase their RF score in the course of
treatment (Levy et al., 2006).

MBT and mentalization-oriented psychotherapy
MBT is grounded in the theories of mentalization, PDs, and psychodynamic
treatment. However, the MBT approach is relevant not just for PDs, but also for
the treatment of depression, anxiety disorders, post-traumatic conditions, eating disorders, and substance abuse disorders (Rudden et al., 2006; Skårderud,
2007; Allen et al., 2011). MBT is a psychodynamic approach in the sense that
the main instrument of change is the intersubjective transactions taking place
between therapists and patients. It is therefore possible to modify different psychodynamic practices to increase the focus on mentalizing, as kinds of
“­mentalization-oriented psychotherapies.” Bateman and Fonagy (2006) suggest
that all psychological therapies exert their influence through their effect on the
patient’s ability to mentalize. MBT cultivates this focus. Even though MBT in
the following sections will be described in a specialized format, many of the
principles presented here might be integrated into everyday psychodynamic
therapeutic practice.

Mentalizing, failures of mentalizing, and borderline personality disorder

MBT as day hospital treatment
Guidelines for MBT exist in two formats: as a long-term day hospital treatment
program and as an intensive outpatient treatment program. Originally MBT
was created as a day hospital treatment (Bateman & Fonagy 1999, 2001). The
study that documented the effectiveness of treatment was small with respect to
number of patients, but the treatment results were impressive. In all, 42 lowfunctioning borderline patients (mean GAF score = 35) in London, United
Kingdom, were randomized to either experimental day hospital treatment or to
the control condition (treatment as usual). The day hospital treatment program
lasted up to 18 months and was followed by outpatient group psychotherapy
twice a week for a further 18 months. Treatment as usual consisted of consultations with psychiatrists, pharmacological therapies, crisis teams, visits to emergency wards, admission to hospitals, or other type of day hospital treatment.
After 18 and 36 months, major differences between the groups became evident
in a wide range of variables: suicide attempts, self-injury, hospital admissions,
depression, anxiety, general symptom distress, interpersonal functioning, and
use of medication. Over the long term, the treatment also proved to be costefficient (Bateman & Fonagy, 2003). In a long-term follow-up, the differences
between the experimental and control groups were maintained at 8 years after
randomization (Bateman & Fonagy, 2008). A study in the Netherlands (Bales
et al., 2012) has also showed excellent results for MBT day hospital treatment.
Guidelines for MBT day hospital treatment are available in publications from
Bateman and Fonagy (2004, 2006). The treatment focus is upon attachment
behavior and mentalization skills and consists of a well-choreographed collaborative effort combining individual therapy and group therapies. The group
therapies are arenas for “mentalizing in practice.” Experiences from the groups
and from the treatment program in general, as well as from external life, are discussed in more detail in individual therapy sessions. The treatment framework
is an important element. Crisis plans are developed and close contact is maintained with families and health service professionals. Pharmacological treatment is followed up closely by a psychiatrist. In addition to the ­mentalization-based
interactional group therapy, patients also attend expressive group therapy sessions (psychodrama, creative group therapy, or group art therapy). More informal interaction takes place in connection with activities and excursions. A
psychoeducational mentalization group has been added recently.

MBT as intensive outpatient treatment
There have been claims that the treatment results by Bateman and Fonagy
(2001) are not necessarily attributable solely to the mentalization component

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of the complex day hospital treatment. Eighteen months of day hospital treatment involves a large number of potential change mechanisms. The precise
content of the treatment technique has also been unclear. In response to this
criticism, an attempt was made to purify MBT to an intensive outpatient treatment program. The treatment components included individual therapy for
1 hour a week and MBT group therapy once a week, for a period of 18 months.
The treatment started with psychoeducational MBT group meetings weekly
over the course of 2–3 months. The treatment technique is described in Bateman and Fonagy (2006).
MBT as an intensive outpatient treatment program was tested in a randomized study with 134 borderline patients where the control group was given
“structured clinical management.” The results showed that patients in both
treatments improved, but that the MBT group experienced a more rapid and
significant improvement on variables such as suicide attempts, hospitalizations,
symptoms, and social adjustment (Bateman & Fonagy, 2009). Outpatient MBT
has a higher potential than the more costly intensive MBT day hospital treatment program, which is meant for patients who score below GAF = 40. Most
borderline patients function on a somewhat higher GAF level. As long as
patients have some modicum of structure in their lives, for example, a place to
stay, some social network, not being involved in self-destructive, ongoing
addiction behavior, being able to adhere to a treatment agreement, and collaborating on a crisis plan, then outpatient MBT will usually be sufficient. MBT
requires a specialized team and is well suited for mental health centers.
Recently we have replicated the study of intensive outpatient MBT (Kvarstein
et al., 2015). Sixty-four borderline patients treated in the MBT program (since
2008) at the Department of Personality Psychiatry, Oslo University Hospital,
were compared to 281 borderline patients treated (from 1993 to 2007) in the
previous psychodynamic day hospital program. Patients in the MBT program
did better on all variables. The effect sizes on symptoms, interpersonal problems, and social functioning were nearly twice as large in the MBT program.
Moreover, the dropout rate was extraordinary low, that is, 5% during the first
6 months, compared to 42% in the psychodynamic program. This study was
also the first study to include MBT adherence ratings of the therapists, which
were found to be satisfactory.

Personality assessments, dynamic formulations, crisis plans,
and treatment structure
MBT requires the administration of customary personality assessments to map
the type and scope of personality pathology, for example, by SCID-II interviews.
During assessment, a MBT dynamic formulation should be developed in order

Mentalizing, failures of mentalizing, and borderline personality disorder

to consolidate the focus and therapeutic alliance. Patients at risk of self-­
mutilation or other kinds of gross self-destructive behavior (or violence toward
others) should be provided with a crisis plan. Moreover, one should carefully
design the treatment structure in order to enhance its overall containment capacity. This is of crucial importance for more poorly functioning patients. The
treatment structure should be easy to understand and it should convey predictable responses. The components are usually the following, although treatment
length may vary according to local conditions:
1 Assessments
2 Enhancing motivation and alliance, for example, by mentalization-based
case formulations
3 Supportive measures, for example, crisis plans
4 Mentalization-based psychoeducational group therapy, 12 sessions
5 Individual MBT, 1 hour weekly for 1–2 years
6 MBT-G for 2–3 years
7 Consultations with a psychiatrist on pharmacotherapy
8 Once a week (video-based) supervision for individual and group therapists
9 Staff meetings and meetings of individual and group therapists
10 Information (psychoeducation) for relatives
11 Information and meetings with cooperating health personnel
12 Follow-up treatment/consultations after termination of the MBT program.
These issues are dealt with in the manuals by Karterud and Bateman (2010,
2011) and they are discussed at length in the practical guidelines for MBT by
Bateman and Fonagy (2006). Since these issues do not directly concern the theory and practice of MBT-G, we will not elaborate on them here. However, it is
important to emphasize the importance of these elements as crucial parts of the
larger group/institutional matrix which holds and contains MBT-G as a specialized endeavor.
The group component of MBT has until now received less attention than
the overall principles and principles for MBT individual therapy. Useful discussions are to be found by Bateman and Fonagy (2004, 2006) and by Karterud
and Bateman (2012). The group therapy component is not any instant invention. It can be seen as an outgrowth of the common psychodynamic tradition
of the Western world and in particular by the group analytic tradition in
England/London. Group psychotherapy for borderline patients has always
been a controversial issue. We will therefore proceed with a short historical
account.

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Is group therapy good treatment for patients
with borderline personality disorder?
The literature on group psychotherapy and BPD is divergent. It is often emphasized that treatment of interpersonal problems constitutes the very strength of
group psychotherapy. Since such problems will show up in the here and now of
the group, they can be explored and be worked through in a direct manner.
Patients with BPD have gross interpersonal problems and for those reasons
alone, group psychotherapy should be well suited. It has also been claimed that a
two-person relationship tends to be too “hot” or “tight” for borderline patients
due to rapid arousal of transference and countertransference (cf. discussion on
attachment arousal in previous paragraphs). Accordingly it might be an advantage to “dilute” the transference by spreading onto multiple persons. Another
argument has been that borderline patients, due to their authority conflicts, have
more difficulty in accepting a confrontation from a therapist as opposed to peers.
Groups therefore may have the capacity to contain the contradictory inner representations of borderline patients and facilitate therapeutic transformation.
On the other hand, a psychodynamic group is an unstructured situation
where suddenly unexpected and dramatic events may arise and where the therapist has less control than in individual psychotherapy. Borderline patients are
emotionally unstable and often easily offended. They easily get captured by
emotional waves in the group or in subgroups which they identify with. Their
mentalizing ability rapidly declines during emotional arousal and they risk
ending up in destructive or meaningless exchanges with other group members,
including therapists. Therapists get caught up in the dilemma of how much
time and attention should be devoted to that particular patient relative to the
needs of other patients and the group as a whole. Moreover, borderline patients
also have a tendency to act on latent antagonisms in the group and promote and
perpetuate destructive splitting between persons and subgroups. Another scenario is that borderline patients get strongly emotionally activated, but hide it
and sit in the group with strong unmentalized and chaotic emotions which perpetuate after the group and require a lot of energy in the aftermath. At worst,
patients find no other solution than destructive acting out.
The clinical literature has discussed these dilemmas for more than 50 years,
gradually being supplemented by research. We find colorful narratives on “the
difficult patient in groups” (Roth et al., 1990). It is difficult to arrive at a clear
overview of this literature since different problems are often conflated. The most
important are: Do we focus on groups containing one or two borderline patients
but otherwise composed of patients with higher levels of personality functioning? Or do we talk about groups where everybody or most of the patients have a

Is group therapy good treatment for patients with borderline personality disorder?

BPD (in a wide sense)? Do we talk about group psychotherapy as a stand-alone
treatment (Verheul & Herbrink, 2007), or as a part of a more comprehensive
treatment program?
The early clinical literature dealt with borderline patients who participated in
ordinary psychotherapeutic groups. It soon became apparent that many of
them needed “something more.” Different therapeutic schools have come up
with different responses to what this “something more” should consist of.
Group analysis, developed by the pioneer S.H. Foulkes and other colleagues in
post-war London, was purist in the sense that the response to “too little therapy” was “more group.” To establish cooperation with other (individual) therapists was considered a defeat for the group in the sense that the group thereby
only “exported” problems that it did not dare to approach itself. Group analysis
therefore advocated twice-weekly group sessions, while one session a week was
considered standard. Regrettably, there is no comparative research on this matter. We therefore do not know the effect of a twice a week format compared to
alternative treatment strategies.
Here, as elsewhere, the Americans have been more pragmatic. They are traditionally less concerned by ideology than “what works.” Patients are obviously
different. It might not be that all patients in a group needed more, but that some
did, and perhaps not for the entire treatment course, but for intensive periods.
Then it would be more appropriate to add something different, like individual
therapy to the more vulnerable patients, rather than an extra group session each
week. How should one construct such a concurrent treatment?
Concurrent group and individual therapy appeared in the literature through
the work of Wender and Stein in 1949, when they described their experiences
from an outpatient clinic in New York. Since this publication, two books on
concurrent psychotherapy (Ormont & Strean, 1978; Caligor et al., 1984) have
been published, as well as a number of articles summarized by Karterud
et al. (2007).
According to Porter (1993), concurrent group and individual therapy is an
effective and specialized treatment form that has its own indications, contraindications, therapeutic mechanisms, developmental stages, and technical requirements. When the therapy is conducted properly, there should be a synergistic
effect since the two components complement each other and address different
needs. Group therapy is particularly suited for exploring interpersonal problems,
while individual therapy is better suited for exploring intrapsychic phenomena.
Early on, concurrent therapy was viewed as being especially appropriate for treating borderline patients (Stein, 1981). However, there is always a danger of a split
developing between the different therapists and the different formats, and this has
been a central theme in the literature (de Zulueta & Mark, 2000; Kegerreis, 2007).

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The terms “combined” and “conjoint” psychotherapy are commonly used for
this type of therapy. It is customary to refer to combined psychotherapy when
the same therapist conducts both the group and individual therapy. In conjoint
psychotherapy, different therapists are involved. The risk of developing a split
is a strong argument for combined therapy, in which the same therapist maintains full control. In practice, however, conjoint therapy is the most common
pattern. One reason for this is that not all individual therapists are likely to
master group therapy and vice versa. There are also good arguments for sharing the therapeutic burden when treating demanding patients. There is no
research that has investigated differential effectiveness between conjoint or
combined therapy programs.
In conjoint psychotherapy, collaboration between the therapists is a critical factor. The collaboration requires a fundamental respect for the unique
elements of the different therapies and a personal and professional respect
between the therapists. Many patients will, over shorter or longer periods,
devalue one of the components and have a tendency to idealize the other.
Even as therapists, we all have remnants of unmentalized narcissism that
tempt us to accept, implicitly or explicitly, such a split if we are so lucky to be
the idealized party. In practice, group therapy is most often the component
to be devalued because it is the most complicated dynamically and puts larger demands on the patient’s mentalizing ability. In groups, each patient has
to share the attention and devotion of the therapist(s) with other group
members. Another reason is that insulting and humiliating episodes are
more likely to occur in group therapy sessions than in individual sessions. In
combined treatment processes, we recommend that the individual therapist
asks about recent group experiences at practically every session. The therapist must also go closely through episodes in which the patient has felt himself
or herself misunderstood, overrun, ignored, or poorly treated. These episodes are grist for the therapeutic mill. It is indeed by working through such
episodes that the patient’s mentalization ability may be challenged, stimulated, and improved over time. The patient’s experiences in group therapy
must be a central focus of the individual therapy, on an equal footing with
relationships to other attachment figures.
Even if there is a rich clinical literature on concurrent psychotherapy, there is
scarce evidence for the claim that it is better than one modality alone, even for
borderline patients. To our knowledge there is only one study that has compared concurrent versus individual treatment with the same approach. Ivaldi
and coworkers (2007) compared outpatient combined (same therapist) individual- and group therapy according to guidelines for “cognitive-evolutionary
therapy” for patients (N = 85) with PDs (whereof BPD was in majority) with

Is group therapy good treatment for patients with borderline personality disorder?

individual “cognitive-evolutionary therapy” alone (N = 24). The results favored
combined therapy on a range of outcome measures, like attrition, GAF scale,
symptom reduction, quality of life, and self-harm. However, one cannot make
any firm conclusion from this study. The patients were not randomized and
there might have been systematic differences between those who were recruited
to the different treatment modalities. On the other hand, this study indicates
that concurrent psychotherapy, when conducted according to certain guidelines, may have some advantages for borderline patients.
What about group psychotherapy as a stand-alone treatment? The evidence
here is also divergent (Verheul & Herbrink, 2007). It is important to distinguish
between groups where all patients have a PD and groups where only some have
a PD. Lorentzen and coworkers (2004) found that patients with mild to moderate PD (measured by GAF, Symptom Checklist-90-Revised (SCL-90-R), and
Inventory of Interpersonal Problems (IIP) scales) had a good outcome by group
analytic psychotherapy. However, 40% of the patients in those groups did not
have any PD. Many clinicians contend that those patients are key actors with
respect to group cohesion. They argue that it is the patients with little personality pathology that contribute the most to the culture of the group, to the benefit
of patients with more serious pathology who are thereby contained and helped
to explore their pathology in a group atmosphere which is more benign than
their own inner world.
There is some evidence for this argument. Piper and coworkers (2007) compared the effect of different types of short-term group psychotherapy for
patients with different quality of object relations (QOR). The QOR will most
probably correlate strongly with mentalizing ability (or RF). Piper and coworkers (2004) had earlier found that QOR was a moderator for treatment effect,
implying that patients with high QOR gained the most from insight-oriented
psychotherapy while patients with low QOR gained the most from supportive
psychotherapy. However, when they analyzed the material across groups, they
found that mean QOR on the group level, regardless of what kind of group, was
significantly associated with outcome. Clinically this indicates that every kind
of well-functioning group needs some patients with fairly mature QOR because
it most probably promotes higher-level group processes. This is in accordance
with general wisdom among group therapists. When adding a new member
they will prefer someone with higher personality functioning. According to the
findings of Piper and coworkers, this will be for the better for all patients since
it will raise the mean QOR in the group. And conversely, if there is a high mean
QOR beforehand, the group can afford to add a patient with lower QOR, since
it will have a low impact on the mean. In other words, stand-alone group psychotherapy may be beneficial for some patients with PD if most of the other

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patients are healthier. According to this logic it is counterintuitive to develop a
psychotherapy group with PD patients only.
The work by Piper and coworkers (2007) is suggestive. However, to prove it
would be very difficult. A persuasive study would need 15–20 well-functioning
groups that were willing to include two to three patients with more serious personality pathology of borderline type. It is possible, but difficult to see where
such a study could be undertaken or how it could be funded. For these reasons,
naturalistic studies and in-depth case studies need to be taken seriously.
It is mainly such other evidence which is highlighted when authors of major
review articles emphasize the positive aspects of group psychotherapy for patients
with PDs. Piper and Ogrodniczuk (2005) maintain that research evidence indicates a positive effect of group psychotherapy for all categories of PDs, except
paranoid, narcissistic, and ASPD. They assert that groups are used too seldomly
in the treatment of patients with PD. The contributing authors of the prestigious
Gabbard’s Treatments of Psychiatric Disorders (Gabbard, 2007) also have a general
positive attitude to group psychotherapy. A much-cited study concerning BPD is
that of Munroe-Blum and Marziali (1995). Time-limited interpersonal-oriented
group psychotherapy (which is described more extensively in Chapter 2, in ‘Similarities and differences between MBT-G and other types of group therapy’) was
compared to dynamic individual psychotherapy. Both therapy conditions displayed about the same good effect on dysfunctional behavior, symptoms, interpersonal problems, and social adjustment. Wilberg and coworkers (2003) also
found good results from group psychotherapy for borderline patients in a followup treatment after day hospital treatment. Budman and coworkers (1996) found
good effects for a diversity of PDs. In addition, there are meta-analytic studies of
psychotherapy (including group psychotherapy) which convincingly display significant effects for PDs (Leichsenring & Rabung, 2008).
A reasonable conclusion of the above mentioned findings seems to be that
somewhat better functioning borderline patients (e.g., GAF score > 50) most
probably benefit from participating in groups where the majority of the patients
have a higher level of personality functioning. However, it is still unclear if such
treatment is better or worse than individual psychotherapy.
Psychotherapy is for most patients and conditions an efficient mode of treatment. However, like other potent remedies, psychotherapy may also have side
effects and it may be harmful. Borderline patients are more emotionally reactive
than most other patients and this makes them also more vulnerable to negative
effects of treatment. They risk being victims of “iatrogenic harm” (“caused by
the doctor/iatros”). Their high drop-out rate is most likely a reflection of this
vulnerability. In published studies, their drop-out rate varies between 17% and
67% (Hummelen et al., 2007).

Is group therapy good treatment for patients with borderline personality disorder?

In order to explore this, we (Hummelen et al., 2007) performed a qualitative research study at the Department for Personality Psychiatry, Oslo University Hospital, on dropouts from groups where all patients suffered serious
personality pathology. We conducted in-depth interviews of eight (out of 29
patients who dropped out during the years 2000–2003) female borderline
patients and their therapists according to the qualitative research principles
of Kvale (1997). The patients’ (and therapists’) responses were organized in
ten themes: for example, “difficulties during the transition from day hospital
to outpatient group psychotherapy,” “the group therapy stirred up too much
distress,” “group therapy alone was insufficient,” “the patient was unable to
benefit from group therapy,” and “poor motivation for change.” The most frequent reason for drop-out was variations of the theme “group therapy stirred
up too much distress.” All patients reported “activation of strong negative
emotions” and seven out of eight reported “too much rumination” in the
aftermath of the group sessions, meaning that they were left alone with feelings that were difficult to digest. The therapists reported the vulnerability of
patients as the most frequent problem. The patients described their emotional problems as “tough and difficult” and being associated with anxiety,
anger, vulnerability, sadness, irritation, being humiliated, guilt, powerlessness, shame, disappointment, rejection, frustration, and contempt. The anger
most often concerned the therapists and was related to their experiences that
the therapists seemingly did not take seriously their difficulties in life in general and within the group. The interviews revealed that the therapists often
were somewhat surprised when they later realized the magnitude of the
patients’ negative emotional experiences.
The patients displayed considerable problems with how to benefit from the
group therapy format. They found it difficult to describe any meaningful purpose for the group and how they could make use of it for working with their
personal problems. They found it difficult to disclose personal matters, often
due to a fear of disappointment and rejection and being overwhelmed by own
emotions, or because they were afraid that other group members, towards
whom they harbored strong and ambivalent feelings, would be overwhelmed or
hostile. Some were afraid to make other patients suicidal and that they would
carry such fears the whole week until next group session. Some considered fellow patients as too vulnerable or too superficial or having no motivation for
change. They often experienced themselves as outsiders and had little or no
sensation of being part of a meaningful collective project, that is, their sense of
group cohesion was low or absent. They had seldom reflected on their own contribution to low group cohesion, for example, that they on average showed up at
only every second group session.

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Overall the patients experienced the therapists as too passive and too little
engaged. They expressed a wish for:
1 therapists that were more helpful in explaining how one could benefit from
group therapy
2 therapists that were more humble, for example, that could admit own errors
and shortcomings
3 therapists that clearly signaled that they had noticed the distress of the
patients and who did something to alleviate the pain.
The patients clearly reported more and stronger negative emotional reactions
than the therapists had realized. They described experiences and consequences
of “mentalizing collapse” which the therapists had overlooked. The therapists
had experienced several of the patients as “well functioning” and “quite mature”
and had been somewhat surprised when some of them dropped out. In hindsight, they realized that they had been deceived by the “mask” which some of
the patients carried.
This study demonstrates, in its condensed format, how borderline patients frequently activate negative emotions and negative self-states in dynamic groups;
that these emotional reactions often are not sufficiently mentalized; that therapists tend to overestimate patients’ mentalizing capacities; that patients may
enter a negative spiral of feeling neglected, misunderstood, and not belonging;
and harbor an increasingly skeptical attitude and poorly articulated critique that
together cause a therapeutic breakup. In such a negative interpersonal spiral,
withdrawal will carry an aspect of self-protection. However, such ruptures also
represent tragic repetitions of previous relational breakups, which are then
enacted in the interpersonal field of the group, including the therapist. However,
to blame the patients is too simple. Professional treatment of patients with BPD
should have at its disposal strategies that can process such enactments and counteract their destructive spiraling effects. Such strategies should be embedded in
the structure as well as the content of the treatment.
Most of the literature which has been referred to in this chapter concerns
patients with moderate or even mild borderline pathology. More chaotic
patients with little or no social network, being out of a job and homeless, with
frequent episodes of self-harm and suicidal behavior, drug addiction, violence,
and other kind of acting out, have not been regarded as suitable candidates for
group psychotherapy. This was surely one reason why therapists started to
experiment with other approaches. The prospects were so poor that there was
nothing to lose. During the 1990s, there surfaced radically new ways of treating
borderline patients. The results were remarkably good (Linehan et al., 1991,
1993; Bateman & Fonagy 1999, 2001).

Is group therapy good treatment for patients with borderline personality disorder?

Dialectical behavioral therapy (DBT) was developed by Marsha Linehan
and coworkers (Linehan, 1993a, 1993b). DBT was initially designed for self-­
harming females with borderline pathology in an outpatient format. However,
it has been expanded to include a range of disorders, for example, bulimia and
drug addiction, and the format has been adjusted to inpatient treatment as well
(Linehan et al., 2007). DBT is a concurrent treatment consisting of an individual and a group component. It is thoroughly manualized and patients receive
psychoeducation and home lessons according to cognitive behavioral principles and a defined schedule. For our purpose, we should note that the group
therapy component of DBT is not based upon free group association, but construed as a “skills training group,” with a program which is closely integrated
with the treatment as a whole. Patients are exposed to a program of emotion
regulation and the development of interpersonal skills. As described in Chapter 2, DBT skills training groups are radically different from MBT-G.
MBT also evolved during the 1990s. While DBT was the response from the
cognitive behavioral field to the challenges posed by the borderline pathology,
MBT was the response from the psychodynamic tradition. Both therapies are
combined therapies. Other common features are a concise theory of the essence
of borderline pathology, a structured treatment program that is consistent with
this theory, clearly expressed treatment guidelines, treatment designed as teamwork, as well as guidelines for therapist cooperation and supervision. All the
available evidence for groups as a treatment modality for BPD has been scrutinized by professional and state quality control agencies in the United States and
United Kingdom (American Psychiatric Association, 2001; NICE, 2009). The
conclusion is that group therapy is recommended as part of broader treatment
programs for BPD. The effects of DBT and MBT weigh heavily in the data.
Compared to psychodynamic group therapy, MBT-G is a more structured
modality. In MBT-G, one installs strategic measures in order to counteract
aggressive escalation and collective group regression, influenced by the fact
that emotions are contagious. Measures are also implemented to facilitate verbal exchange with all patients and to reflect upon the experience of sequences
that involves different patients. This aims to counteract the problem of patients
leaving group sessions with unmentalized emotions. Moreover, MBT-G has a
clear focus for the treatment (enhance mentalizing abilities) and prioritizes
exploration of interpersonal encounters. MBT-G evolved in London, United
Kingdom, the hotbed of group analytic psychotherapy (Foulkes, 1948, 1964,
1975). It was shaped by the needs of long-term (18-month) day hospital treatment for extremely poorly functioning patients. Later it was modified by experience and the needs of intensive outpatient treatment of somewhat better
functioning patients, but still in the serious realm (GAF score = 40–50). It was

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further modified when being exported to other countries, like the Scandinavian countries, which this manual testifies. However, the core group analytic
elements remain. Compared to group analysis, the main purpose with the
therapeutic modifications were (1) to obtain more control of the group processes, (2) to maintain a focus on mentalization, and nevertheless (3) benefit
from spontaneous interpersonal transactions.
Dynamic group psychotherapy is by essence “psychotherapy through the
group process” (Whitaker, 1981). In addition to knowledge about personality
pathologies and their treatment, one needs thorough knowledge about group
dynamics and in particular the phenomena of group belonging, collective
group regressions, why emotions are “contagious,” and an understanding of
dominance, social withdrawal, and subordination. This volume is not a textbook or manual for group psychotherapy in a general sense. However, since an
evolutionary perspective most often is lacking in other volumes, we find it
necessary to take a detour before we dive into the details of BPD and MBT-G.

Group dynamics and evolution
Group scholars often contend at the beginning of their volumes that man is a
“herd animal” (Bion, 1961) or “social to the core of its being” (Foulkes, 1975).
There are seldom references to evolutionary evidence or specific animal studies.
However, such evidence was to a large extent lacking when Bion and Foulkes
constructed their theories. What exactly does it mean, that man is a thoroughly
social, herd animal? The last decades have witnessed exciting new evidence and
a series of conceptualizations which ought to have a significant impact upon
our understanding of the fundamentals of group dynamics. The most important contributions concern:
1 group affiliation among social animals and in particular higher primates
(Cheney & Seyfarth, 2007)
2 primary emotion systems (including attachment) among all mammals (Panksepp, 1998) and the mirror neuron system (Rizolatti & Arbib, 1998)
3 the evolution of thinking (Tomasello, 2014) and modes of mentalizing among
higher primates, young children, and children older than 4–5 years and their
consequences for self-consciousness (Bogdan, 2010), culture (Tomaselllo, 2014),
self-cohesion, and identity (Fonagy et al., 2002).
Group behavior in itself, for example, individuals as being observed in a group
setting, tells us little about the current mentalizing level of the protagonists. It is
fully possible to behave in an inconspicuous manner in a group without mentalizing that much, as well as being engaged in what goes on. In a therapeutic

Group dynamics and evolution

group, it is easy to overestimate the current level of mentalizing among its
members. In the following we will try to explain why that is so.
Basic modes of social behavior are linked to the primary emotions. As
explained in the manual for mentalization-based psychoeducational group
therapy (and taught to patients in MBT programs) (Karterud & Bateman,
2011), primary emotions concern (1) SEEKING (interest, appetite, and exploratory behavior), (2) FEAR, (3) RAGE, (4) LUST (sexual), (5) CARE (and love),
(6) SEPARATION DISTRESS (including sadness), and (7) PLAY (joy) (Panksepp, 1998). These are behavioral programs coupled with modes of subjective
awareness (feelings) which are found among all mammals. Basically we do not
need any ability for mentalizing in order to engage in and exploring the surroundings, to protect ourselves against predators, to attack rivals, or to find sex
partners. However, within complex societies it helps a lot if these behavioral
programs are modified by mentalizing!
Among Homo sapiens, group membership may be based upon rational deliberations alone. One does not need to be particularly fond of others in order to
cooperate in a scientific committee. However, therapeutic groups exploit the
mammalian ability to stick together and care about each other through emotional bonds.
Among mammals, social complexity increases with the different species of primates until one reaches the chimpanzees and it culminates with Homo sapiens.
Even among Homo sapiens it is the emotional bonds that ultimately keep most
groups united. These bonds are most probably derivates of the attachment system which underpins qualities such as friendship, group loyalty, and group cohesion, abilities that transcend pure rational deliberations. Attachment evolved
originally as kinds of transactions between mother and child, but was gradually
extended to include other family members, as well as friends and clan members
(Hrdy, 2009). Attachment bonds are founded in rather simple behavioral programs where fear signals and distress calls from the child elicit attachment behavior from the mother. Mothering behavior is mediated by the neuropeptide
oxytocin (Panksepp, 1998). Successful attachment behavior is coupled with positive emotions, like well-being and calmness following stress regulation, coziness,
and love, which are emotions that involve the neurotransmitter dopamine and
the reward system. When the attachment bond between child and their caregiver
develops and expands in scope and significance, their inner (object) representations of each other will become associated to the reward system so that merely
the thought of the attachment figure may promote experiences of well-being.
The social anthropologist Sarah Hrdy (2009) suggests that Homo erectus
(around 1.5 million years ago) extended care and raising responsibilities of
infants to other family members and their allies and thereby started the journey

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towards “it takes a village to raise a child.” Evidence suggests that men during
this period became increasingly monogamous. There are reasons to believe that
the presence of several attachment figures will enhance the ability to establish
emotional bonds to other than core family members, thus paving the way for
group cohesion in a more general sense.
However, cohesion in groups that extends to small family groups or small
alpha-male colonies, involves more than positive emotional ties. Higher primates, such as chimpanzees, who may live in groups counting 50–70 animals,
will most often adopt a social structure that is highly hierarchical. Lowerranked individuals are regularly exposed to harassment, offered only remnants
of food, and have to accept the poorest areas of land. The alpha male, on the
other hand, can enjoy the glory of recognition, sex monopoly, the best food, and
access to the most resource-rich regions of the territory. Selfish, demanding
attention, harassing, and arrogant—this is probably the origin of narcissism
(Karterud, 2010). What, then, connects lower-ranked and harassed animals to
these groups? After all, when necessary, they react to the same alarm calls, to
flight signals, and assemble in the group and participate in the periphery of the
group’s undertakings. The most likely explanation for the participation of
lower-ranked individuals in the group concerns the requirement for a basic
need of safety (de Waal, 2009). To belong to a group provides a survival benefit
which outweighs the drawbacks of living in the resource-poor sections of the
community. In the group, one is above all safer with respect to predator attacks.
There is more food due to rudimentary cooperation and some modicum of
sharing despite social rank. In addition, there are social needs to be met. If rhesus monkeys are forced to choose between food and company with other monkeys, they choose the second option until the hunger becomes severe. They’d
rather be hungry in company with others, than satisfied alone!
Male aggression is a major challenge for larger primate groups. Male rivals
may kill or mutilate each other or kill offspring that they have not fathered. This
must be mitigated lest it threaten the very existence of the group by chaos, anarchy, and fragmentation. Social norms are therefore necessary as well as a way of
maintaining “laws” and mechanisms for promoting reconciliation. Monitoring
aggression (as well as subordination) is learnt during upbringing, for example,
through rough and tumble play (Panksepp, 1998). Alpha males may guarantee
law and order, while elderly females of high rank often initiate conflict resolution through reconciliation (deWaal, 2009). A hierarchical albeit “unjust”
social system seems better than chaos and anarchy.
It turns out that individuals in a group of 50–70 primates can identify each
other. Moreover, they can also detect the social rank of others. Notwithstanding social rank however, they react towards strangers in quite different ways

Group dynamics and evolution

compared with encountering fellow group members. Stranger fear seems to
have evolved as a significant mode of protection. A basic survival skill is to be
able to distinguish strangers from group mates.
Group cohesion is thus a composite phenomenon. It concerns attachment, but
also safety, power, social dominance, and subordination.
Field studies of higher primates during recent decades have disclosed surprisingly sophisticated group behavior (Cheney & Seyfarth, 2007). However, it
is still unresolved whether, or to what extent, they mentalize. Since chimpanzees (and baboons) can identify each other and have some kind of knowledge
of which family individuals belong to, and their social rank, it must imply that
they have inner (object-) representations of each other. However, what is the
nature (or quality) of these object representations? In the language of John
Bowlby, what do a chimpanzee’s inner working models of the mind look like?
Are the object representations invested with a mental life of their own in terms
of desires and needs? Or are they more like images of some kind of functional
organisms who occupy a social space and who can be manipulated with simple
means? Within the “Theory of Mind” tradition, there are tests (“false belief ”)
on the ability to conceive that another mind has its own representations, separate from one’s own, that is, that there is an independent mind out there with
its own perspective on the world (Baron-Cohen et al., 1993). There are specialized versions of these tests, adapted for different animals. The matter is still
controversial, but most scholars favor the opinion that chimpanzees, for example, do not accomplish this, implying that their images of others (inner object
representations) do not include “mental functions” in the sense which humans
attribute to others.
However, there have been extended discussions on how to understand the
phenomenon of cheating. Cheating has often been observed among primates,
so there is no doubt that this is a kind of behavior they can manage. On the
“YouTube” website, there is a video-recording of a low-ranked rhesus monkey
who has caught a (delicious) fish and who seems to fear that higher-ranked
members of the flock will confiscate the fish if they become aware of the catch.
The monkey then releases a false predator alarm call which causes the rest of the
group to flee in panic. Alone with the fish, this previously ill-treated monkey
can enjoy a gourmet meal in peace and quietness! The question now is if our
monkey friend harbored inner representations of group mates as beings who
become afraid when they hear alarm calls, or if there are representations of
beings that are inclined towards a certain behavior given certain stimuli. Most
scholars agree that cheating behavior in itself does not presuppose mentalizing.
It presupposes an ability to predict some kind of behavior among others, but
not necessarily “mind-reading.”

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However, there are several mental operations that primates do master and
which can be conceived as precursors or preconditions of cognition and mentalizing. They are summarized by Baron-Cohen and Belmonte (2005), who
also suggest their brain localization. Primates seem to harbor an “intention
detector mechanism” which premier job is to differentiate living creatures (with
intentions) from not-living organisms (e.g., to differentiate between a snake
and a branch), and to identify the most typical intentions (e.g., friendly, hostile,
going for sex?). Moreover, Baron-Cohen and Belmonte suggest an “emotion
detector mechanism” which can differentiate the most common (primary)
emotional states among other animals. Primates are aware of gaze direction of
other animals and have an ability for shared attention which is a precondition
for cooperation towards joint goals. Furthermore there is a system for empathy
which is supposed to facilitate more advanced social systems. The faculty of
empathy seems to be connected with the ability for self-awareness. This ability
is present among chimpanzees (as well as dolphins and elephants) (deWaal,
2009). These animals recognize themselves in a mirror and they are curious
about their mirror image. Chimpanzees also have the capacity for interpreting
certain types of intention among other animals, in a situation-bound manner.
For example, female chimpanzees may understand when male apes are in the
process of “pumping up” for a fight. They seem to interpret correctly the reluctance for reconciliation among male rivals and they might in such situations
behave like mediators, something that benefits the group as a whole. However,
this capacity for interpretation is situation-bound and by this they are different
from individuals who possess a Theory of Mind in a more general sense, meaning harboring an inner working model of the mind of others. They might therefore better be described as “naive behaviorists” than “naive psychologists”
(Bogdan, 1997, 2000). Chimpanzees understand certain goals and intentions
of others, but not the phenomenon of false beliefs. Summing up the state of the
art of Theory of Mind research, Call and Tomasello (2008, p. 187) write “Our
conclusion for the moment is, thus, that chimpanzees understand others in
terms of a perception-goal psychology, as opposed to a full-fledged human-like
belief-desire psychology.”
However, even naive behaviorists are thinking behaviorists. Based upon a
range of empirical studies, experts on primate cognition conclude that chimpanzees perform mental operations that have to be accepted as cognition
(Tomasello, 2014). They seem to possess mental images that are processed with
respect to goal attainment. What qualifies for the label “cognition” is that the
process contains the following elements: 1) schematic cognitive representations, 2) the ability to make causal and intentional inferences from these cognitive representations, and 3) monitoring oneself during the decision-making

Group dynamics and evolution

process. The entire process concerns the ability to reach thoughtful behavioral
decisions which goes beyond the ability to perform “offline” simulations of
potential perceptual experiences. Primates communicate with gestures and
sounds. However, what chimpanzees seem to lack, according to Tomasello
(2014), is shared intentionality which goes beyond the capacity for shared attention, that is, attending to the same object. Shared intentionality lies at the heart
of the extensive collaboration which characterizes subjects of the Homo sapiens
species. It evolved probably around 2 million years ago (Homo erectus) as a
selection of capabilities that favored collaborative foraging. Shared intentionality is a crucial step in the evolution of Homo sapiens. It implies the advent of a
“we” and later of collectivity. In shared intentionality, “we” “is” the agent. When
we do things together, joined by shared intentionality, we have come to terms by
a mutual agreement where I know that you know (and vice versa) that the
nature of our project is basically cooperative, from planning through execution
to sharing of outcome. Such kinds of projects presuppose the capacity for intersubjective (and thereby self-) monitoring, for example, the need to know when
we have agreed upon something, if we have agreed upon the same project, and
where you are and where I am in relation to you (intentionally and emotionally)
during the execution.
When group theorists speak about humans “being social to the core of his/
her existence,” they mostly refer to phenomena that belong to the faculty of
shared intentionality, for example, related to emotional attunement and implicit mentalizing. One cannot help being affected by other subjects and one cannot help interpreting others (and consequently monitoring oneself). These
abilities belong to the fabric of the human self.
Shared intentionality presupposes communication (vocalization and gestural
signs), but not verbal language. Verbal language evolves, according to Tomasello (2014), in concert with (group) cultural practices that depends upon collective intentionality. Collective intentionality concerns matters of interest for
the group as a whole, not only for two (or a few) persons collaborating around
foraging. Verbal language evolves as a tool for handling communal and political
(group) affairs. Language is the common agreed-upon and culturally sanctioned set of signs, metaphors, and inference rules that come to represent the
“common ground” of the group. Since language rules are culturally sanctioned,
and are not the invention of any particular subject, verbal utterances may
acquire the appearance of “objectivity.” Inferences made according to the group’s
standards for rationality makes it possible to assert “how things really are.” In
Tomasello’s words (2014, p. 108):
And so with modern human such things as intentional states, logical operations, and
background assumptions could be expressed explicitly in a relatively abstract and

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normatively governed set of collectively known linguistic conventions. Because of the
conventional and normative nature of language, new processes of reflection now took
place not just as when apes monitor their own uncertainty in making a decision, and not
as when early humans monitor recipient comprehension, but rather as an “objectively”
and normatively thinking communicator evaluating his own linguistic conceptualization as if it were coming from some other “objectively” and normatively thinking person. The outcome is that modern humans engage not just in individual self-monitoring
or second-personal social evaluation but, rather, in fully normative self-reflection.

Fully normative self-reflection is another word for explicit mentalization. When
did it enter the historical scene? Estimates are obviously highly speculative, but
genetic data (from the FOXP2 gene) suggest that brain structures that are essential for language can be traced back to around 300,00 to 200,000 years before
present time (BPT) (Coop et al., 2008). However, language in the pragmatic
sense of Tomasello (and Wittgenstein) developed slowly in concert with developments in group cultures. There are reasons to believe that due to general
development and evolution, migration, and climate change, complexities of
group living took a new turn around 35,000 BPT among settlements of Homo
sapiens (the Gravettian culture) in the Caucasian region (Finlayson, 2009).
These developments in language and cognition might be the seeds of the IndoEuropean language. The next event that took language and cognition to new
levels and sophistication was the invention of written language which took
place around 5000 years BPT in the Middle East region of Eufrat and Tigris that
hosted the agriculture revolution.
When does the individual acquire the ability for explicit mentalization? As
outlined in the first chapter, it occurs through the “cognitive revolution” of ages
4–6 years. With the capacity for explicit mentalization, that is, being aware of
different mental perspectives on the same phenomena and by that being able to
consider oneself from the perspective of another, the (representational) self is
born. The faculty of imagination is an extension of this capacity for offline
self-reflection. Through imagination the subject is capable of considering multiple future scenarios in the light of the past and present and choosing the most
appropriate path.
One can also question why do individuals develop the ability for explicit mentalization? Is it a preprogrammed genetic script that just unfolds independently
of the environment, like the anatomy of the heart? Radu Bogdan (2013) makes
a strong case that it is not. Human children begin their life in sociocultural captivity. And they cannot help but try to find out the rules and meaning of their
sociocultural surroundings in order to master it and becoming informed members of it. The greatest challenge is to come to an understanding of the sociocultural as a matrix of mental states and mental processes. To do so, they activate

Group dynamics and evolution

their innate capacity for intuitive psychology (implicit mentalizing) and mental
rehearsal. By pretend play they engage in sociocultural learning of adult roles
and games (mother–child, doctor–patient, fighting in wars, etc.). “Children
cannot help but imitate adults (they are imitation machines), and once stimulated, cannot inhibit the action schemes inspired by the adult behaviors, especially in novel sociocultural contexts” (Bogdan, 2013, p. 119). However, more
complex group dynamics call for sociopolitical strategizing. By around the age
of 4–5 years, most children are mentally and neurobiological ready for a larger
world and will adapt to the pressures of juvenile sociopolitics.
Strategizing means:
mentally figuring out and metamentally rehearsing offline how to handle the thoughts,
attitudes, utterances, and actions of others, and in response, one’s own. Differently said,
strategizing is metamentally rehearsing offline how to reach one’s goals by means of the
mental states and actions of oneself, either altruistically, cooperatively, or with ulterior
selfish motives. It is primarily the mental states of others and oneself used projectively
as means to ends that define strategizing, and in turn foreshadow Imagining.
Examples of strategizing, so construed, include: rehearsing what to say and what to
do, thinking how others think of you; planning how to relate to others and how to react
to their reactions; deliberate and planned lying or obfuscation; gossip, including selfinvolving gossip; elaborate stories or communicative exchanges mixing reports of one’s
mental states with those of others; justifying publicly one’s motives, reasoning, and
actions; autobiographical recitations; fantasizing about what one could do in the future
in relations to others; self-evaluation and criticism as well as self-advertising; defending
one’s opinions; interpersonal diplomacy; and many other exploits along the same lines.
(Bogdan 2013, p. 176)

By not adapting, or adapting poorly, to this world of juvenile and later adult
sociopolitics, one’s capacities for explicit mentalization will stay behind. “A
training ground for mentalizing” is the major slogan for MBT-G. This will be
explained in detail later. Let it suffice here to alert the reader to the references to
the natural course of self-development. In childhood, there are sociocultural
grounds for pretending and imagining, as well as (training) grounds in the surrounding social matrices. Group therapy has to offer a similar ground and
stimulate and cultivate the desire for entering this ground in a renewed attempt
to develop the capacity for explicit mentalizing.
According to Tomasello and Bogdan we are fundamentally group beings by
the fact that our BrainMind (Panksepp & Biven, 2013) is shaped by the group
from the very beginning and that the tools we use (language and reason) have
their origin in groups. Tomasello and Bogdan are less concerned by the emotional part of the story. As well as being predisposed for rational group behavior
by being explicit mentalizers, we are equally disposed for primitive group
behavior by the fact that we are carriers of the apparatus for primary emotions.

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We cannot help but react emotionally to our surroundings. Moreover, we cannot help but be affected by the emotions of others in a group.
It always make a strong impression when one witnesses a flock of several
thousand birds taking off almost simultaneously as a flight reaction because of
perceived danger, or when a huge herd of grazing antelopes suddenly sets off.
The fear that generates the flight spreads like lightening through the flock.
Partly it will depend on a shared reaction to the same alarm call. However, we
also assume that mirror neurons (or their precursors) are involved. Mirror
neurons were initially detected among rhesus monkeys by di Pellegrino and
coworkers in 1992 and evidence strongly suggests that they also exist among
humans (Rizzolatti & Arbib, 1998). Mirror neurons in one’s own brain fire
when one observes certain behaviors executed by others, as if the actions were
one’s own. The theory suggests that mirror neurons subsume the immediate
emotional resonance that occurs between people and that they are essential for
intersubjective transactions. Imitation starts literally at birth—an infant just a
few days old can mimic movements which the mother performs with her
mouth and tongue. We witness here an innate program at work. Comparable
emotional resonance is thought to be a major cause of emotional contagion in
groups.
The group literature contends that the contagious effect increases with the
size of the group. Panic in large crowds is an example. The prime tool of Hitler
in his fight for power in Germany during the 1930s was carefully designed mass
rallies. One gets a taste of it when being in the midst of supporters during a football match. It is difficult to remain untouched. Viewed from outside it is as if
people in an excited crowd are hypnotized. An important topic in the group
literature is the question of what causes such mental states. Freud (1921)
objected to the view that it could be explained by (mass) suggestion. He contended that when members of a group/crowd took the one and same object as a
leading figure (the group leader or the leading idea), which he labeled ego ideal,
the group members would thereby identify with each other and so become
more open to external influence. Today the pendulum has swung more in the
direction of mirror neurons. However one conceptualizes it, a major argument
for including working with large groups in the training of group therapists is
that the candidates will experience the emotional power of such groups and
what it does to one’s mentalizing capacity (Karterud, 1999).
However, the same mechanisms are also operating in small groups. That is
the main thesis of Bion in his classical text Experiences in Groups (1961). Bion
observed that group members’ rational efforts at figuring out what happened
between them in the here and now were systematically undermined by collective forces in the group. He labeled these forces “basic assumptions.” The reason

Group dynamics and evolution

for this label was that therapeutic groups often seemed to behave as if they had
come together for quite some other purpose than expanding their understanding and insight. It was as if they were gathered in order to:
1 fight or flee from something, or
2 be taken care of by an omnipotent leader, or
3 devote themselves to enthusiastic dreams about future salvation from all
pain and distress.
The three basic assumptions were therefore labeled:
1 fight–flight
2 dependency
3 pairing.
According to Bion, there is no need for any special knowledge or education in
order for people to “cooperate” on basic assumptions in groups. Group members are victims of mechanisms that operate on a “proto-mental” level. However, individuals differ as to how easily they get caught up in the basic assumption
function. Some are more readily recruited to the fight/flight group (e.g., borderline patients), while others are more disposed to the dependency group. In
Bion’s terms: individuals have different valence for different basic assumptions
(Karterud, 1989).
These are realities which all group therapists have to take into consideration.
Group therapists can through structural actions (e.g., time, space, contracts,
and group composition) and their technical abilities counteract the tendencies
towards basic assumptions and facilitate the rational “work group” aspect of the
group (Karterud, 1999).
However, Bion’s theoretical web needs modernization. He leaned on Melanie
Klein’s version of psychoanalytic theory of early human mentation. This theory
has not survived empirical evidence from modern infant and child research,
either with respect to cognition or emotions. The strongest current theory of
emotions is Jaak Panksepp’s neuroaffective theory, mentioned earlier in this
chapter. There is evidence for seven primary emotions among mammals. One
could possible add dominance/submission for higher primates and Homo sapiens. Bion singled out three “proto-mental” motivational categories while there
are at least seven. So how does the basic assumption theory look in the light of
modern knowledge and concepts?
Firstly, the fight/flight group: the problem here is that “fight” and “flight” are
conceived as equal phenomena and belonging to a higher-order unity. When one
starts to measure fight and flight, one soon finds out that aggression in groups is
fairly easy to identify, while flight is a vaguer concept which occurs in all types of

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group modes. The phenomena that Bion described is better characterized as collective RAGE (in Panksepp’s notation). Borderline patients have a strong valence
for rage groups (Karterud, 1988). They are attracted by rage groups and promote
rage groups.
Flight is a mostly caused by FEAR. Groups composed of members with predominantly avoidant PD, will often resort to collective fear and flight strategies.
These groups are fear groups, not fight/flight groups.
Secondly, the dependency group where people are passive and wait to be fed
by an omnipotent leader. This is a constellation which is often seen in the public
mental health services. It occurs when leaders and group members act reciprocally upon the primary emotions of SEPARATION DISTRESS and CARE. In
other words, the attachment system is activated by both parties. The patients
experience themselves as small, vulnerable, abandoned, and unable to take care
of themselves, while the therapists/leaders occupy a caregiver role where they
give advice, support, empathy, and consolation. Dependency groups are therefore better labeled as care-separation groups.
Thirdly, the pairing group where the members behave with an optimistic
belief in future salvation. The aristocracy was Bion’s favorite prototype of a pairing group. For different reasons it is less frequent in the mental health services
(Karterud, 1989). It seems to require a certain level of personality functioning,
while rage, fear, care, and separation distress are more archaic. Bion noted that
breeding and sex played a crucial role in the pairing group, as well as a cheerful
atmosphere. The entertainment industry is the modern group formation that
capitalizes on the pairing group. Sex and romance and illusions and flight from
reality flourish, and the industry attracts people with narcissistic features who
also have charismatic and messianic qualities. The pairing group is a complex
group formation. It exploits the primary emotions of SEX and PLAY. People’s
hunger for sex and play in Western societies seems insatiable.
There is no group mode that capitalizes primarily on SEEK. The reason is that
seek is a more basic primary emotion which fuels the others. Seek is the primary energetic directedness towards the world, in other systems conceived
more narrowly as novelty seeking or exploratory behavior. It is more like libido
in the Freudian sense. Seek is involved in all group modes.
One should probably add dominance (and subordination) to the list of primary emotions as well (Karterud, 2015). It is not predominant among all mammals, but seems to be an innate feature among higher primates, that is, highly
social animals.
Conceived this way, groups can be dominated by all primary emotions, be it
rage, fear, sex, care, separation distress, play, or dominance. Whether they undermine the group’s work with its primary task or not depends on the intensity of

Challenges with borderline patients in groups

the emotions and to what degree they are collectively shared. When strong
enough, individuals will lose their mentalizing capacities and resort to prementalistic modes of cognition, in particular psychic equivalence. In groups, they
tend to reinforce each other in this respect and the group as a whole will regress.
Summing up, we can conclude that as members of the species Homo sapiens
we have in our genetic heritage a range of dispositions for group behavior. We
are programmed to attach ourselves to others, but also to fear strangers, to be
empathic towards others, to cooperate in groups, to dominate or to subordinate, to follow group rules, to identify with “ingroup” and be skeptical towards
“outgroup,” to imitate others, to march in line, and to be infected by others’
emotions, to mention the most important. That we are genetically programmed
does not mean that all individuals of our species have these properties to the
same degree. There are considerable variations between individuals and groups
(Karterud, 1988) and the inclinations are shaped by socialization and culturalization. However, when joining a group these forces are set in motion, at a
“proto-mental” level as Bion’s preferred term, beyond our will and conscious
awareness. To become a member of a group does not in itself require sophisticated mentalizing abilities.
It follows that group behavior in itself, either by complying with group rules
or being engaged by sweeping emotions in the group, does not tell us much
about the individual’s level of mentalizing. I emphasize this because therapists
seem to have a tendency to overestimate patients’ mentalizing capacities. It has
to be challenged before we can say anything valid about it. In MBT-G this is
done in a controlled and systematic manner.

Challenges with borderline patients in groups
As explicated in the previous section, it comes naturally to humans to be members of groups. Or to be more precise, groups are man’s natural habitat. We are
evolutionary designed for it and we become socialized and cultured for it. However, psychotherapeutic groups have some crucial features that are different
from more natural work groups.
The following components are special and they might arouse fear:
1 It is expected that people will talk about the most shameful aspects of
themselves.
2 It is expected that people will involve themselves in a group discourse about
these aspects, which is not customary in other social situations (i.e., commonly used social strategies might no longer be valid).
3 In the beginning it will therefore be quite unclear how people “do their job”
in the group.

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On the other hand, these fears will likely be counterbalanced by:
1 more acceptance of shameful experiences than is customary
2 relief when a despised part of oneself becomes accepted and understood
3 consolation by the observation that such a risky project is directed by professionals who are experts in group dynamics and group therapy.
Once the process has started, powerful curative factors of group therapy will
slowly do their job: installation of hope, the realization that one’s own problems
are not unique but similar to others (universality), psychoeducation, altruism
(the experience of being helpful towards others), corrective emotional experiences, acquiring social skills, and learning by copying other’s strategies (imitation) (Yalom, 1995).
In general, one can say that borderline patients come with similar problems
to other patients, but to a stronger degree. But note that groups can exaggerate crucial mental phenomena. Groups with borderline patients are comparable to a sound system where the switch for the loudspeakers is turned too
high. There is a risk that everything becomes too intense, too loud, and too
fast. The main reasons are the emotional instability and identity problems of
borderline patients. Generally they are more easily triggered than others,
react more intensely with a subsequent decrease of their mentalizing capacity, and probably take longer to resume mentalization. This applies to all emotions, although anger and separation distress are the most volatile (Karterud
et al., submitted). In groups, this implies high levels of stranger anxiety. It
might take a long time before borderline patients are able to trust other group
members, and new members may be met with suspicion. Above all, the anger
is stronger and the ability to control it is weaker. Feelings of shame are often
high, not least feelings of helplessness and despair which can be an ordeal for
the group when associated with suicidal thoughts and threats. Envy and jealousy may be prominent and connected to issues of who “gets most,” be it
attention, care, or love from the therapists. Opinions on these matters, and
whom is preferred and how, are often asserted with firm convictions of representing the truth (psychic equivalence).
Primitive defenses are often prevalent, such as denial, splitting, and projective
identification. Patients will often tell the group about external events shaped by
such mechanisms. It is more troublesome when it happens in the here and now
of the group itself. Enactment is a well-known phenomenon in psychotherapy
and thoroughly discussed in the group literature (Roth et al., 1990). Roles and
behavior in others will be induced through projective identification to correspond with the protagonist’s inner world. Mild and moderate versions may, when
identified and worked through, open up avenues for change. Malignant versions

Challenges with borderline patients in groups

may in the worst case lead to negative therapeutic reactions and therapeutic ruptures. Often there will be victim scenarios where the protagonist denies his/her
own contribution. In combined psychotherapy, a common type of splitting is
idealization of the individual therapist and devaluation of (part of) the group.
However, the reverse can also happen when the individual therapist is characterized as “hopeless,” “remote,” “an old pig,” “immature,” “uninterested,” etc. This too
will be presented in a psychic equivalence manner, as something that represents
the truth rather than being an opportunity for exploration. Other group members may be targets for idealization or devaluation as well. All such phenomena
challenge therapists’ ability to handle their countertransference, as will be discussed in later chapters.
Insecure attachment patterns will play a dominant role. Patients with a disorganized pattern will have trouble in finding a suitable role in the group, often
resulting in poor attendance. Poor attendance may also be found among
patients with a dismissive attachment pattern. Absence is a way to regulate
intimacy and distance. Such patients, and particularly when they harbor narcissistic traits, do not easily understand that their frequent absence has a negative
impact on the other group members and the group as a whole. Overinvolved
patients, on the other hand, have difficulties in differentiating themselves from
others. The problems of other patients, the feelings of others, and in particular
their despair and helplessness and corresponding reproach towards the therapists for not providing enough help, quickly become their own. They tend to take
these problems home with them and might later complain that it is too burdensome to be in the group as “there are too many problems there” or because there
are “too many sick people” (Hummelen et al., 2007). Overinvolved patients may
in addition be locked in a “help-rejecting complainer” role which is a deepseated ambivalence towards attachment figures (Yalom, 1995). They can loudly
voice their complaints but simultaneously reject all offers of help and soothing.
One can imagine an original scenario when an initially reluctant attachment
figure eventually rushes in to help the child, being rejected, however, with the
implicit message that “now it is too late.”
Pesudomentalizing is possibly the most common type of collective disavowal
in therapeutic groups in our times. We write “possibly” since there is no research
evidence for this claim, and own observations come mostly from groups with
PDs. The inclination for pseudomentalization is probably linked to changing
ways of social expressions in the Western world. When therapeutic group analysis was developed in the aftermath of the Second World War, it represented
something novel with respect to free and open communication. It turned out to
be possible to talk to other people about issues that were taboo in the surrounding repressive culture. Today people are bombarded with intimate confessions

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Historical and theoretical background for mentalization-based group therapy

in mass media and agony aunt columns flourish where “experts” of different
persuasions tell people about the significance of feelings, relations, and openness. School and youth cultures encourage a different sort of discourse: people
Twitter about everything and nothing and uncover their bodies and intimate
secrets on Facebook. To talk to others, even strangers, about oneself and one’s
mental sufferings is no longer unique and sensational. In fact, our borderline
patients have often taken on roles as helpers in their particular circle of friends
and may look upon themselves as particularly insightful. In addition, they may
have quite a lot of previous psychotherapy experience. The effect of all these
factors together is that many patients bring with them a kind of understanding
and discourse style which resembles psychotherapy and counseling and insight
and which they try to practice in the group, but which will fail because it often
is replete with mannerisms and undigested words and expressions which do
not capture the essence of ongoing intersubjective transactions. If the therapists
“buy into” this discourse style, the result may be endless sequences where
patients talk in a seemingly insightful way about themselves and others and
involve themselves with ostensibly insightful commentaries to fellow group
members, but without any real progress.
Notwithstanding the problems discussed above, borderline patients also bring
with them positive aspects which engage therapists’ interest and curiosity. Many
therapists experience this work as exciting and rewarding, although tough.
Groups with borderline patients are seldom boring, unless they have developed
a pseudomentalizing culture. Borderline patients are above all relational. They
approach you, are curious and engaged, and often creative. It is not only its severity which results in the countless articles, books, meetings and conferences on
the condition. Borderline pathology also touches something profoundly humane
which everybody can recognize as fundamental to existence. Above all, it is
rewarding to therapists, and it might be deeply moving, when one witnesses
therapeutic progress that helps the individual out of destructive confusion
towards a stronger identity, meaningful prospects for the future, and an ability to
thrive in love relations.
There are some complicating factors which have to be mentioned here, but
which transcend the scope of a group therapy manual (Karterud et al., 2010).
These concern the fact that borderline patients who are referred to specialized
treatment typically carry the burden of additional disorders. Almost everybody
will have suffered a major depressive episode. Some may be depressed at admission and others will acquire a depression during treatment. Some border on
psychosis and some may turn psychotic. Some have a comorbid bipolar II disorder and become hypomanic. Some have attention deficit hyperactivity disorder (ADHD) which burdens the person with additional attention problems.

Challenges with borderline patients in groups

Some have serious anxiety disorders; many will have substance use disorders
and some will have eating disorders. These additional symptom disorders may
in some instances qualify for concurrent pharmacotherapy. In addition to group
therapy there might be a need for parallel psychiatric consultation. However, it
is my clinical experience that many colleagues exaggerate the need for concurrent pharmacotherapy. Patients usually come to our clinic at Oslo University
Hospital with a terrible cocktail of medicines. The main task for the psychiatric
consultant is to make a plan for terminating the medication. In principle, MBT
is a medication-free treatment.
The main message in this chapter is that when treating borderline patients,
feelings and relational issues will rapidly become extreme, and that this tendency easily becomes augmented because fellow group members share the
same tendencies. The process might get out of hand and the treatment may turn
destructive. The alternative is stagnation. Therapists need to tread a tightrope
between chaos and stasis. They need strategies to help counteract such collective (group) regression. When mastering this dynamic, therapists may be able to
also help borderline patients benefit from reflective discourse on intersubjective transactions. How to accomplish this is covered in the next two chapters of
this manual.

41

Chapter 2

Main principles
for mentalization-based
group therapy

Introduction
All types of psychotherapy aim to enhance mentalization in one way or other.
MBT is a kind of therapy that specifically targets failures of mentalization and
where the therapist prioritizes certain strategies in order to engage the patient in
a dialogue with the explicit aim to enhance mentalization. The principles for
these strategies and the mode of dialogue are described in the individual MBT
manual (Karterud & Bateman, 2010).
In MBT-G, the aim is the same: to engage patients in a dialog that fosters
mentalizing. The therapists use many of the same active ingredients as in individual therapy, but since the therapeutic setting is radically different, the practical methods have to be different. Although MBT-G may invite longer
individually focused sequences than what is usual in psychodynamic group
therapy, it is important to emphasize that the goal is not “individual therapy in
group.” MBT-G is a dynamic group therapy in that it has a dynamic approach to
the group processes. The group is not merely a backdrop for individual exploration or for conveying knowledge, as is the case for structured cognitive behavioral groups or psychoeducational groups. Just as in psychodynamic group
therapy, the aim is to develop the group as a norm- and culture-bearing system
(matrix) where the individual attributes of each member can be played out and
where important events, either as reported from outside life or as manifested in
the here and now, are subjected to collective reflection.
But this is done in a more controlled way than in ordinary psychodynamic
group therapy. The rationale for this is given in Chapter 1 of this manual. Put
briefly, groups composed of people with severe psychopathology, when left to
themselves with regard to means and ends, tend to alternate between chaos and
pseudomentalizing. Group members will quickly descend to psychic equivalence and lose any reflective perspective on what is going on. They will often be
emotionally overwhelmed and either become very demanding or retreat to
defensive and nonproductive positions and tend to drop out of treatment. This

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Main principles for mentalization-based group therapy

means that the space for thoughtful reflections on mental states will be undermined and a lot of the therapist’s time and attention will be spent on “putting
out fires.”
One way to gain more control is to create a structure, that is, a favored working method, which differs from the usual principle of free group associations of
group analytic psychotherapy. It is our strong opinion that free group associations require members with a good mentalizing capacity in order to be productive. Free associations in psychoanalysis and free group associations in
group analysis have their historical roots in a time when the individual was
inhibited by a suppressive family and societal culture. The therapeutic community in psychiatry was a reaction to a similarly repressive treatment culture
(Karterud, 1989b). In the therapeutic community, the idea of free and open
communication was adopted, and from it group analysis was born (Karterud,
1999). Seen in a historical context, it was perhaps mainly a liberation project for
the middle classes. Many therapists felt freer with this way of working, as did
some patients with a somewhat higher capacity for mentalizing. It is not certain, however, that the therapeutic community was equally liberating for less
well-functioning patients.
Thus, MBT-G is not set up for free group associations in the group analytic
sense. Instead, the group therapist takes control of the group and strives to
make way for what we label the group as a training ground for mentalizing. This
includes an increased focus on emotionally charged interpersonal events (scenes).
In clinical practice this means:
◆

◆

◆

that patients are informed about the group’s emphasis on interpersonal
events and that they should cooperate in exploring these events in a mentalizing way
that therapists organize the group in such a way that it provides enough
space for the exploration of important events
that therapists utilize interventions aimed at promoting mentalizing, both in
their structuring endeavors, as role models and dialogue partners, and the
way that they stimulate group members to collectively explore important
events.

All of these points will be described in more detail in the following sections.

The group as a training ground for mentalizing
Just as in other kinds of group therapy, we differentiate between two basic therapist roles: (1) dynamic administrators of the group, and (2) dynamic therapists
for the group.

The group as a training ground for mentalizing

As dynamic administrators of the group, the therapists make sure that:
◆

◆

◆

◆

the practice is carried out within the boundaries of the law, and in accordance with norms and rules of the society
time boundaries are clearly defined, for example, duration of each session,
duration of each patient’s treatment, holiday breaks, etc.
the criteria for group membership are clear, that a maximum group size is
defined, as well as whether the group is closed or slow-open
the physical space for the treatment is clearly defined and suitable (clean,
orderly, comfortable, chairs are arranged, etc.)

◆

the routines for payment are clearly defined

◆

a record is kept for each patient and the events taking place in the group

◆

◆

◆
◆

◆

the group is conducted in a professional manner, meaning that the therapists have the necessary skills, have access to supervision, and cooperate professionally with their colleagues
it has been clarified how and under what circumstances therapists may be
contacted outside of sessions
the therapists administer notes between members and the group as a whole
the therapists recommend norms for patients’ relations with one another
outside the group
the therapists take action when something interferes with the group, be it
noise from the adjoining room or if one member is threatening another.

The above items are rather noncontroversial and easily understood.
More problematic is the purpose of the group, and which methods should
be used in order to reach its goal. This is problematic for several group therapies. It is easier for people to understand the purpose of task groups, for
example, a football team or a bridge club. The purpose of a bridge club is simply to facilitate the playing of bridge by the members, at a certain level,
and the methods in order to achieve this goal are not hard to understand.
Psychodynamic therapists, however, have had difficulties in expressing the
purpose of their treatment. Is it to make the patient “well,” whatever that
might mean? Or is it to give the patient more “insight,” “self-understanding,”
to become more “integrated,” “a more whole person,” or “symptom free”? Or
to become themselves, to lead a fuller life, to make use of happiness and to
avoid adding too much further suffering to their miseries, as S.H. Foulkes
used to express it? Since the purposes have been somewhat unclear, so have
the methods to achieve the goals, including the role and tasks on the part of
the patient. Is the goal achieved simply by attending the group meetings?

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Main principles for mentalization-based group therapy

Are the patients expected to associate freely? Are the patients expected to
contribute to solving other group members’ problems?
Questions about this will arise in every group. It is not unusual to hear patients
say “I don’t understand what this group is doing” or “I have no idea how to
behave here.” These questions can be quite timely. Therapeutic groups are often
doing things that have little to do with psychotherapy, and members are often
behaving in ways that are far from promoting the goals of the group. And when
goals and methods are poorly defined, it is not easy for therapists to answer
these questions constructively. Answering using therapeutic clichés, like “What
do you think?” are likely to produce nothing but pseudomentalizing.
For MBT-G the answer to the question of purpose is as follows: The purpose of
the group is to increase the members’ ability to mentalize in close relationships.
What “increasing the members’ ability to mentalize” means, has been
explained to patients in the psychoeducative component of MBT programs
(Karterud & Bateman, 2011). They have been educated about bad versus good
mentalizing, about the role of fuzzy contexts and emotions, and that close relationships are especially problematic. If the question arises again in the dynamic
group, the therapists can ask other members for their opinions. They are
expected to have some thoughts about it, and everyone may benefit from recurring discussions about this theme.
The next question is then, “How do I set about increasing my and others’ ability to mentalize?” Or, “What do I do?” or, “What is my role?” The answer to this,
for new group members, can be summarized in five points:
1 You have to be willing to talk about relevant experiences from your own life,
that is, take the initiative to bring in events that are connected to your problems with mentalizing.
2 You have to be willing to explore these events in a mentalizing manner.
3 You have to make an effort to relate to others in the group in a mentalizing
manner.
4 You have to make an effort to find out what is happening in the group and
between group members in a mentalizing manner.
5 You have to make an effort to attach to the group and its members.
In the interview which therapists conduct with patients prior to group therapy,
they should emphasize that none of this is easy—and if it were, they might not
need to be there in the first place—but that patients will be helped by the group
and the therapists to work on and practice these issues. This is the reason why the
others are there too—to help one another reciprocally. It should not be difficult to
highlight the first point with examples from the patient’s life. Nor should it be

The group as a training ground for mentalizing

difficult to find resonance for the word “resistance” in this context, for example,
that it can be difficult to bring in sensitive things from one’s life, because of shame,
fear of being judged, and so on. Points 2–4 are also straightforward to go through
with patients once they have understood what a mentalizing stance is about. Of
course it will be more difficult to actually practice this. The last point, about attaching to the group, will prove more problematic for some. This is especially true for
patients with a dismissive attachment style. “It’s OK to be in group therapy, but
does one really have to attach to the others? And what does that mean, actually?”
Whether the attachment pattern is dismissive or overinvolved/ambivalent, it gives
the therapist a good opportunity to talk about the importance of attachment.
It is important that the therapists convey the importance of “caring.” This is
what attachment is about. In a therapeutic group, one is not indifferent to others’ suffering and worries. The other is not a stranger. There is an implicit contract of reciprocity in a therapeutic group. In the same way that I expect to be
heard and receive a positive engagement, others expect the same from me. And
it is expected that one cares about the group as a whole. Being a group member
implies a commitment to attend every time and to give priority to the group
once per week, at the expense of most other things. And this commitment is not
merely an abstract principle. It is founded on the fact that it matters for the
group as a whole, for its work and success, that everyone attends. What the therapists are implying by this is a kind of ethics of communication (Habermas,
1989). Communicative cooperation comes with an ethical obligation.
What this means for each individual will naturally differ. Some will have
problems attending regularly; others will never miss a session. Some will be
overly involved in other members, while others barely think about the group
once they’re out the door. A therapeutic group is not a disciplinary machine
aimed at conformity. It is not behavior as such that matters. The ideals of caring
and committing are important primarily in a normative sense, meaning that
these ideals serve as something which patients’ motives and considerations can
be measured against. Consolidating these kinds of ideals as part of the group’s
ethical code, owned and practiced by key members, will typically occur during
the so-called norming phase in the development of the group and it will be a
recurring theme in slow-open groups, often brought to light when new members enter (Karterud & Stone, 2003).
In light of this, we argue that MBT-G has an educational advantage compared
to other psychodynamic groups, and that this helps therapists, patients, and
supervisors. When the “work group,” as defined by Bion (1961) is reasonably
well defined, it becomes clearer what is not “work,” that is, when the group is
doing things outside of its primary task. In practice, this often means the group
gives way to “basic assumption functioning,” for example, that suspiciousness,

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hostility, and quarrelling takes over, or the group descends to passivity and
dependence, expecting to be fed by the therapist, or to endless clichéd babble
that is leading nowhere.
In order for the group to function as a training ground for mentalizing, one
must make clear to the patients what is expected from them. Just as important
is that the therapists organize the group. This involves both mental work and
concrete, practical work. The practical side has been described already. Mentally, it concerns the work the therapists do by digesting and organizing the
experiences from the last session. When the therapists meet after a session they
sum up the events in the group and each member’s contribution, seen from a
mentalizing perspective. Their comments are recorded and rehearsed at the
meeting before the next session. Here, a strategy for opening the upcoming
meeting is formulated. We strongly recommend that therapists start the session
with references to the last session and use this as an introduction to the present.
By this mental work on the group between sessions, the therapists create an
explicit continuity in time for the group. The way it is practically handled also
ensures that each member is mentioned (and remembered) and that the group
is reminded of its purpose. The slogan is: The therapists are minding the group.
Taken together this is assumed to strengthen the group cohesion and to provide a sense of membership and clarity of the purpose of the group. We emphasize these three factors because borderline patients most often struggle with
these issues (“I don’t understand the purpose of this group”; “I have no idea
what I’m supposed to do here”; “I don’t feel attached to anyone here”).
The next element that may optimize the group as a training ground for mentalizing is that therapists encourage turntaking during the opening phase of the
group. This strategy makes MBT-G different from other psychodynamic groups
which most often start sessions by following the patients’ own initiatives and deal
with whatever may follow in the spontaneous group process. It has to be emphasized that turntaking in MBT-G is not some rigid portioning out of time and
attention to each individual patient. What we recommend is for therapists to ask
who wants space for discussion of events, while at the same time reminding the
group who has been given and who has not been given attention in previous
meetings. This way, attention and relevance of events becomes a theme for the group
and each member is repeatedly reminded about their role and responsibility.
Moreover, the therapists are active, in collaboration with other group members, in the clarification of events. The process of clarification (where, when,
who, how?) may in itself contribute to mentalizing, in that the group member is
helped in sorting out thoughts and feelings in a sequence of events and helped
to be able to formulate a relevant scene. Some patients are, at the beginning of
treatment, incapable of formulating a relevant narrative. When a scene is

The group as a training ground for mentalizing

clarified, the stage is opened up for a general exploration of the sequence of
events. This is “mentalization training” in a narrow sense. How can one understand the actors who are involved in the scene? Which emotions were involved
and how were they handled? What is it about the event that indicates problems
in mentalizing (or good mentalizing) for the narrator? How long should one
work on such scenes? When is the understanding “saturated?” When has the
main character understood something new? In this phase it is important that
therapists keep their opinions in check and stick to a curious “not-knowing”
mentalizing stance. The therapists’ task is not to do the mentalizing job on
behalf of the member in focus or the other group members. The therapists’ main
task in this phase is to stimulate and contribute to an engagement of all group
members in the exploration and mentalizing of the emotionally charged scenes
at hand and try to formulate some kind of summing up when the sequence
moves towards a closure. This formulation should be framed in a kind of language/discourse that conveys the general mentalization-based perspective on
BPD applied to the specific intersubjective experience for that particular patient.
During the process schematically described above, there is a continuous interaction between the participants. This interaction is of course also characterized
by emotions and thoughts in the here and now which reflect varying levels of
mentalizing. This is rich material, but when and how should therapists address
this? It is difficult to give exact answers. But generally, therapists should intervene
when something happens that can be assumed to have a significant impact for individuals and the group as a whole. For example, if a polarization flares up between
individuals or subgroups. Or when group members react in ways that are striking: “Can we stop here for a moment? It seems that you, Kristin, reacted to something here. Is that right? What was it?” Events here and now are potent material
for exploration and mentalizing. They happen while they are being talked about,
all actors are present as well as many witnesses, and the emotional temperature is
often moderate or high. This will be a challenge for most people, and especially
for borderline patients. The greatest challenge for group therapists is to switch
between mentalizing external and internal events in ways that feels meaningful
while the same time preserving the wholeness and flow in the group. If this manual
was only about opening with a report from the last meeting, arranging a queue of
group members who wish to bring something up, clarifying and working on it,
and then moving on to the next member, MBT-G would soon turn into a mechanical exercise. What makes MBT groups alive and exciting, is that therapists
constantly seek out a mentalizing perspective, stimulate metacognition, “supervise” a working through of difficult interpersonal events that members recognize
from their external life, and connect those to emotionally charged events in the
here and now of the group itself.

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We consider it especially important to develop participants’ capacity for metacognition. Several interventions facilitate this, for example, the initial encouragement and reflection about turntaking. Again, this is not a question of
arranging a queue. Each member is repeatedly posed questions that force them
to think about the following: Has something important happened in my life
recently? What is it with that experience that is important? Shall I talk about it
in the group? How should I describe it? What if I do not reveal it? And so on.
Likewise, when therapists ask whether the work has been successful (“Did we
get anywhere?”) or about time dilemmas (“What do we do now, there are 15
minutes remaining and Terje, Petter, and Linda have all said they want to bring
something to the group?”).
In conclusion, therapists in MBT-G take a number of steps to optimize the
group as a ground for mentalizing. These include clarifying roles and tasks of
the participants, doing summaries after sessions, writing reports, minding the
group, preparation for upcoming meetings, cooperation with participants on
turntaking, repeated reflections on the way the group is working, clarifications
and invitations to mentalizing events in ongoing life, and invitations to mentalize events in the here and now. In the following sections we will go through the
latter points in more detail.
Finally, it is important to emphasize that we are talking about group therapy
as part of a combined treatment. In combined treatment the therapists don’t
have to do “everything.” They can lean on the whole MBT structure, and especially the psychoeducative group and the parallel individual therapy. Thus they
can concentrate on that which groups are especially suited for: exploring interpersonal transactions.

Focus on interpersonal transactions
The focus on interpersonal events has an organizing function for MBT-G. It has
significant implications for both therapists and patients. Patients are asked to be
vigilant, to notice significant events in their daily lives and in the ongoing group
therapy, and to bring them into a focus of exploration. The therapists must
ensure that these events can be processed in the group. We will now go through
in more detail how therapists can do this.

Continuity and coherence of meaning through
the therapists “minding the group”
In MBT-G, the therapists take more responsibility for the group processes than
in analytic groups. Among group analysts one can often hear the slogan “leave
it to the group.” This is not legal tender in MBT-G. In MBT-G, it is the group

Continuity and coherence of meaning through the therapists “minding the group”

therapists who take primary responsibility for the group’s continuity and
coherence. In particular, they create a context and continuity through their
thinking about the group. This happens continuously throughout the group
meeting and is summarized and reflected upon in the therapists’ meeting
before and after the session. It is formulated in a written form which the therapists continue to have in their minds and think about between sessions. It is
further processed in group supervision. In this way, meaningful contexts are
created that tentatively integrate each group member’s process (e.g., what topics are most urgent, what is their most important challenge with regard to
mentalization, is the patient new, well established, or approaching termination?) with ongoing interpersonal processes (e.g., alliances and conflicts) and
processes in the group as a whole (e.g., well-established norms and cooperation versus collective resistance and formation of subgroups). These meaningful contexts give rise to working hypotheses that the therapists bring to the
group, try out, and modify by new experiences. Thus there is a dialectic
between the dynamic group that exists in the mind of the therapists and the
living group that meets in real life.
Each session starts with a preparatory meeting and ends with a closing meeting between the two group therapists, lasting for 10–15 minutes. The work
being done at these meetings is unfortunately not covered by the MBT-G rating
scale (which is explained later in this manual) because it cannot be observed
routinely on video recordings. However, every group session is influenced by
these meetings. At the closing meeting the group as a whole and each group
member is commented on from a mentalizing perspective. Was the group
meeting good/average/poor? How were the phases handled? What can be said
specifically about the participation of each member? What should be written in
the records? What should the therapist be aware of for the next meeting? Did
the therapists have a shared understanding of the processes? Were there any
countertransference reactions, and if so, were they commented on? At the preparatory meeting the therapists go through the minutes from the last meeting.
They have now had a week to think through the meeting and during this time
they may also have had inquiries from or about individual patients. At this
meeting, the last session is brought up, and the therapists discuss whether in the
upcoming group there is anything in particular they should be aware of, prepared for, or take the initiative about.
Example: At a preparatory meeting, the therapists comment that the last meeting was OK.
The group has several new patients, but it seems that things are “moving along.” The last
arrival, Laila, is on board, but she has a bit of an expressionless face and talks a little too
cleverly and pseudomentalizies in a way that makes it difficult to know how the group is
affecting her. The therapists agree to see how this develops. Concerning another patient,
Hilda, it has recently been discovered that she has a serious substance abuse problem. The

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Main principles for mentalization-based group therapy

therapists agree that this must be addressed again. Trude has been absent twice, and this
should be mentioned. Furthermore, there have been major changes to Kari’s life situation
and the group must be updated on how things are going. Trine has put her problems at
work on the agenda and can be expected to bring these in again. Hege is on leave from the
group due to the birth of her child. Sonja has cancelled because of fever. The therapists use
most of the time for discussion about the relationship between Trine and Berit. Therapist
A has heard from Berit’s individual therapist that Berit brings up the relationship to Trine
in her individual therapy and that there seems to be some tension between them. The
therapists discuss what this may be about, but conclude that neither of them will take the
initiative to bring it up. They will, however, be more vigilant with regard to this relationship than they otherwise would have been.
At the subsequent after-meeting, the therapists agreed that the meeting was quite
good. The group seemed to develop well. This was perhaps most evident for Berit, who
had her best meeting ever. She brought up a difficult event regarding her friend, an event
she thought was very typical, and talked about it quite coherently and about her own
emotional reactions and subsequent reflections. She was open and invited comments
from the others, discussed these in an open manner, and utilized these in her further
reflections. She displayed a genuine and moving despair over her own difficulties in mentalizing and how difficult it was for her to accept this. She reaped genuine sympathy from
the group and her capacity for mentalizing here and now was praised by both patients and
therapists. Furthermore, her reaction to these acknowledgements was commented on
(her ability to accept validation). Therapist B expressed his own understanding of the
story in light of Berit’s attachment pattern, said something about his own countertransference (he was moved), and that the individual therapist should be informed about her
work in the group.
Kari was also praised by the therapists at the after-meeting. While she previously had
been extremely avoidant and her mentalizing ability used to collapse whenever the focus
was on her in the group, it was as if she now was trying to be more genuinely rooted in
herself. She discussed an upcoming date where she also involved and engaged the others
on what she expected to get out of it, what emotions she believed would be set off, how she
could cope with them, what this meant for her, and so on.
Hilda’s substance abuse was addressed for nearly half an hour, a little too long, but probably necessary in order to get the group involved. The therapists agreed that Hilda’s level
of mentalizing was very low, actually leaning towards the negative. In the group, Hilda
had expressed that her substance abuse was nothing to discuss and that she didn’t have
anything else to bring up either. Therapist B was able to use his countertransference in a
constructive way (“I get a feeling now that I’m almost nagging at you”—“Yes you are!”)
which also incorporated the other members of the group. The dilemmas for Hilda and the
group were discussed at many levels. The therapists noticed that she later spontaneously
engaged in Kari’s story. The therapists concluded that Hilda’s substance abuse should be
addressed at every meeting in order to monitor the development, but that it should perhaps be more limited in the future.
Trine brought in her theme about difficulties at work, as expected. This time the emotions were stronger than ever, and more clearly articulated. However, it was painful to
hear (countertransference) how she was locked in a psychic equivalence mode in the
events she brought up, and also to witness her psychic equivalence in the here and now.
On the other hand the other group members managed to challenge her in a constructive

Regulation of group phases

way. The therapists were not sure what Trine learned from the meeting, if it would help her
to endure at work, or if she would give up and quit.
Trude said that she still was not well. She participated in the work of the others in a
constructive way and she brought up a theme of her own that the group agreed would be
the first one to be addressed at the next meeting.
Laila had hesitantly announced a theme at the beginning of the session which she later
withdrew without protests from the others. The therapists agreed to focus more on her
next time.
It seemed obvious that Trude and Laila should be in focus next time, as well as more
stuff from Trine about the drama at work. The members would probably hear about Kari’s
date, and at least the therapists would be looking for any development in Hilda’s motivation to deal with her substance abuse.

Along these lines, a note would be written in each patient’s record. The notes
should be glued together as a group note and reviewed before the next
meeting.

Regulation of group phases
Group meetings have their typical phases and these must be handled in ways
that optimize the primary task of the group. Broadly speaking, groups have
three major phases: the opening phase, the middle working phase, and the termination phase. Many psychodynamic group therapists leave phase regulation
to the group so that the group as a whole is held responsible for how it is handled. In a well-functioning dynamic group, this will become a part of the group
culture. In MBT-G, it is recommended that the therapists take more responsibility. The group therapists should not just sit down in their chairs and await
what happens. The therapists should start, after saying hello, by passing on messages from those who are absent, and comment on patients that are not present,
but have not left a message. There may also be messages on video recordings,
from the clinic about changes in routines for payment, or information about
meetings for the relatives of the patients, etc. The therapists also comment on
the presence of patients who have been absent several times. The meeting is
then open for comments on these initial messages.
The next task for the therapists is “building bridges” to the previous meeting.
Every patient should be mentioned, so it will appear like a round when the therapists disclose their views on the last meeting with regard to individual patients,
themes, focus, completion of mentalizing work, allocation of time, group issues,
and so on:
“Last time we worked pretty thoroughly with your themes Kari, and yours Henrik.
Kari—you were concerned with disturbing thoughts about something alien
­
growing out of your body. You’ve never told this to anybody before. Our impression
was that it felt a relief to be able to talk about it and that it became less scary.

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Main principles for mentalization-based group therapy

Are we right? You Henrik talked about the relationship to your parents, condensed
in an episode last Tuesday. Is there anything that should be brought up in connection with that? Maybe we didn’t quite finish with Jonas, for several reasons, we think.
Partly it was due to time running out, but perhaps it wasn’t quite clear what your
main problem was, Jonas. The group was concerned with your relationship with
your father, but were there other issues there as well? Hilde said she would like to
wait until today to talk about something and maybe it is still relevant? Then we
thought that what you brought in at the end, Eli, should be followed up today—what
do you think? And then there’s you, Bente, who we haven’t heard anything from for
a while, you should probably be given the opportunity, are you up for that? Any
other things we need to be thinking about?”

In this way, the therapists bring continuity to the group and communicate that
they have been thinking about it and the respective members since the last session
(“holding the group and its members in mind”), while their reflections also are
presented as topics for discussion in the group. The round serves to organize the
group, and at the same time it is a recurrent reminder that each member should
be given attention in the group, that time is limited, that it must be allocated, and
that balance must be created between the members. This is something the members have to relate to in the opening phase. They are forced, so to speak, to take a
metaperspective. The therapists notice who takes initiatives and who is more
withdrawn and use this as observations that can be brought up along the way:
“Bente, you were a little hesitant when we initially discussed who had something to
talk about in the group. It now seems apparent that you really had something that
was very important for you. What do you make of that?”

The round can be summed up and closed in different ways. One way is that the
therapists come with a suggestion:
“OK, what if you start, Hilde, and after that maybe you should continue Bente, and
there’s you two, Jonas and Eli?

Another way is for the therapists to let the group decide:
“OK, there are several themes here. Where should we start?”

In practice, group members tend to lose their perspective of time along the way.
Once group members start getting involved in a story, they will bring their own
associations, their own agendas will appear, and things will happen in the group
here and now which call for comments and engagement. Thus, it is not difficult
to fill a group meeting of 1.5 hours with material emerging from the event of
one group member. In regular group psychotherapy, this usually happens.
There is no initial organizing. The group typically starts after an initiative from
one of the members and after that it develops and unfolds through its own

Balanced (mentalizing) turntaking

dynamics. MBT-G is different. At some point the therapists must remind the
group of the reality of time:
“We have been through Hilde’s story and yours is perhaps coming to an end, Bente?
Jonas and Eli also have things to bring in, and then there is you, Turid. So how do
we handle this?”

Again, the members are “forced” to take a metaperspective. Are we now “finished” with Bente? What does it mean to “finish” something? What is most
urgent among the other issues? And so on.
In the same manner, the therapists should comment on termination. They
should remind the group of how much time is remaining. What is most important during these minutes?
“Are we going to finish with Jonas? Or do we have to leave some of it until next
time? How is Hilde now? Has she calmed down? What will it be like for her to leave
today? And the others? And, how was it? Did we get anywhere? Did we move
forward?”

Again, metacognition is encouraged. The interventions convey a concern for
the members’ self-state at the same time as they serve as a reminder of the fact
that people are here to work. Has this work been successful? It encourages
metacognition since it is not the cognitive content of the members’ thoughts
about a subject matter that is the focus. Members are asked about their thoughts
about their own and others’ thought and feeling processes.

Balanced (mentalizing) turntaking
As noted previously, in the section about regulation of group phases, MBT-G
encourages a kind of turntaking, implying that group members take turns being
at the center of the group’s attention. Turntaking is for many psychodynamic
group therapists a big No-No. They want the members’ relational difficulties to
be manifested in the here and now, spontaneously by the group processes. They
also allow, even encourage, themes to flow back and forth freely in an associative exchange of experiences, thoughts, and feelings. In an analytic group, no
single member “owns” a theme. In a well-functioning group, this can be productive even if it comes at the expense of the possibility of detailed working
through of crucial events. In MBT-G, things are different. Here, we want and
encourage detailed accounts of interpersonal events that are experienced by the
individual members. Consequently, we must also safeguard the individual
members’ thematic “property” against comments that take the attention over to
something else. If in-depth exploration of interpersonal transactions is favored,
there is no way around turntaking in some form or other.

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Turntaking can be practiced in a number of ways. In groups with low group
cohesion, we recommend that therapists take the initiative to structure the group
in the opening stage by way of a consensus on two to four members that have
something in particular to bring in. Each group member is then expected to be
in focus at least once every three meetings. However, this is not meant to be a
strict rule. In better functioning groups, it can be natural to start off with a theme
from the last session, or perhaps someone starts with a group-relevant theme
that appeals to most members. But even if a group starts off in this way, it is our
experience that meaningful themes will appear along the way that should be
given individual attention. We then get a more spontaneous form of turntaking.
In MBT-G, there will be interplay between these forms and we label this as “balanced” turntaking. It should be emphasized that this goes beyond the structural
element of everyone being put on the group’s agenda. Adding the word “mentalizing” to the heading for this section means that what each member brings to the
group will be subjected to mentalizing group work. The main elements in this are
(1) clarification, (2) mentalizing in a more limited sense, and (3) closing.

What counts as an “event?”
The words the therapists use in the opening phase when referring to the patients’
“material” are important. If the therapists say “Who wants some space today?”
this is an open invitation to get involved. It’s an invitation to talk about “whatever.” We may alternate between that kind of question and “Does anyone have an
event they want to discuss?” Both are useful. Many patients don’t know what to
bring in, what is relevant, and cannot single out episodes of mentalization failures. As some patients say: “How am I supposed to know that, it’s like that for me
all the time, more or less?” It should be made clear, explicitly and implicitly
(through the work that is actually carried out), that it is OK to bring in “anything,” as long as when discussing “anything,” something will emerge that turns
out to be of importance for the patient’s mentalizing ability, and that this is what
the therapists and the group will focus on. In most cases this will be an interpersonal event and in most cases emotions will have been involved which have impacted the involved parties. This is where the group should concentrate its efforts. It
doesn’t need to be close relationships, but often it is. Groups are especially well
suited for exploring interpersonal events and relationships because they can
utilize events here and now as concrete examples of the same themes. In this
regard, we are in line with Yalom (1995) who is the greatest spokesperson of our
time for group therapy as “interpersonal psychotherapy.” Groups are less suited
for exploration of the intrapsychic. Here individual therapy has an advantage.
Nevertheless, patients who bring in a more well-defined event often also
report them in ways that needs clarification. To present a consistent and

What counts as an “event?”

coherent story, with a beginning, middle, and an end, with comprehensible actors involved, each with their different qualities, leading up to an emotional climax that puts the mentalizing ability to the test, is a work of mentalizing in
itself. Many patients will therefore struggle with this throughout their treatment. It is a goal in itself to be able to present a coherent narrative. In practice,
one will encounter not only unclear stories, but also unclear motives for storytelling. Nor can one assume that the story is being told with an ambition to
mentalize. It may just as well be motivated by a desire to recruit support for
what is felt to be unjust treatment, or to distract the listeners from more
urgent matters.
Which events are relevant for the group? It should be made clear that it is not
only interpersonal events in life outside the group that exemplify failures of
mentalization. It can also be events from the past or worries about future events.
It can be events that have been challenging, but also those where one has coped
well, for example, where good mentalizing has been evident. And not least, it
can be events from the ongoing group therapy. Especially important are events
that strengthen the group morale by confirming the purpose of therapy: “It
helps!”
Example: Henrik (37) has a dismissive attachment style. The people in his life have been
there for him to manipulate. According to him, they manipulate him too. To trust others
by assuming they have good and friendly intentions is naive in Henrik’s worldview. He has
never leaned on anyone. These attitudes are related to experiences of always having felt
“dirty,” and convictions that others won’t touch him because of that. This idea exploded
when he was diagnosed as HIV positive. After around 2 years in the group, when discussing an episode at work, he spontaneously begins telling the group that he has noticed a
change in how he regards others, and he thinks this is due to his experiences in the group.
He is less wary. He is more spontaneous and talkative with others. He relaxes more when
he’s around people. Sometimes he tells himself that he “simply likes others.” He now feels
it is OK to be in the group, and he is looking forward to the meetings. The other group
members listen intensely. The therapists focus on the here and now: “What is it like to hear
Henrik say this?”

Events can also be in the future. It can be situations that one is dreading and
worrying about and would rather avoid.
Example: Marianne asks for time in the group. She tells how she has become more aware
that she has a problem of tolerating being alone and that she has had to admit both to herself and her individual therapist that in situations like that she numbs the anxiety with
alcohol and that she often drinks too much and that this has created a lot of problems.
Now the Easter holidays are approaching, and her daughters are going away skiing with
her parents while her partner has to work out of town. Marianne wonders whether she
should have herself admitted to the psychiatric ward for the Easter period. The therapists
acknowledge her frank account of her problem of being alone and drinking to calm her
anxiety. But why doesn’t she join her parents and daughters on the skiing trip? She asserts
that is because “We can’t be in the same room” and because “We cannot talk together.” This

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becomes the focus for exploration in the group. What does it mean to be together in the
mountains during Easter? What normally happens? What does this, in turn, do to Marianne? What happens with her parents? How do they interact? The other group members
get engaged and come out with many questions and comments. What was originally
unthinkable for Marianne—to go on holiday with her parents—seems to become a possibility through the thought experiments in the group. She wants to think about it some
more, and discuss it further with her individual therapist.

Being a new member in a group is a major event for the individual as well as
other members and the group as a whole. New members should be allotted time
for self-presentation at their first meeting. Often they will behave in quite a
reserved manner: “My name is Linda, I’m 26 and I live downtown. I have quite
a lot of problems, but I could perhaps talk about that later on?” Yes, that is perfectly all right to say in the group. Later on when Linda (and other new members) feels more comfortable in the group, she should be given space for her life
story. The focus here is not on any “events,” but a kind of life narrative that gives
everybody, including the protagonist, a feeling of the rough contours of the
person.

Clarification of events
Therapists should be active with regard to clarifying events. The more one can
engage the other group members in this, the better. It can be interventions like
“Hold on a second, I don’t quite follow.” “Where were you?” “Can you repeat
what she said, as precisely as you can?” “What came first . . . ?” “Was this after
you . . . ?” “Does everyone follow this?” Therapists should monitor their own
activity and comments from other group members. Strategically they should
aim to establish a workable scene rather quickly, within, say, 5–10 minutes. It
takes some discipline when comments from other group members will vary
from “Oh my God, I can’t believe it,” “If that had been me, I would’ve punched
him in the face,” “People who drive BMWs are assholes,” “I’ve been through
exactly the same and it sucks, it was the time when I . . . ,” where the one commenting is about to grab center-stage, to a more supportive “I think you’re
brave” and “Good that you got to say just that.” What is often striking for the
therapists is how quickly other group members identify with the one telling the
story, or with other actors or parts of the story and comment just as if what has
been told is a piece of hard reality. It is as though they’re being sucked into the
story itself. For the one telling it, this may partly be a good thing. It can give the
person telling the story the necessary support and encouragement to carry on.
For the group therapists, it is different. They seek a metaperspective which they
want others to share. This metaperspective means that they cannot dwell for
very long on content at this stage that has a low level of mentalizing and which

Clarification of events

they otherwise would comment on (e.g., “Bente, you say that everyone who
drives a BMW is an asshole, I’m not sure how to understand that . . . ”).
Unless the subject of discussion is quite clear, the therapists may after a time
make a kind of summary:
“Ok, if I understand you correctly you were pretty annoyed with some fellow students at the seminar who displayed a negative attitude, and that you didn’t find any
way to express this, and, on the way home, when you got off the bus at the petrol
station you were almost hit by a BMW, and you “blacked out,” and shouted at the
driver and let him have it and gave him the finger and almost dented the car. Does
that about sum it up?”

When it comes to patients that don’t have anything in particular to bring to the
group, but who are on the “agenda,” one must show respect and patience, but not
too much of the latter. Sooner or later patients have to get down to business. The
most important task for the therapists and the group is then to help the patient
define a theme that is relevant and workable. It is OK, to start off with, that someone
has “been depressed” for the last week, or “everything has been bad.” But the group
cannot work with “been depressed” or “everything is bad” in other ways than simply to listen, accept, comfort (“I’m sure it’ll pass”), or give advice (“Why don’t you
try getting out of the house more often?”). The focus must be shifted from the person
as a victim of negative emotions (depression, all-bad feelings), to the person as an
accountable agent in the world. The challenge is to find an interpersonal event that
is relevant and meaningful for the patient and which is connected to the relevant
emotions. It can be a telephone call from their mother, or a letter from a former
partner, or a meeting with the neighbor, that “made me even more depressed.”
In general, we assume that patients who don’t have anything in particular to
bring, are displaying some sort of defense or resistance in a psychodynamic
sense. Some patients also react to the word “event”: “There’s nothing happening
in my life, I don’t have ‘events’ like other people to tell you about.” The resistance
can be maintained even after the word “event” has been clarified and there is an
explicit invitation to “talk about anything.” This is more common among new
members than well-established group members. The therapists may then make
what is happening here and now, the refusal itself, into the event for that particular member, and invite the group to take an interest in this and try to find
out more about it. How do we understand that someone doesn’t have anything
to talk about? Does absolutely nothing happen in the person’s life? Maybe it is
difficult to talk about something here? But the good news is that the patient is
coming to the group. Perhaps he or she is uncomfortable with the way of working here? Or maybe he/she is not so sure about the others? Or has become
unsure about what he/she wants help with? How can the group help with this?

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Notice here that we encourage therapists to actively engage the group in exploring these themes and put a bracket on theories about denial, projective identification, dismissive attachment styles and the like. Whatever the reasons are for
the reluctance to get involved, the aim is to try to get the group engaged in
attempting to find out. The therapists may, however, explore the resistance after
successfully having completed a turn:
“After this, I’m left wondering, Henrik. You said beforehand that you had nothing
in particular to bring to the group. It then turns out that you have had a really
uncomfortable experience that really got a hold on you. How do we understand
this? Did you think that it was no big deal? Or that it was embarrassing to talk
about it in the group? Or are there other things that made it difficult for you to tell
us this straight away?”

If the therapists aren’t wide awake, potential events risk disappearing in a flood
of words and emotions that serve more as tools for “emptying” oneself, rather
than as a means towards new understanding. This is demoralizing for everyone
and a misuse of the group.
Example: Lise (29), with BPD and ADHD, is ending group therapy after the next session.
Lately her functioning has declined again. Her attendance in the group has been very
irregular. This time she is half an hour late. Another theme is just being closed and thereafter the therapists ask who has something they want to talk about. Another member
comments that “Lise looks tired” and this leads to a long tirade from Lise, with a lot of
details and shifting themes, centering on her boyfriend who is suffering from varying
maladies and is being a pain, but whom she can’t seem to get rid of. The others do their
best to follow. It is like they’re being pulled into an unreal world. When something appears
a little clearer, something else and strange appears. The therapists try to structure the process, but they too become seduced into following each new theme that appears. After a
while the therapists abdicate from their roles as authorities for the group. The fact that she
is about to terminate the group next week is not mentioned.

In this case, seen from a mentalizing perspective, there is only one event to
deal with: The fact that Lise is ending therapy after the next session. Everything else is unimportant. When Lise herself can’t make this a theme, the
others must do it for her and help her in sorting out her thoughts and feelings
around this upcoming event. In the session referred to in the example, everybody got confused and the therapists became overwhelmed by their own
­countertransference—perhaps not wanting to face the limitations of their
effectiveness—and lost their MBT perspective.

Identification of failures of mentalizing
In working with events, the most important factors are the therapists’ own perceptions of what constitutes good versus bad mentalizing, their ability to clarify
fuzzy events, and their ability to recruit the other group members for conjoint

Identification of failures of mentalizing

explorations. Firstly, the therapists must identify the core issue, then they have
to reveal and articulate it, and then they have to arouse curiosity in others—let’s
find out what this is about! And at the same time this must be done using language that everyone understands and with realistic intentions. The therapists
shouldn’t invite the others to hazardous escapades, but rather to stay within
areas where they have reasonably good oversight.
Listening actively to a story does something to you. To use the words of
Foulkes, the story creates a resonance in you. What kind of resonance this is will
vary from person to person. Different memories, moods, and emotions are activated, giving rise to specific thoughts here and now. In a freely associating
group, the task is to express these experiences. Naturally, this makes for a rather
unpredictable course. In MBT-G, the course is being directed. The other group
members, apart from the most experienced and sophisticated, will tend to say
anything that comes to mind out of their own spontaneous resonance. And this
may have nothing to do with the failure of mentalizing in the protagonist. Furthermore, in a longer story there will be many different, bigger or smaller
examples of mentalization failures. What to choose? It will be in the spirit of
MBT to have an open discussion about this. What is “good news” in the story
and what is the most problematic? The therapists have to wonder about this
openly, and in the group discussions to take what can be labeled a “normative
common-sense position”: It is sensible to think before you act, to pay attention
to your feelings, to have understood the other in a reasonably correct way, to
weigh different perspectives, not to think in terms of black and white, and so on.
At the same time, it is sensible to be tolerant and nonjudgmental, to convey
understanding of the fact that stupid mistakes are often made, that misunderstandings of one self and others often do happen, that it is difficult to pull oneself together, and so forth. From this perspective, how can we understand what
happened in this event? What is suitable for further exploration in the group of
course also comes down to the current mental state of the member and the
therapeutic alliance with the group and therapists.
Example: Terje says hesitantly that “There’s something I perhaps should talk about in the
group . . .” He starts off with a kind of conclusion that “he messed it up again.” The story is
about him going for dinner last Sunday with his girlfriend and her mother and stepfather.
He was a little nervous beforehand, but not too bad. Then something happened as he
entered the house, and “he freaked out,” had a couple of drinks and then some more until
he was “totally pissed,” but he managed to get out without causing any major scene. He
went to town where he met some old mates and they had more to drink and things got out
of control. But he did manage to stop himself before he vandalized something and went to
the police station asking to be placed in the drunk tank. The other members ask questions
along the way and someone says it was good of him to voluntarily turn to the police for
help. In the past he had fought them. Terje recovers somewhat by the group exchange, but
then he leans forward and puts his head in his hands and says “My God” when the

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therapists ask what happened as he entered the house. He just can’t bear to think about it.
The situation in the group is now that he is (1) talking about an episode with a grave failure
of mentalization, and (2) clearly expressing a current collapse in the here and now. Feelings here and now come first. Therapist: “It seems that there is something here that is
pretty hard for you. What do others in the group think, what should we do?” “Leave him
alone.” “Don’t push him.” “But it’s something he needs to talk about.” “Maybe he needs to
calm down a little.” “Maybe he can say something about it later.” In the course of this
exchange Terje gets a new hold of himself. He stutters some additional information that
signals that he’s on his way. “It’s just so damn shameful.” “What, ending up in the drunken
tank?” “No, the fucking thoughts.” “What kind of thoughts?” Then gradually the story
about how his suspicion towards his girlfriend’s stepfather comes to light. Terje believes
the stepfather gets too close. “He looks at her in a certain way.” Terje is sure that if given
the opportunity, he would make a move on her. Terje gets both upset and angry, and those
emotions came over him when the stepfather stood there with his smug grin and welcomed them to the house. Terje is not sure whether it is his mind playing tricks on him, or
if the stepfather really is a “fucking pig.” It is this uncertainty that is tormenting, and he is
too embarrassed to talk to others about it, so he just wants to sink through the ground. As
the meeting progresses, Terje becomes able to join the exploration of what happened in
the crucial moment in that house, and what is going on inside him in relation to the others
here and now.

Engaging the group members in mentalizing events
As previously noted, the mentalizing ability of group members and the patient
currently in focus may be enhanced by the very clarification of a significant
event. However, direct work with the event itself is at least as important. If we go
back to the previous example of reactions to “negative fellow students” and the
rage against the driver of the BMW, it is the task of the therapists to engage the
group members to explore this scenario. The therapist can ask an open question
such as “What do you make of this?” It is then opened up for comments of all
kinds and the therapists are advised to stay in the background. They observe
what direction the group discussion takes. This discussion is a mentalizing
exercise not only for the “owner” of the event, but also for the others. The group
therapists eventually join in with their repertoire of techniques: exploration
based on a not-knowing stance, regulation of emotional temperature, adjusting
to the level of mentalizing, challenging unwarranted beliefs, focusing on emotions in the event and emotions here and now, on the interpersonal context of
emotions, on striking transference manifestations in relation to the therapists
or the group as a whole, on the therapists’ own countertransference, and so on.
This is often an engaging and lively phase of the group meeting. The most
important rule is that the therapists should not do the mentalizing work for the
protagonist or the group as a whole. This sets MBT-G apart from other therapies
that utilize various forms of “individual therapy in groups.” The therapists’ main

Engaging the group members in mentalizing events

task is to promote the protagonist’s and the other group members’ ability to
perform an integrated cognitive and emotional understanding of important
events in their lives and what is going on between people and oneself in the here
and now.
Example: Beate has attended the group five times and has mostly commented on others’
material. There have only been disparate and limited pieces of information about herself.
On this day the group gets a message from Beate’s individual therapist that she might not
come to the group. Then there comes a message to the contrary and right after that another
one yet again with the opposite information. It is obvious that Beate is not doing well.
Beate arrives around 10 minutes late, at the end of the opening phase. She is welcomed by
the therapists who comment that they have received different messages, and that it was
good that she came. Beate gives a brave smile, but is breathing with constraint and says
that it has not been easy. The therapists say that it is obvious that she is struggling with
something emotional so perhaps it is best if she can go first? The others think this is a good
idea, but Beate is hesitant, she stutters and says she can hardly talk, that she doesn’t know
what to say, that her head is all foggy, and that she is terribly ashamed. With a little help
from the therapists she manages to tell bits and pieces of a love story, enough to give the
other members something to ask about and soon more people are involved in the exploration of the event. It concerned her relationship with a man from Colombia. He was in
prison for drug-related crime, and in a way it was OK that he was “inside,” because then
she knew what he was doing, since she was terribly jealous, but soon he would be released
and this meant a huge dilemma for her with regard to what she should do. He didn’t have
a residence permit, but that was likely not to be a problem since he would simply “go
underground.” Should she take him back, or build up the strength to end it with him? The
thing was, she really cared about him and she couldn’t bear the thought of being alone.
The worst thing here and now was that she was so ashamed to have got herself into this
situation.
At this point, when Beate has told this much of her story, her mentalizing ability is significantly improved. Her head is no longer “all foggy.” She is more coherent and is looking
straight at the person she is talking to. The other group members are strongly engaged in
her story. It has been clarified for all, and at the same time it is clear that simple advice like
“Get a hold of yourself ” is no good here. In a long sequence, they discuss the shame here
and now (“I understand that, but we’ve all been there, and you’re wrong if you believe we
despise you”), people say it is good that she came to the group and told her story, that she
managed to sit through it, instead of running away, and she is praised for how well she told
her story. But why does she have this belief that she cannot be alone? What is that about?
And what is it about this man that attracts her? Does she forget all that is bad about him
when he looks at her in certain ways? Doesn’t she really deserve better? Why do her relationships with men so quickly turn destructive? In a long sequence, these themes are
explored in concert with the other group members. The sequence has no conclusion, but
Beate is far more composed than when she came and she ends by thanking the group for
listening to her, and she says she now has a lot to think about.

In this example, there are no problems in engaging the group members in the
exploration of the event and its ramifications. The problem lies perhaps more in
holding them back so they don’t get overly eager and take over, trying to solve

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the problems for Beate. The function of the therapists here is to remind the
group, in different ways, of the mentalizing stance. What Beate needs is food for
thought and stronger anchor points for her fleeting value system.
In the next example, there are also no problems in engaging the other members. It is about a patient, Kristine, who has been in the group for two and a half
years and is one of the veterans, but who has been a bit stagnant in her process
and is still hanging on to a good deal of black-and-white thinking.
Example: Kristine brings in an event that has to do with her father. He moved in with her
a while back when she wasn’t doing well, and he has stayed there. Recently Kristine has
suggested that her boyfriend’s sister, together with her two children, should stay in their
apartment for a week, because she is being harassed by her ex-husband who is threatening
her. Kristine’s father, however, has put his foot down, and said no to this. Kristine has
never seen her father so determined and is taken aback by this. Consequently she has now
moved in with her mother and doesn’t want to have any contact with her father. This sets
off a lot of activity in the group. Many of the members have thoughts and comments.
Some of it concerns clarification of the circumstances. And a lot is about identifying the
failure of mentalization. What is the problem here? Obviously there are many problems.
The boyfriend’s sister is in trouble. How much should you help your family? And what
about the father? “Good of him to move in with you when you needed help, but why didn’t
he move out again?” After some time the group is focusing on Kristine’s relation to her
father. “Surely he has some rights too, as he has continued to stay at hers?” But why didn’t
Kristine and her father agree on how to handle this situation? Kristine comments that she
“has never been turned down by her father before.” He never “puts his foot down.” Never
put his foot down? Other group members wonder about this. Why is this so? “Fathers
normally put their foot down! What kind of relationship do you two have?” “You must
have been spoilt, in a way?” “Real bummer! So that’s why you moved in with your mother?” There’s a lot of involvement and wondering and Kristine is progressively taking in
what is being said, with more and more curiosity and reflection. In this sequence, the
other group members do a lot of work, and Kristine finally thanks them for all their dedication and says she has a lot to think about.

Identifying and working through of events in the group
In a psychotherapy group, the members will be in constant interaction with
each other, verbally as well as nonverbally. They will inevitably interpret each
other implicitly as well as explicitly. Most of this flow of intersubjective transactions will occur outside of the members’ (including the therapists’) awareness. The therapists should rarely intervene or comment as long as the
communication serves the purpose of the group. However, each group meeting will present events that need special attention because they signal problems
with mentalizing here and now. Emotional reactions should always be commented on. If none of the other group members do it, the therapists should
take the initiative. In the same way, misunderstandings or unwarranted beliefs

Identifying and working through of events in the group

should be commented on and challenged. In a well-functioning group, the participants will deal with events like this on their own. The therapists should
support this by an attentive presence and contribute in clarifying and working
through the events. However, often the therapists must take the initiative and
bring here-and-now events into focus:
“Wait a minute; it seems to me that Lise, who brought this theme in, has dropped
out of the discussion. Is this true Lise? Did something happen that made you
withdraw?”

Psychodynamic group therapy traditionally focuses on the here and now.
MBT-G actually has a stronger invitation to members to bring in external
events than most other group therapies. Nonetheless, MBT-G strives to achieve
a dynamic interplay between “there and then” and “here and now.” Events here
and now provide especially potent therapeutic opportunities because they (1)
often illustrate what is being talked about “there and then,” and (2) demonstrate
in real life what is likely to happen in the problematic “external” transactions
that members talk about. Good therapists are able to make use of the here and
now in creative ways. As we will see, this is especially true when it comes to
therapists using the relationship to themselves and their own feelings in the
therapeutic process.
The most common reason for addressing an event in the group is that it is
accompanied by an emotional reaction. This gives it a natural and immediate
character of a here-and-now phenomenon that needs to be explored. The task is
partly to understand the emotional reaction. Is it shame, guilt, envy, irritation,
sadness, or what? The reader is referred here to the item on the MBT-G rating
scale that concerns focus on emotions, about emotion awareness, tolerance for
emotions, conceptual understanding of emotions, and ability to express emotions. Why are patients reacting as they do? Note here that the therapists should
maintain their not-knowing stance and explorative attitude, even if it may seem
obvious what it is the patient has reacted to. We recommend interventions such
as: “I can see that you are sad, Grethe. What, of the things you’ve told us, are you
most sad about?” What makes emotional reactions natural here-and-now phenomena to be explored is that everybody is bound to react to it, and that each
does so in accordance with their specific predispositions.
Example: Hanne has asked for time in the group. When there is an opening, one of the
therapists turns to her and invites her in. She turns away, while making a face that is
difficult to interpret, but that indicates that she is upset in some way, and she mumbles
something about “Now is not the time . . . I can’t speak.” The therapists firmly advise her
to say something on what this is about. Stuttering and disconnected, she tells the group
that during the meeting she has become so annoyed with Eva that everything else has
been lost to the background. But it’s only her own fault and she doesn’t want to burden

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Eva with this, so therefore . . . Now she has caught the attention of not only the therapists. The other group members engage and more than one say that they understand the
dilemma very well, but that it would be wrong to just stop here and sweep this under the
rug. The therapists ask whether they can find out whether Eva (who was the main character in the last sequence), can endure Hanne’s feelings. Hanne looks squarely at Eva,
who smiles (bravely) and says that “Sure, I can handle that.” Hanne calms down a bit and
says that it’s the same thing she has reacted to before, that Eva pisses her off, because Eva
does so many stupid things and gets so self-destructive, and that she recognizes this
pattern so well from her own life. During this elaboration, Eva changes, her expression
alters, and somebody comments on this. Eva, who is now struggling to hold back tears,
says that “It’s always like this, there’s something wrong with me. Someone always reacts
to me and gets cross with me, that’s why I stay away from ordinary people.” Hanne is
even more upset now and says “Yes, right, she can’t take it, I torment her. I also create a
mess with others all the time.” The therapist now comes in to say that he “can’t see that
Eva can’t take it. Eva is still in the group, but she’s reacting emotionally and emotions are
what the group is about.” The attention is now turned towards Eva and her emotions.
One member points out “But Eva, right now you’re doing what is most difficult for you.
You’re sad and you’re letting other people see that.” Eva: “Yes, and it’s horrible, I’ve been
on my way out the door.” Therapist: “But you’ve stayed in your chair.” Eva: “Yes, I don’t
know why.” Eva now joins in the reflection of her handling of sad feelings, of how she
deletes them before she feels them, like when her father died, but that it has become
more difficult lately. But she is just beside herself now, she says, and feelings surge about
how useless and hopeless she is and she should just go and hang herself. Some of the
other members nod, recognizing such feelings, and encouraged by some comments by
the therapists, they talk about tolerating feelings and how difficult it is. Eva says that the
first reaction, like how she reacted here, “Oh yes, it’s no problem at all,” comes automatically. That’s how she’s always reacted. That is the nice and compliant doll. After dwelling
on this, the therapists again turn to Hanne. What does she think now, after hearing how
important this theme is for Eva and how Hanne actually helped bring it out into the
open? Yes, Hanne understands that, but nonetheless it is hard for her. Hurting others is
the worst thing she knows. “What is so bad about that?” the therapist asks. Well, she
thinks it’s awful and it is nearly unbearable to think that others should suffer nearly as
much as she does. The therapists ask for the other members’ thoughts on this. Different
aspects are brought to light, but the most strongly felt is that Hanne (“like most of us in
this group”) seems to take too much responsibility for others’ emotions. The significance of personal boundaries is also discussed. “It’s as if you don’t separate yourself
from others, so that the suffering of others becomes your own.” Eva is now actively
engaged and connects what happened in the group between her and Hanne and what
seems to be a general problem when relating to other people. The mentalizing ability,
which collapsed at the beginning of the sequence, is now reestablished and she participates in exploring important aspects of her own feelings, own self-regulation, and
boundaries towards others.

Variations on the “event” above will occur in all therapeutic groups. What is
important is that the therapists identify the event, stop and explore the
experiences of all involved members with regard to current emotions and

Identifying and working through of events in the group

interpersonal transactions, determine what significance the event has for
the involved members and for the group as a whole, consider the ramifications for the protagonists, and involve the other group members in this
endeavor.
The outcome is not always as good as in the preceding example. The following
is another example from a group where an external event set off an internal
event that was so overwhelming that the group didn’t manage to explore the
external one.
Example: Berit has told the group there is something she “just has to talk about.” The previous week she found out that her boyfriend had been called to the police station for
questioning and that this had to with him having sexual contact with girls he met through
the Internet, some of whom were minors. The theme had many ramifications and implications. Most of the group members participated in the exploration, but not Lisa, who
seemed absent-minded. The therapists were aware that Lisa had a tendency to dissociate
in the group and they addressed her and asked her where she was in relation to what was
being discussed. Lisa says that she has “switched off ” and that she can hardly breathe. She
asks for permission to go and get some water. When she comes back she says she can’t
handle this theme and asks to leave the group meeting. Lisa’s reaction is now the center
of attention. The therapists try to engage the other patients in an exploration of what is
going on, but Lisa simply states that she can’t handle the theme and that she has other
important things to do this afternoon and that she can’t ruin her day. Berit now feels
guilty for bringing the theme in to begin with; especially bringing it up without first briefing the group on what it was about, and the focus from the others is now on how Lisa is
doing. Berit finally gives praise to Lisa for being so outspoken with her boundaries. The
theme of Berit gets lost.

In this session, the purpose of the group is sacrificed. Lisa is praised for
“being so outspoken with her boundaries,” but it has come at a high cost. The
cost was a blocking of the group’s collective mentalization ability. Lisa
blocked it by making a certain theme taboo. At the same time, Lisa revealed,
by her incipient anxiety attack, that she had serious difficulties in dealing
with this theme. This is a very complicated situation for the therapists and the
group as a whole. Looking back we might say that the therapists should have
dwelled longer on the dilemma of the group as a whole, for example, its main
method of free and open communication versus Lisa’s needs and her anxiety.
If Lisa persisted with her ultimatum to the group after a thorough discussion,
it would probably have been better if she left the group so that the group
could do its job. The content of her thoughts and emotions, including her
reaction in the group, should be worked on in Lisa’s individual therapy. It is
important to underline that in MBT-G, unlike traditional group analysis,
“the group” is not idealized or made sacrosanct; it has a job to do and must be
allowed to get on with its work, even if it means Lisa dropping out, at least for
this session.

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The closing of sequences
A whole group session can easily be filled with just one event and what it sets off
in the others and in the group as a whole. But within the MBT-G model, events
have to be closed in order to make space for other events. When should the
therapists start thinking about closing? It depends on many things. One is the
graveness of the event. Groups like this do sometimes deal with questions of life
and death. A serious suicide act demands more time and attention than a quarrel with a friend. Another factor is the relevance of the event for the protagonist,
and for the group as a whole. Sometimes trivial matters are brought up. Other
times, themes will represent core conflicts and hold opportunities for significant changes. Or it can be a conflict in the group that has a large impact on the
group’s ability to mentalize in a collective sense. Therapists must take such
broader implications into consideration and adjust the timing accordingly. It is
also of importance at what point during the meeting the sequence takes place.
There is more time at the group’s disposal at the beginning than at the end of a
session. How many members there are who are “waiting in line” is also of
importance.
To what degree a sequence has engaged the other members also counts. With
a highly engaging sequence, where many participate, where the temperature is
high, but not too high, and where there are still interesting comments, one is
normally hesitant to close. However, it is the concern for the member in focus
that counts the most. Even if the sequence is for everyone, one should make
sure that nobody “steals the scene.” This can easily happen. Someone else may
relate to the story being told, and bring in a similar, but more “juicy” story that
catches all the attention. The therapists should therefore protect the main actor’s
“ownership” of the scene. A turntaking sequence is approaching its end when it
has been “saturated” with perspectives. It is when people start repeating themselves and nothing new is really emerging and when the temperature is dropping. And not least when the main actor has declared that he/she has “absorbed”
the comments and seems “satisfied.”
The beginning of the end of an “ordinary” sequence can be that the therapists
say to the protagonist something along the lines of: “We’ve been discussing this
for a while now and looking back at this event, what do you think about it now?”
This type of question is beneficial in itself, as it appeals to the member’s metacognitive ability. The answer will indicate whether the sequence is reasonably
finished. If the member says “Well, I’m still just as pissed off with this BMW
guy” or “I don’t know what to say, I’m pretty confused” there is still some distance to cover. It’s different if the answer is something like “I’ve got a lot to think
about now.”

Starting the group

Every now and then therapists may feel that the sequence hasn’t brought
about any changes in the main actor. A lot of time and attention has been spent
but it is as if it hasn’t led anywhere. In this case, this should be said: “How is it
Irene, have you learned anything from this?” Irene: “To be honest, no!” Therapist: “It was important that you said so. Then we have a problem. But what is the
problem? It is apparent that we’ve been doing something that didn’t quite work
for you. What could we have done differently?” Notice that this intervention
also stimulates metacognition.

Starting the group
MBT-G can start in different ways. It can start from scratch, it can start as a
psychoeducational group and subsequently adopt a dynamic mode, or it can be
an existing group that redefines its foundation.
At the Department for Personality Psychiatry, Oslo University Hospital, we
chose the last option. MBT was formally implemented in August 2008, but not
all elements were ready at that moment. The retraining of the therapists was not
complete and the groups continued for some time in their former psychodynamic mode. However, inevitable tensions arose in the nine different groups
of the program when new patients were admitted who had been exposed to
3 months of MBT group psychoeducation. They arrived with expectancies that
were not fulfilled. After a while, the head of the clinic marked the “formal” transition to MBT-G by a letter to all group therapists and former group members
which explained why MBT had been implemented and what consequences this
implied for the dynamic groups with respect to structure, content, and commitment for the patients. Some groups encountered more problems than others.
Not all patients (or therapists) embraced the changes. However, by and large the
message was well received. In most groups, there was lively discussion on what
this would imply for the group as a whole and for each group member. Naturally it took a long time (several months) before the new structure and new mode
of thinking and relating were settled.
When implementing the MBT program at the Bergen Clinics Foundation (a
drug addiction clinic in the Norwegian town of Bergen), the group started as a
psychoeducational group and transformed itself to a dynamic MBT group after
eight sessions. This route has different kind of problems that must be addressed.
Redefining a psychoeducational group might be more difficult than redefining
a dynamic group. In a dynamic group, there is a focus on group dynamics from
the very beginning. Members learn about interaction, process, and the significance of spontaneous involvement. A psychoeducational group is closer to a
school class. It is possible to attend without being emotionally involved and

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therapists do not dig into events or their manifest and latent conflicts. On the
other hand, patients in psychoeducational groups may become eager to get the
“real thing” when they learn about dynamic MBT groups. The transition
depends also on the motivation and level of personality functioning of the participants. We have witnessed both smooth transitions and strong resistances.
The transition for the group in Bergen was troublesome. The members were
females with BPD and drug addiction. Most of them were distrustful and
adopting a mentalizing stance was not their favorite remedy for coping with
other people. Listening to therapist experts was far easier than engaging in
mutual exploration of shameful experiences.
The easiest way is to start the group from scratch. However, one should note
that there is no shortcut to MBT-G. Like any other dynamic group it has to
develop through the typical phases that encompass the members’ need to get
to know each other, developing trust in each other and trusting the therapists,
to agreement on basic group rules and learning the MBT mode of group work.
The struggle with these themes will gradually materialize as a certain kind of
group culture. This manual will not cover such basic issues of group psychotherapy. Readers are referred to general textbooks, for example, part 9 of
“Group analysis and psychodynamic group therapy” (Karterud, 1999). The
author has no experience of starting a MBT group from scratch. However, he
has supervised several such groups. The impression is that a well-established
group culture is reached somewhat faster than is most often the case with
group analytic psychotherapy. We would suggest around 6 months compared
to around 1 year for group analysis. Group culture formation in MBT-G is
facilitated by therapists who are more explicit with respect to goals, means, and
working procedures.
Therapists should not be too obsessional in defining and working through
mentalizing failures during the formative phase of the group, or when integrating new members. Members need to get to know each other. A good way is to
ask for facts which contextualize events, such as “Where did you live then?”
“Have you additional siblings?” “So you started quite early with self-harm” and
“Did you complete the high school?” The therapists can gradually sharpen the
interpersonal focus and educate members through concrete group experiences
into how the MBT-G model works.
Most often MBT-G will take the format of a slow-open group. New members
are admitted when existing ones leave. New members will experience processes
similar to what other members have gone through. Becoming a new member in
a formal sense is far from being a committed member based upon personalized
meaning and profound experiences of group cohesion. Every new member has
his/her own trajectory from being a curious (but typically skeptical) newcomer,

Starting the group

maybe through a period as outsider, to the role of a committed member that has
internalized the value system of the group.
Example: Anne, in her fourth meeting, expresses some disappointment and criticism of
the group. She finds it somewhat slow and passive and asks for “more direct feedback.”
Kristin seems to be an eager listener. She has attended the group for around 3 months,
although with some absences. She has been mostly listening with only sporadic and short
narratives from her own life. The last session was the first one where she talked about herself in more depth, in a sequence lasting around 40 minutes. The main theme in her family
history concerned over-involvement from others and vague self-­boundaries. It concerned
who was the proper owner of themes, conflicts, and emotions in the family. Kristin: “I just
want to say, Anne, it takes time. I was also a kind of frustrated, a kind of outsider here. But
I want to tell you that since the last session, the stuff I told about my mother and my cousins
and everything they struggle with, it continued in my head through the week, but then it
struck me, and I thought that the group agreed with me, that I should keep more distance,
and I felt that the group were with me in a way, I didn’t feel alone, I thought I’ll do the best
I can and that there are people here that agree with me, so I didn’t feel alone.” Lise: “Well,
great! We’re lined up. Wow!” Kristin: “Yes, I felt strong support when we talked about it last
time and it made a difference. I realized that much of it were their problems, my mother’s
and the others. I got some kind of distance from it.” The therapists acknowledged her
experience of enhanced mentalizing with smiles and commentaries: “It is clear that last
session was important for you and that you got something that made it possible to reflect
in another way and thereby think other kinds of thoughts about the matter.”

To become a group member in this more profound way seems to be linked to
this phenomenon of having told one’s story and having experienced acceptance,
engagement, and curiosity around it. Before such an experience of mutual
involvement it might sound artificial to present isolated events and fragments
of one’s life.
Example: During the opening phase, the therapists address Hilde and say that she got
started with something last session, but seemingly did not get to the end, so they wonder
if the group should just take up the thread. It is her sixth group meeting. She mumbles
“Yes, well . . . it’s OK if you think so,” but adds that there isn’t any news from her side. Basically she is rather bewildered with respect to the group. Today, for example, she didn’t feel
like coming. Actually she doesn’t know what she is doing here or what people expect from
her. Other group members ask curiously if she perhaps has not been in therapy, in particular group therapy, previously. “Oh yes, I have,” and they get a history of frequent hospitalizations on a mental health center support ward, adding up to around 1.5 years,
because of repeating self-harm. Through this story, group members learn about her parents and her boyfriend and not least about the “power struggle” which emerged between
her, her family, and the health authorities. She hated being controlled, but at the same time
she provoked it by repeating self-destructive acting out. When there was no control
regime around her, she felt abandoned and alone. There was not much treatment in those
years, she said, but she was cared for. She had noticed that things are different here. This is
somehow her own project. She had noticed that nobody controls her here. However, in
some strange manner, this has increased her bewilderment.

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The sequence lasts for around 45 minutes. The other members listen intensely to this
dramatic but also sad story, and they ask simple questions so that the story can unfold in
detail and relevance. People say that the story makes them understand her bewilderment
with respect to what she might say or do in the group. In addition, it seems good that she
now has come to a place where people will be concerned about her, but not in any controlling way. She might be helped to find out what is her own genuine project on the road
towards liberation.

The treatment course and termination
Groups have their typical developmental phases (Karterud, 1999). Most scholars speak about an orientation phase, a conflict phase, a norming phase, a working phase, and a termination phase. The group as a whole has reached its goal
when it has established a mentalizing working culture (phase). There is no
developmental stage beyond that. When the group has reached this stage, the
task is to maintain it, repair it, and renew it. It can be compared to democracy as
a form of government. When it is established, there is no “higher” stage beyond
it (Fukuyama, 1992). However, democracy have to be cared for, magnified, and
realized in all areas of society. It must be maintained, repaired, and renewed.
An established group (and an established democracy) is a vulnerable organism. The members’ lives and the life of the group itself never stand still. Some
terminate and new members arrive, some enter critical states, the therapists
may get ill or may themselves terminate. Such occurrences can push the group
back and therapists will encounter new (but presumably shorter) phases of conflicts about goals, meaning, and norms.
Most MBT groups will last for several years. However, the individual members have only limited time. There is no gold standard for how long this time
should be. At Halliwick Hospital in London, the birthplace of MBT, the treatment length of the regular MBT program is limited to 18 months. Thereafter
one can have some kind of individually tailored aftercare, but no regular and
systematic psychotherapy. At the Department for Personality Psychiatry, Oslo
University Hospital, the upper limit for the group part of the program is 3 years.
However, mean treatment time is around 2 years (Kvarstein et al., 2015). There
is as yet no empirical knowledge on what “is best”—18, 24, or 36 months. It is
an open question if group treatment beyond 18 months increases treatment
effects. For patients with disorganized and dismissing attachment patterns it
may take a long time, often around a year, before they become reasonable stable
and committed group members. It doesn’t feel right then to rush into a termination phase. All parties have invested a lot in the attachment process. Only now
is there time to “dig out the gold,” or, using another economic metaphor, to
“harvest the gain from the invested capital.”

The treatment course and termination

The individual trajectories are of course different from person to person.
Some drop out or terminate early in cooperation with their therapists.
Example: Turid (22) used to drop out of all kinds of relationships. She had dropped out of
school, of all kind of jobs, and had cut connections with all former friends. She lived at the
family home, but the contact with other family members was sparse and superficial. Most
often she was on the run. She used to be picked up by strangers at bars, ending up at some
party, taking drugs or being doped, and couldn’t remember much of what had happened
when she woke up after some days in an unknown place. Then she would flee home, spend
a couple of days recovering, and was off again. She hated it when people asked her how she
was. The group became a nightmare for her. She became dizzy and sick and clung to the
group chair in order not to faint and she was unable to provide any coherent narrative to
the individual therapist when he asked about what happened in the group sessions. Her
drug misuse escalated. One day she arrived drunk at the group meeting. Meetings
between her and her different therapists did not help. She was unable to follow any crisis
plan. After 4 months with frequent absences it was decided to stop the group treatment for
Turid. She continued in individual therapy with the same therapist and expressed her
gratitude for not just being dropped. Slowly she got control of her drug and alcohol problems and managed to take on a suitable job which she held for years while she simultaneously completed high school.

The above example illustrates a “controlled” premature termination. A few
patients are unable to cooperate and have to be thrown out of the group. We
refer to the example in item 7 in Chapter 4: “Managing authority.”
However, most patients stay the course. And when is it completed? Having
achieved control over self-destructive acts is one indicator. For example, when
drug misuse is under control, when acute hospitalizations are no longer necessary, when self-harm has gone, or when suicide attempts and suicide thoughts
are minimized. Other indicators include being stabilized in school or employment. However, such behavioral indicators should be coupled to clear signs of
enhanced mentalizing abilities. It will typically express itself in (1) the quality of
the stories that patients bring to the group, and (2) the ability to partake constructively in the ongoing mentalizing discourse, in particular around hereand-now events.
The narratives that are told in the group become more articulated, focused,
and relevant, indicating that the individual has internalized the group discourse
style. There is less need for clarification through the group. The protagonist has
done the clarifying (and mentalizing) job by her/himself. The narratives are
also more complex and above all they will contain a reflective perspective.
Example: “Yes, I have something I will tell you. It happened a couple of days ago. We visited my parents-in-law. I guess you remember how scary my father-in-law has seemed to
me. It used to make me feel dumb somehow, and I have been nervous to talk about it with
my partner. Well, there was a whole bunch of people there. Then it struck me how avoidant my mother-in-law was in setting limits for the children. They were allowed to mess

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around. However, I stopped them when they started to tamper with our PlayStation. I just
said no, plain and simple. The most important thing was that I experienced my father-inlaw quite differently. He should have supported his wife, but he was absorbed in talking
about himself. I believed I listened better this time, and it struck me that what he talked
about was rather trivial. And partly untrue, I believe. I have never before had such kind of
thoughts, but thought them then, like “You are rather self-preoccupied.” It’s strange to
think such thoughts, me who has been scared to death by him. I discussed it with my partner afterwards. Not to criticize, I said, but it struck me that your father just lets things
happen around him, as with the children, as long as he gets attention on himself, and
honestly, what he talks about is not that interesting. I chose my words carefully because I
know my partner hates criticism towards his parents. However, this time, strangely, he
nodded and then we talked about it. I believe it is the first time we have managed to talk
seriously about them and us.”
Example: Berit (34) has had leave from the group for about a month. She has visited the
homeland of her boyfriend, for the first time, and met his family. The group members
were eager to hear about the tour. “Well, by and large it was fantastic. However, there were
some real bumps along the way. You can imagine. The family was huge. Quite different
from here. Aunts, uncles, and cousins everywhere, and neighbors. And lots of food, and
wine, and laughter and dance. A real hubbub. We moved around, staying with his parents,
siblings, and uncle. And me, not really speaking the language very well. How could I
understand when they joked? And they did most of the time. By the third day I was tired
out. I woke up and just started to cry. Do you know what happened then? Strange really. I
began to think about the group, about all of you, and I started to talk to you. Someone said
this and someone said that, and I got hold of things in a different way. I decided to talk
with my boyfriend and told him that I needed a break, not because I didn’t like his family,
but I had to breathe, I had to breathe together with him, and then we did things that day,
just the two of us, and I got grounded. It was as if we found an outlet together; we realized
that I, we, needed space to breathe, and then it was quite OK with the huge family, and
slowly I mastered the language better. It was an immense experience.”

Both of these examples, coupled with signs of social stabilization, indicate that
for those people, group therapy is approaching an appropriate ending. Most
patients terminate without any follow-up, while some get sporadic individual
sessions for a limited time.

Coordinating and mentalizing meetings between
all involved therapists
MBT contains several treatment formats and several therapists. A precondition
for good treatment is that the therapists are informed about their respective
roles, that they coordinate their initiatives, that they have a reasonable consensus on the psychodynamics and the personality of the patient, that they respect
and tolerate the diversity of different treatment formats and different therapists,
for example, that one and the same patient may have different kind of transference to different therapists and may evoke different countertransference.

Coordinating and mentalizing meetings between all involved therapists

Accordingly it is important to have regular meetings for coordination and
reflection between all involved therapists. This entails team meetings, supervision meetings, ad hoc meetings, and meetings every 6 months for evaluation of
treatment progress. The following clinical examples will illustrate these points.
The patient who evokes different kind of countertransference in different
settings:
Else (24) is a self-destructive and self-harming woman who fulfills eight of nine borderline criteria. She has dropped out of schools and jobs and lives a marginal life around a
gang of addicts. She drinks habitually, in heavy doses, often through night and day and
can perform “crazy things” in order to gain higher status in the gang.
By admission to the MBT program she “agreed” that her drinking habits “were alarming” and had to be moderated. Once started, it was not that problematic any longer. However, fellow group members were shocked when hearing her drinking stories. It does not
impress Else. She believes that “all the mess in the group about the drinking” is due to
bourgeois and moralistic group therapists. She doesn’t care and by the way “she actually
has not so much to tell the group.”
During the first months her mentalizing level was around zero. The group therapists
had to handle their countertransference aroused by denial and rejection and an experience of meaninglessness and no prospect of progress. However, the therapists in the psychoeducational group reported on a different side of the same patient. She attended
regularly and looked interested and motivated. The individual therapist could also report
on a greater sense of alliance. The alcohol excesses did worry the patient, although she
fluctuated. She had agreed to be referred to a detoxification unit. A fifth therapist had been
engaged for that project.
In a meeting between all therapists they agreed to stick to the alcohol focus, they
acknowledged that the alliance can increase, and that a main issue in this first phase of
treatment should be to “hold and contain” the contradictory parts of her. One part seems
to realize that life is too hard and that she needs to be taken care of, while another part
could not care less and may perform spectacular and dangerous things that demonstrate
that she doesn’t give a damn. The group therapists became more relaxed and trusting
about the effect of the treatment system as a whole.

The patient who frustrates the group therapists with surprisingly poor
functioning:
Fredric (23) is referred because he has dropped out of work and isolated himself from
family and friends. He gets a diagnosis of mixed PD with paranoid, borderline, avoidant,
and obsessive–compulsive traits. In better functioning periods he hangs out with a sociocultural subgroup. In the MBT group he becomes “totally blocked.” He can hardly utter a
word and he “gets sick.” The group therapists are surprised by his poor functioning and
wonder if the assessment has been appropriate. He has indicated that he periodically
“hears voices” and the group therapists believe he at least fulfills criteria for a schizotypal
PD, if not schizophrenia.
Fredric talks about his group experiences with the individual therapist. There are people in the group who he ordinarily would not socialize with. The manner of speech is
strange. Things seem just to float around. Nobody sticks to “the topic.” And people

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interrupt each other. There is no respect. Fredric had tried to indicate with his hand that
he wanted to say something, but was overlooked. However, in his individual therapy he
also displays interest in this strange way of being together. Many hours are devoted to
these themes. Being informed about the focus in the individual part of the treatment, the
group therapists calm down. “It’s OK. We can contain him in the group while you work
with his experiences. Maybe he slowly can get along.” After some months, Fredric is able
to endure the group without clinging to the chair. He starts to make sense of what it is all
about and slowly manages to comment upon the discussions in a rewarding manner.

The patient who exploits “sleeping” group therapists and recruits the group in a
frontal attack on the individual therapist:
Rita (30) is an immigrant from a Latin American country and brings with her strong traumatic experiences. In Norway, she has had to flee from several abusive men. She has been
referred from the rehab program of the local crisis center.
In her individual therapy she reacts with strong disgust at the male therapist. She has
the opinion that he is “an old pig that is after her.” She talks about this several times in the
group and succeeds in recruiting a subgroup that supports her views that “it is like an
abuse to be exposed to such a therapist.” She wants another one. She asserts this strongly
to the individual therapist, saying that the whole group supports her request for a new
therapist. Anything else would just be abusive, “and I assume that the system here cannot
just be protected to any cost.” Needless to say, the situation is not easy to handle for the
therapist. He witnesses psychic equivalence to an almost delusional degree. What strikes
him as most curious is the reference of support from “the whole group.” He contacts the
group therapists to get their side of the story. Yes, they admit that perhaps they were “not
alert enough” last session and that Rita was not challenged in her criticisms against the
individual therapist. They could not give any good reasons for their passivity but promised to raise the matter in the next group session. It turned out to be a lively and emotional
meeting. Rita and her subgroup were challenged and the seemingly united campaign
against an external enemy collapsed. Rita’s emotions and thoughts about the individual
therapist continued for a while. However, the “solution,” with the support of the group,
was abandoned. Gradually it was possible to reflect upon several sources of these painful
emotions.

The patient who devalues the group and the individual therapist who encourages
the group therapists to “carry on carrying on”:
Reidar (33) became seriously depressed when his father died and literally tried to drink
himself to death in the aftermath. He didn’t succeed, but developed chronic pancreatitis.
Since then he had lived a cumbersome and marginal life of drug abuse and occasional jobs
far below his potential. He had “lost all illusions,” thought “civilization is a great lie” and
he was tired of “this lousy life.” There were some short affairs, but he could not sustain any
intimate relationship. He knew a lot of people, but had no close friends. The social
rehabilitation office referred him for treatment: “Otherwise, nothing will happen to him.
He’s just drifting.”
Reidar liked the individual sessions. They had an intellectual aura that appealed to him
although he was disappointed by the fact that the therapist would not discuss the content
of the many fascinating books he noticed on the book shelves. But the group was “a

MBT-G in different contexts

nightmare.” The therapists were “passive and seemingly disinterested” and the fellow
group members were “lazy and stupid.” They clung to modes of existence which he had
long since left. He just “would be dragged into the mud by them.” When the individual
therapist asked him to be more concrete about his experiences of individuals and events
in the group, he responded with resignation that “it was too boring.” The others just made
him feel low. He regarded it as ridiculous to open up for such a bunch. They just hadn’t
anything to give. He preferred people at the cafés downtown.
No wonder that he hadn’t got the “energy” to attend the group regularly. On average, he
turned up at every second meeting. His absences were addressed and explored repeatedly,
but to no avail. The group therapists complained to the individual therapist who assured
them that he was “working on the case.” However, when asked, Reidar had nothing to say
about the group except for general devaluating phrases. It was as if he was not mentally
present in the group. The group therapists wanted to throw him out and several meetings
were held to discuss this. Each time he promised to do his best (he appreciated the individual therapy), but his behavior did not change. All this changed when he found a new
and better functioning girlfriend. His own problems with intimacy could not be denied
any longer and he found a new motivation for psychotherapy (which he had previously
experienced as a request from the rehabilitation office). Now he turned it into his own
project.
Approximately 1 year had passed when the individual therapist asked his customary
question, “And how was the group last week?” and got the surprising answer that “Oh yes,
it was fine.” Reidar had presented a relational problem with his girlfriend, received
engaged commentaries and questions, and then he was hooked. A long and meaningful
group sequence followed. This was a quite undramatic, yet highly significant turning
point. From then on, he hardly missed a group session.

MBT-G in different contexts
In this manual, we outline the principles of MBT-G for its most common format, which is intensive outpatient treatment. But MBT-G may also be used in
other settings, for example, as part of short-term or medium-term inpatient
treatment, or as group psychotherapy in private practice. It is inherently flexible. The degree of group cohesion, degree of psychopathology, and alliance will
guide the amount of control the therapists should have over the group. In a psychiatric short-term ward, one is unable to build substantial group cohesion
because the patients come and go in quick succession, and because their current
mental disorders put demands on concentration and attention. This implies
that group therapies should be highly structured. MBT-G allows for this and
makes it possible for the therapists to have good control. In practice, this will
mean a synthesis between psychoeducative and dynamic MBT-G. In one and
the same session one can oscillate between psychoeducative and dynamic
sequences. A good starting point would be the four meetings about mentalizing, failure of mentalizing, emotions, and emotional regulation, as described in
the MBT psychoeducation manual (Karterud & Bateman, 2011). One may

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rotate between these themes and spend more time on discussing the different
participants’ own experiences. If it is to be used in short-term, specialized wards
for people with a higher level of functioning than what one will find in more
crisis-ridden, psychiatric short-term wards, one may add special group exercises designed to promote mentalization (Allen et al., 2011; Karterud & Bateman, 2011).
In intermediary and long-term wards, the structure and technique will
depend on the type of clients. Modifications will of course be needed if most
patients have schizophrenic spectrum disorders. If treatment of addiction is
the target, the group therapy could be a more structured version of what is
described in this manual. In institutional treatment, events in the milieu
will have a strong priority besides external events and events in the group
(Kibel, 1987).
In institutions, one should also take advantage of the interchange between
weekdays and weekends. Some wards may even be closed over weekends. It is
useful to establish “before- and after-weekend groups.” In Friday’s “beforeweekend group” the participants take turns in discussing which mentalization
challenges they will face during the weekend, for example, containing anxiety
or depression, resisting ideas about suicide and drinking, meeting one’s family
or neighbors, or coping with loneliness. The therapists should keep an interpersonal focus. Which interpersonal encounters or situations might increase the
weight of the symptoms and which might ease them, and why would that be?
What can patients do to find out more about this and handle it satisfactorily? In
Monday’s “after-weekend group” the participants go through their experiences.
What happened? What does the protagonist think about what happened? What
do the others think?
Mental health centers (MHCs) are key organizational structures for mental
health services in most European countries. They run a number of group therapies, often directed by specialized group units or group clinics for outpatients.
Many of these group units have developed from previous day wards. In modern
mental health services, the boundaries between a psychiatric day ward and an
intensive treatment program in a group unit are vague. Modern developments
favor intensive outpatient treatment programs and MBT-G has its natural place
in such programs which should exist in every MHC. MHCs face many patients
with different kinds of personality pathology, as well as varying degrees thereof,
without the substantial identity problems and self-destruction that is part of
borderline pathology. Many of these patients would still struggle with making
use of conventional psychodynamic group therapy. For these patients, MBT-G
represents a clear and structured alternative, with or without parallel individual
therapy.

Similarities and differences between MBT-G and other types of group therapy

In private practice groups, the participants often have a higher level of functioning, being able to fulfill basic educational, work, and family life roles. Selfcohesion and identity will be more robust, the attachment patterns will be more
secure, object constancy will be firmer, emotional regulation better, and way of
life will be less destructive. Nonetheless, these people also have problems with
self-esteem, work performance, and relationships. In such higher-functioning
groups, a strong group cohesion will more easily develop and it will be a natural
part of the group process to regulate time and attention for each individual participant and problematize the reasons for any asymmetrical distribution. Usually
this does not happen in a structured way to begin with, as this manual recommends. Any degree of turntaking that might take place also happens more spontaneously. Can “ordinary” psychodynamic group therapy still make use of
anything from this manual? In our opinion, yes—in several ways. Therapists will
benefit from recognizing and differentiating in a clearer ways between good and
poor mentalizing. They should know about psychic equivalence and pretend
mode. Also within psychodynamic group therapy therapists should stop aggressive escalation, take control over the group when necessary, and make use of
techniques that are appropriate in order to promote mentalizing in irreconcilable
participants. Furthermore, therapists should help groups out of collective pretend modes, assist patients and groups to clarify interpersonal events, and assist
in a collective exploration of such events, focusing on what kind of mentalizing
failure, if any, is involved. However, in well-functioning groups this does not need
to be as structured as is recommended in this manual. In well-functioning groups
this will unfold more spontaneously from the group process, almost “on its own,”
although there is of course no such thing as “on its own.” In reality, this apparent
spontaneity happens as a consequence of a long-term and fertile interplay
between the group therapist’s theories, imagination, and practice, and the resonance this invokes in the group. The therapist’s discourse ideal tends to be established in the group’s matrix if he/she is clever enough.

Similarities and differences between MBT-G
and other types of group therapy
Cognitive group therapy
There are several varieties of cognitive group therapy. They have the following
in common:
◆
◆

a clearly defined (cognitive) goal
the therapists take a clear and authoritative role as leaders, both regarding
content and process

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Main principles for mentalization-based group therapy

◆

a pedagogical focus with regard to (didactical) learning and skills training

◆

short inserted “lectures” by the therapists

◆

◆

◆

the group dynamics should facilitate the above-mentioned intent and interpersonal events here and now are not exploited, or to a very limited extent,
as therapeutic material
the therapy is supported by rather extensive work books which explain cognitive theory and also serve as note pads for individual (home)work
specific recommendations for individual homework.

Most variants of cognitive group therapy, often called “cognitive therapy in
groups,” are more similar to psychoeducative group therapy than psychodynamic group therapy. A particularly thorough variant by Michael Free (Cognitive Therapy in Groups; Free, 2007) serves to illustrate this. This is a manual for
a time-limited therapy set within 24 meetings. The content of every meeting is
meticulously defined and the text is accompanied by 150 pages of forms and
PowerPoint illustrations which are presented to group participants. In this way,
the participants have to relate to a massive theoretical corpus. Compared with
this therapy, mentalization-based psychoeducative therapy is actually quite
dynamic.
There are few resemblances between cognitive group therapy and MBT-G. If
any, it would be that the therapists of both formats seek to define the group goals
as clearly as possible, and that the therapists are actively engaged in making the
group structure support the goals. Another common denominator is emphasizing so-called chain analysis. We will discuss this in the next paragraph. Cognitive group therapy and MBT-G are otherwise widely different genres. MBT-G is
a kind of therapy that activates the group members here and now in a collective
dynamic discourse where intersubjective transactions are in focus. Cognitive
therapy in groups is more like a school class or a course where you are given
justified recommendations for working at home with the curriculum that is
elaborated at school.

Groups for skills training in dialectical behavior therapy
The first year of DBT is defined as combination treatment. The group component is a premise for the individual therapy, and vice versa. The individual therapist, however, is defined as the “primary therapist.” Marsha Linehan (1993a,
p. 103) writes that:
skills training with borderline patients is exceptionally difficult within the context of
individual therapy . . . The need for crisis intervention and attention to other issues generally precludes skills training.

Similarities and differences between MBT-G and other types of group therapy

The treatment is therefore divided into two components where skills training is
ascribed to the group component. In DBT, the word “skills” is used synonymously with “abilities,” and “includes in its broadest sense cognitive, emotional,
and covert behavioral (or action) response repertoires” (Linehan 1993a, p. 329).
The skills in focus are associated with the following main categories: (1)
mindfulness, (2) tolerance for affect, (3) emotional regulation, and (4) interpersonal skill/capability/competence. The treatment is strongly oriented towards
problem-solving and behavioral mastery. There is a skill defined for most things
and half of the book Skills Training Manual for Treating Borderline Personality
Disorder (Linehan, 1993b) consists of different handouts and forms supporting
the identification, practice, and strengthening of the skills in question, or the
identification and restraint of unwanted skills. As an example, “crisis survival
skills” are defined as consisting of “distracting skills” and “self-soothing skills,”
and the manual describes what this implies.
The skills training groups in DBT are usually slow-open groups. They can
consist of two to eight members. They meet weekly, and the meetings last for
about 2–2.5 hours, usually with a break in the middle. Linehan characteristically labels the therapist “the skills training therapist,” not “the group therapist.”
Structurally, these groups adhere to manuals for cognitive group therapy and
do not relate at all to dynamic group therapy, for example, like MBT-G. The
group component in DBT is essentially psychoeducation combined with skills
training where the therapists take advantage of the fact that many patients are
gathered, to support their experiences of recognition, identification, learning
from each other, and mutual support.
In this way, the group therapies of DBT and MBT are widely different. Technically, though, DBT and MBT share some common ground. One example is
so-called chain analysis. In DBT, the focus is on problematic behavior, and as
soon as a relevant piece of problematic behavior is identified, one seeks to
develop an exhaustive and step-by-step description of the chain of events which
lead up to and succeeded unwanted behavior. In individual therapy this will fill
a considerable part of the treatment:
The essence of conducting a chain analysis is examining a particular instance of a specific dysfunctional behavior in excruciating detail. Much of the therapeutic work in
DBT is the ceaseless analysis of specific instances of targeted behaviors. (Linehan,
1993a, p. 258)

Linehan writes that both therapists and patients often tend to overlook the significance of this. Linehan does not define as explicitly as in MBT that the focus
is interpersonal events, but in practice this will often also be the case in DBT. A
DBT chain analysis is as least as detailed as in MBT, but the focus on

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mentalization as “target behavior” is not as consistent. In DBT, one will find
repeated “Socratic questions” beginning with “who,” “what,” “when,” “where,”
“how,” etc. In chain analysis, Linehan recommends an attitude which is quite
similar to the not-knowing stance in MBT: “Rather than understanding the
connections in the chain, the therapist should play the part of the naive observer who does not understand anything and who asks about everything” (Linehan, 1993a, p. 259).
In DBT, detailed chain analysis is first and foremost a task for the individual
therapist. In MBT-G, chain analysis (in a simplified version) focusing on mentalization and intersubjectivity is one of the main tasks. This manual contains
detailed instructions on how patients can be trained in this skill through “practice” within the group. The rationale is that when this ability is internalized and
used outside the group therapy room, both regarding self-understanding and
interpersonal transactions, it will enhance self-cohesion and interpersonal
competence.

Group analytic and psychodynamic group psychotherapy
MBT-G developed from, and therefore shares many points of resemblance
with, group analysis (GA) and psychodynamic group psychotherapy (PG).
Group analytic and psychodynamic group psychotherapy belong to the same
therapeutic “family.” Group analytic psychotherapy is the British version taught
at a number of European institutes for group analysis and which follows the
tradition of S. H. Foulkes (1948, 1964, 1975). Psychodynamic group psychotherapy is the American version, described in textbooks like that of Rutan et al.
(2007). For our purpose, the similarities between these forms of therapy are
greater than the differences. The most important common feature of these therapies and MBT-G is that they are all based upon an active use of the group
dynamics, that is, what happens here and now through the intersubjective
transactions in the group. The relations to fellow patients, the therapists, and
the group as a whole are at the center of exploratory attention. The most important differences are the following:
◆

◆

◆

MBT-G has patients with BPD (in a wide sense) as its target group. GA and
PG have broader indications, and they would be cautious in having several
borderline patients in the same group. GA and PG strive for “balanced”
membership.
MBT-G is a time-limited kind of treatment (1.5–3 years) while GA and PG
are quite often without a predefined time-limit.
MBT-G is usually combined with individual therapy. GA and PG are usually
stand-alone group therapies.

Similarities and differences between MBT-G and other types of group therapy

◆

◆
◆

◆

◆

◆

The purpose of the group, the role of the patients, and the group’s manner of
working are more clearly defined in MBT-G than in GA and PG.
GA and most PGs rely on free group associations. MBT-G does not.
MBT-G therapists start the group in a particular way and issue invitations
for balanced turntaking. This is not done in GA and PG.
MGT-G has interpersonal events as a privileged focus to a stronger degree
than in GA and PG.
MBT-G therapists are more active and this is especially true for their role in
(1) structuring the group, (2) exploring events, (3) engaging other group
members in explorations, and (4) regulating arousal in the group.
Therapists in GA have a greater tolerance for turbulence and chaos and are
working according to principles of “Leave it to the group” and “Trust the group.”

◆

MBT-G therapists make far less use of group interpretations than in GA.

◆

MBT-G therapists make less use of individual interpretations than in PG.

◆

MBT-G therapists are more open (transparent) than in GA and openly explore their own contribution to events in the group, and use this as a model
for a mentalizing stance.

Interpersonal group psychotherapy
In our comparison with different types of group therapy, we will allow some
more space for interpersonal (group) psychotherapy (IPT) since IPT is not as
well known as general psychodynamic therapy, and since this tradition incorporates a form of group therapy sharing a number of similarities with MBT-G.
Interpersonal psychotherapy is founded by the work of the American psychiatrist Harry Stack Sullivan and professionals following in his wake. Irvin Yalom
has influenced several generations of group psychotherapists, and his renowned
textbooks are strongly informed by interpersonal theory and practice (Yalom,
1995). His own personal version of interpersonal group therapy is inspired by
his interest for continental existential philosophy (Yalom, 1980). Yalom is not
only extremely interpersonally oriented in groups, he also strives to be as
authentic, open, honest, and present a therapist as possible in a therapeutic
group. He promotes an ideal of being as transparent as is humanly possible with
regard to his own thoughts and feelings. Moreover, he strongly emphasizes the
here and now and calls for the therapist’s creativity with regard to “catching the
moment.” Yalom is also an exceptionally skilled writer. MBT-G therapists can
learn a great deal from Yalom when it comes to (1) interpersonal focus, (2)
authenticity, (3) openness about the relationship between therapists and
patients, and (4) creative use of the here-and-now interaction.

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Interpersonal psychotherapy has over time developed a more manualized
and evidence-based form. It started with time-limited, interpersonal psychotherapy for depression, and subsequently included other disorders, especially
bulimia. Myrna Weissman has been central in the modern shaping of interpersonal psychotherapy (Weissman et al., 2000). Technically we notice the use of
the so-called communication analysis:
The therapist invites for a detailed account of an important conversation or a row with
the partner, for multiple purposes: It is both to achieve an understanding of what the
transaction means, and to understand the way the couple communicates. The therapist
listens to the details of the communication and halts in order to understand the patient’s
feelings and motives on critical points: What did you say next? . . . What did you feel
then? (Weissman et al., 2009, p. 115)

There are clear similarities with chain analysis in DBT and the exploration of
interpersonal interactions in MBT. However, IPT lacks the theoretical rationale
and purpose embedded in MBT. Compared with psychodynamic psychotherapy, the authors claim that IPT is focusing:
more on the actual situation than precursors in childhood; it focus on the patient’s life
outside the therapist’s office and it does not interpret dreams or transference. IPT
deploys a more structured and pragmatic stance in order to change interpersonal patters, as a means to diminish symptoms of an affective syndrome or some other psychiatric condition. (Weissman et al., 2009, p. 132)

Before IPT received its modern design through the works of Weissman and colleagues, the Canadian psychologists Elsa Marziali and Heather Munroe-Blum
(1994) developed an “Interpersonal group psychotherapy for borderline personality disorders” (IGP). This is thorough empirical work, both in the development of guidelines, training of therapists, and measuring of treatment effects. It
concerned time-limited closed groups, lasting for about 1 year (30 group sessions). The technique was especially adjusted to borderline patients and it has
many similarities with MBT-G:
◆

◆

◆

Avoid interpretations and confrontations in the way which has been recommended by Kernberg (1975). Marziali and Monroe-Blum (1994) recommend a “noninterpretative, emphatic feedback approach.”
Show interest and engagement in the patient’s subjective experiences and
way of communicating. Use explorative questions.
Abstain from the role as expert when it comes to the patients’ (unconscious)
inner world; admit and tolerate your own insecurity and confusion and find
ways to communicate this: The therapist “models for the patient tolerance
for anxiety and ambiguity while various solutions to the dilemma are considered. In this model of treatment, it is the patient who has control over the

Similarities and differences between MBT-G and other types of group therapy

dialogue, and it is the therapist who communicate uncertainty and confusion while maintaining a sharp interest in each patient’s narrative” (Marziali
& Monroe-Blum, 1994, p. 71). We recognize here many of the elements in
MBT’s not-knowing stance.
◆

◆

Actively regulate the “temperature” in the group to avoid overexposure or
defensive emotional flatness.
Focus on here-and-now interaction in the group, but do not interpret events
as enactments or repetition compulsion.

Compared with a psychoanalytic interpretative technique, IGP:
primarily focuses on the acquisition of new learning by observing and experiencing the
“here and now” interpersonal dialogue, whereas the former emphasizes the acquisition
of new knowledge through understanding and integrating the content of what is communicated. In the IGP model of treatment, change is more due to the experience of
interactions in the group and less to the acquisition of insights about the genesis of
internalized conflicts. Thus, the context of knowing is more important than the content
of what is known. This reflects the belief that for the borderline patient the context has
been historically imbued with debilitating levels of painful emotions that block effective cognitive processing of new information; thus when the context (member-to-member and member-to-therapist transactions) are well understood and adequately
managed by the therapists, the borderline patient’s inherent capacity for information
processing is enhanced. (Marziali & Monroe-Blum, 1994, p. 74)

Today we would state this more simply and clear, but the essence remains the
same: Training in understanding and handling of interpersonal transactions
here and now will increase one’s mentalizing ability.
As for therapeutic technique, there is a focus throughout on the interaction
between the group members and between the members and the therapists. The
therapists should devote special attention to how the following themes play out
in the group (because of the borderline pathology):
◆

◆

◆

◆

Searching for boundaries (for themselves, in cooperation, and for the group
as a whole)
Attack and despair (quick activation of the fight/flight response, projective
identification, and ruin of relations)
Grief processes and repair (as natural tendencies that are liberated in
treatment)
Integration and self-control.

In IGP, there is a special emphasis on “intersubjectivity and the management of
group derailments.” It concerns intersubjective consciousness and competence
within the therapists, how they can handle projective identification in the
group and how they can understand when the group derails, their own possible

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contributions to this, and how they can get the group back on track again.
Summing up:
Distinguishing group dialogue that is “stuck” from dialogue that advances the work of
the group is another important approach with IPG. For example, when patient dialogue becomes polarized, the therapists are alert to the fact that an intervention is needed. Their aim is to restore the balance of a give-and-take dialogue that advances
interpersonal process within the group. When the meanings of the “stuck” dialogue are
misunderstood by the therapists, derailment occurs. The therapists are again alerted
that an intervention is needed. Mending the derailment may have the greatest therapeutic impact on the patients because they witness the effects of the therapists’ confusion and suspended capacity for processing both their own and the patients’ emotions.
However, contrary to the patients’ experiences with managing explosive emotions, the
therapists are able to produce a balanced response and process the meanings of the
derailment. As the therapy progresses, the patients are increasingly able to address
the derailments in the interpersonal dialogue. These patient “interventions” are manifestations of the integration of self-control that is the ultimate aim of IGP. (Marziali and
Monroe-Blum, 1994, p. 99)

The above mentioned quotes capture the essence of the “group as a training
ground for mentalizing,” and they correspond with our claim that the “process
is more important than the content,” that it all depends on the quality of the
dialogue, and the emphasis on the therapists as models for good mentalization.
IGP is therefore the group therapy mode which is most closely related to MBTG. IGP and MBT-G also share a positive relation to empirical data and studies,
while GA is more skeptical about the value of quantitative measurements. IGP
was developed through a synthesis of borderline theory (available at that time)
and experiences from the testing of different group techniques. There is a standardized program for skills training in the education of IGP therapists, and the
treatment effect has been tested in a randomized controlled trial where the control condition was individual psychotherapy (Munroe-Blum & Marziali, 1995).
The effects turned out to be roughly the same for the two treatment formats, but
the group therapy mode was more cost-effective.
When we compare IGP with MBT-G, we may say that there are many similarities, but that MBT-G on most points has gone some steps further. The theory is
more thorough and grounded in a number of supporting disciplines (evolution,
genetics, neurobiology, developmental psychology, psychopathology, treatment theory, etc.) related directly to therapeutic techniques. MBT has a larger
degree of evidence supporting its efficiency for borderline patients. IGP
describes guidelines for group therapy, but does not, strictly speaking, have a
manual comparable to MBT-G. The manual for MBT-G is more theoretically
consistent, systematic, and comprehensive than IGP, and it contains moreover
a rating scale which makes it possible to evaluate therapists’ competence.

The group as a whole: Constructing and mentalizing the matrix

The group as a whole: Constructing and mentalizing
the matrix
Since MBT-G strongly emphasizes the therapist’s leader responsibilities, does it
neglect the significance of the group as a whole? The answer is no. In the following section, this short answer will be elaborated with reference to the group
analytic concept of matrix. This concept has a foundational role in group analytic theory and practice. It was launched by the founder of group analysis, S. H.
Foulkes, early in his career, but not explicated extensively until his second textbook, Group Psychotherapy: The Psychoanalytical Approach (Foulkes & Anthony, 1957). The matrix can be thought of as an invisible web which influences
people in a concrete ways. It is also a theoretical web. The very concept links
with other theoretical elements of group analysis. The concept presupposes a
theory of the relationship between the individual and the group while at the
same time it represents a crucial building block for such a theory.
Foulkes expressed himself in such ways as “Man is primarily a social being, a
particle of a group” (Foulkes & Anthony, 1957, p. 234). The conception of the
isolated individual, as a kind of solipsism, is a historical phenomenon which
gained support during the nineteenth century. Foulkes was strongly opposed to
this. He believed that man’s “groupishness” is embedded in the genes, having
evolved through millions of years (cf. the earlier section on “Group dynamics
and evolution”). Bringing strangers together in a group, as one does in a group
analysis, will arouse fear of an antagonistic kind, but this will be overshadowed,
claimed Foulkes, by:
an overwhelmingly strong impulse, amounting to an absolute and irresistible need, to
make contact and to re-establish the old and deeply rooted modes of group behaviour.
We think indeed that as soon as the group takes hold and the formerly isolated individuals have felt again the compelling currents of ancient tribal feelings, it permeates them
to the very core and that all their subsequent interactions are inescapably embedded in
this common matrix (Foulkes & Anthony, 1957, p. 235)

When people come together, they are compelled to communicate with each
other. The communication might be silent, but never nonexistent. In a therapeutic group, verbal communication is a sine qua non. One gets together simply
in order to talk to one another. One comes to the group in order to understand
more of oneself, and perhaps differently. In order to understand more and differently, based upon interpersonal transactions, one has to expand one’s own
communicative repertoire. One has to immerse oneself in a process which has
communicative diversity and self-reflection as its very purpose. Symptoms,
which represent distorted communications as well as private, secret, and shameful fantasies and needs, have to be translated into a realm of commonly

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Main principles for mentalization-based group therapy

accepted public communication. The therapist’s skill resides in his or her ability
to understand distorted communication and assist in this translation process.
Communication, which includes the process of making the un/pre-conscious
conscious and the process of verbalizing, is the essence of group analysis.
The concept of matrix refers to the communicational network that will establish itself in a group. It is the communicational structure (role assignment,
norms, relations, discourse style, etc.) which has materialized during the history of the group. Matrix is not a static phenomenon. It has a significant process
feature since structure and content will continuously become modified through
the group’s ongoing “negotiations” (Whitaker, 1981). Foulkes emphasized that
the interpersonal relations that constitute the matrix, as well as all events in the
group, literally happen between two or more persons. A lot of the communication that flows in the matrix takes place at a nonverbal or unconscious level. The
forces in the matrix:
may be conceived as passing right through the individual members and may therefore
be called a transpersonal network, comparable to a magnetic field, The individual is
thought as a nodal point in this network, as suspended in it. (Foulkes & Anthony, 1957,
p. 259)

In the article “The group as matrix of the individual’s mental life,” Foulkes
(1973) distinguishes between a foundation matrix and a dynamic matrix. The
dynamic matrix is what we perceive at a phenomenal level in a given group. We
have a tendency to overlook the foundational matrix since we all are a part of it.
It operates more silently in the “bottom” of the group. It is what unites us by the
fact that we belong to the same species, we have the same biological makeup
with respect to perceptions and language, we belong to the same language community, to the same culture, and so on. In short, we share a common genetic
design and are socialized through a network of common values and norms and
communicational styles. Such are the silent preconditions for our speech acts in
the group.
Group analytic theory contends that symptoms are repressed unsymbolized affects which have not been transformed by communicational processes
in the individual’s primary group (the family). The group can be conceived
as a resonance box, meaning that experiences that have been “homeless,”
that is, devoid of a communicational community, now may find resonance in
other people in the group, or in the group as a whole. By this, there may be
initiated a symbolizing and communicative process which lends words and
meanings to experiences that previously were devoid of words and meaning.
The main task for the group analyst is to facilitate these processes of symbolization and communication. A major tool in this respect is free group
associations.

The group as a whole: Constructing and mentalizing the matrix

Matrix is a phenomenon which is not reserved for analytic groups. Foulkes
emphasizes that he speaks about communicational networks that will become
established in all kinds of groups. Certain features by this matrix will be shared
by many groups (foundation matrix), while specific groups will own their specific dynamic matrices. Group therapists face the task of constructing, or designing, the matrix in order for it to serve the primary purposes of the group.
It is not the case that the “natural matrix” of group psychotherapy is the one
which is founded upon free group associations. Free group associations are the
group analytic counterpart to free associations in psychoanalysis. It was a technical tool which Freud created in order to counteract the repression barrier. He
contended that free associations will loosen up the repression mechanism and
thereby facilitate the process of making the unconscious conscious. However,
today few would seriously claim that borderline pathology is due to repression.
There is far more evidence for the theory of deficient psychic structure (lack of
consolidation of self and internal objects) (Karterud et al., 2010). Accordingly it
seems rather strange to maintain that the tool for building psychic structure
should be an unstructured treatment situation. According to classical literature,
it is individuals who have “too much structure,” for example, the old “neuroses,”
who might benefit from lack of structure.
Just as free-associative group analysis therapists create their own group culture, therapists who follow MBT-G guidelines will create their own species of
matrix. The question is not which kind of matrix is “best,” but rather whether
they suit their purposes in a constructive manner. In this manual, we try to outline in detail what kind of dynamic processes we stimulate and why they are
appropriate for borderline patients.
Group analysis and MBT-G construe different kind of matrices. The therapies
are also different with respect to how they understand and respond to the
dynamics in the matrix (“mentalizing the matrix”). Group analysis recommends group interpretations, such as:
“Yes, mothers can surely be frustrating. However, I wonder if the current group
discussion creates a kind of assumption that most sources of pain reside outside
the group. According to that, it may make sense to consult each other on how to
cope with all frustrations out there. But a deeper cause seems to be the fact that
there are two new members in the group. Talking about mothers implies shutting
one’s eyes for what is frustrating here and now.”

This kind of interpretation, close to a statement of what is “actually” going on in
the group, and which implies that the therapists have some particular abilities
to “see” such things, is not recommended in MBT-G. To understand group
dynamics in itself is not a high-ranked goal in MBT-G. Even if group dynamics

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represent contextual factors here and now, which several people might benefit
from exploring, such an understanding is subordinate to the higher-ranked
goal of enhancing mentalizing ability through reflectioning on intersubjective
transactions. Group interpretations in MBT-G should be short, descriptive,
aimed at evoking curiosity, and avoid references to unconscious processes.
They should be used in order to point at something going on here and now,
something which prevents constructive group work: “It is rather quiet here
today, isn’t it?” Many will not even label such an utterance as an interpretation.
It is more like an open wondering about an obvious group phenomenon. Interpretations in a classical sense should convey a hypothesis about a causal connection, as in the earlier example where the therapist postulates that the
conversation about mothers is “caused by” frustration created by two new
members in the group.
The fact that regular group interpretations occur rather seldomly in MBT-G
does not imply that MBT-G therapists ignore the dynamic matrix. As outlined
in the introductory chapters of this manual, the principles of MBT-G are constructed with constant reference to group dynamics. In addition, there is in
Chapter 3 an item (number 8) which concerns “stimulating and assisting the
group in discussions of group relevant themes.” Through such discussions
group members will slowly come to “own” a project which was initiated by the
therapists and presented in an abstract manner. When the norms and rules have
been negotiated in the group, and internalized, the members will begin to feel
at home in a matrix which they have co-created.

Chapter 3

The mentalization-based group
therapy adherence and quality
rating scale (MBT-G-AQS)

Introduction
The principles for MBT-G have been outlined in Chapter 2. In this chapter,
these principles will be operationalized through nine group-specific items. We
recommend that the reader consults Chapter 2 when reading Chapter 3 and 4.
In addition to the nine group-specific items, the manual includes ten items that
are modified from the manual for mentalization-based individual therapy
(Karterud & Bateman, 2010). Altogether, the complete manual for MBT-G consists of 19 items.
These items can be rated on the MBT-G adherence and quality scale (MBTG-AQS). The scale can be used for education, supervision, and research purposes. By using the rating scale, therapists may receive qualified feedback on
their therapeutic style.
We will first discuss the place of this rating scale within the general tradition
of (group) psychotherapy rating scales. Thereafter we describe the construction
of the scale and the rating procedures. In Chapter 4, we will describe each item
in detail. Readers who are not interested in the science of group therapy ratings
can skip Chapter 3 and go directly to the item descriptions in Chapter 4.

On rating scales for group therapy
Manuals and rating scales have been controversial issues in the field of psychotherapy (Karterud & Bateman, 2010). Rating scales have been developed primarily for research purposes, in order to provide measures of the degree to
which the therapists stick to the proscribed guidelines for the treatment in
question, that is, for measuring so-called treatment integrity. Manuals and rating scales were initially developed for behavioral therapy (Wolpe, 1969), soon
followed by cognitive therapy, interpersonal therapy, and various psychodynamic modes. The tradition is by now well established in individual psychotherapy and there is a rich literature on the technology of such rating scales. The

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The mentalization-based group therapy adherence and quality rating scale

overriding questions concern validity and reliability: The items which are chosen should reflect the most prominent features of the treatment, and independent raters should be able to reach a high degree of agreement as to how therapists
actually perform with respect to the proscribed guidelines.
The MBT adherence and quality scale (MBT-AQS) for individual therapy
consisted of 17 items. A reliability study showed that the reliability of these
items varied considerably. Some were rather easy to agree upon, others were
more difficult (Karterud et al., 2012). However, the overall rating was found to
be good enough for scientific purposes. Later on, we established a MBT quality
laboratory at the Department for Personality Psychiatry, Oslo University Hospital. It turned out that the reliability improved considerably through more
extensive training and in concert with more elaborated rules and procedures
for rating. During 2013/2014 the reliability of MBT-AQS has been around 0.90
(ICC-2) at this laboratory. This is a high degree of agreement. There is no doubt
that MBT can be assessed in a reliable manner.
Within the field of group psychotherapy, the situation is different. The question
of treatment integrity has, by and large, been ignored. It is true that there exists a
tradition which can be traced back to Bales’ (1950) Interaction Process Analysis,
which rates the activity of group leaders, and to systems that rate member–leader
interaction (Mann et al., 1967). However, these ratings were part of general process analyses (Beck & Lewis, 2000). They did not concern how therapists adhered
to specific and manualized guidelines. There has been considerable concern as to
this state of affairs, for example, by Chapman and coworkers (2010, p. 15):
One of the most neglected areas in group research literature has been that of leader
effects on groups . . . Accordingly, a recent review of the current status of group psychotherapy research by Burlingame, MacKenzie, and Strauss (2004) issued a call for the
development of leader measures as a next step in the group treatment literature.

A notable exception is the Group Psychotherapy Intervention Rating Scale
(GPIRS), developed by Sternberg and Trijsburg (2005). GPIRS is a scale developed
for group psychotherapy in general and accordingly does not lean on any particular treatment manual. The items, amounting to 48 (!), are designed to comply with
empirical research norms. Each item should represent “specific interventions with
established effectiveness in enhancing group therapeutic factors” (Burlingame
et al., 2002). The items are organized in three higher-order domains:
1 Structuring the group. This domain includes interventions that promote
group norms, that define therapist and patient roles, that implement group
exercises, and so on.
2 Facilitating verbal interaction. This domain includes interventions that aim at
facilitating verbal interaction, openness between members, mutual feedback, and so on.

SELECTING ITEMS FOR MBT-G-AQS

3 Creating and maintaining a therapeutic emotional climate. This domain includes
interventions that aim at a safe group milieu, decreasing anxiety, hostility, and
uncertainty in the group, and so on.
These higher-order domains seem valid for most kinds of group therapy: structure, verbal interaction, and a safe emotional climate. As will become apparent,
all items in MBT-G are easily located in such a scheme. GIPRS contained 48
items. They should be rated for occurrence (yes–no) and quality on a 1–4 Likert
scale (poor–adequate–well done–excellent).
However, it is well known that reliability declines when the number of items
increases. Ideally, the fewer the better. It is hard to decide exactly which item out
of 48 is appropriate for a certain intervention, especially when such decisions
are undertaken in rapid succession, following the flow of the group dialogue. It
comes as no surprise that a validation study of GIPRS, based upon 71 group
sessions, revealed that only 26 of the 48 items were actually rated. It is regrettable that this study did not adequately report on the reliability of these 26 items.
Current knowledge (Karterud et al., 2013) indicates that rating scales should
contain fewer than 20 items.
The Mindfulness-Based Relapse Prevention Adherence and Competence
Scale is another recent example of rating scales for group therapists (Chawla
et al., 2010). This rating scale is, in contrast to GIPRS, founded upon a highly
specialized manual. The groups in question are conducted according to cognitive behavioral principles, for example, by a high degree of structuring, focus on
the individual, and use of group exercises. It is easier to achieve high reliability
for therapists in such groups since interventions are structured according to a
preconceived plan and follow stricter rules. As such, they have less relevance for
process-oriented groups like MBT-G.
In conclusion, when designing MBT-G-AQS there were few relevant previous scales on which to base our approach.

Selecting items for the MBT-G-AQS
The MBT-G-AQS consists of 19 items. Nine items are group specific, while ten
items are modifications of items originally belonging to the rating scale for
individual MBT (Karterud & Bateman, 2010). When designing the group
scale, it was important, as explained in Chapter 2, to end up with a total number of items that was fewer than 20. Within this boundary we wanted to
achieve a fair balance between group-specific items and items indicating MBT
in a general sense. The easiest task was to define items that indicated MBT in
a general sense, since we could benefit from the experiences gained by the
work with the individual scale. Of the 17 items that originally were defined as
indicative of MBT, we removed the following seven. The reasons differed;

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some items seemed to be superfluous, while others had low reliability (Karterud et al., 2012):
1 Adjustment to level of mentalizing. This item is now defined as part of a general mentalizing stance.
2 Stimulating mentalizing through the process. This item is also now defined as
part of a general mentalizing stance.
3 Focus on emotions and interpersonal events. This item is covered by several
group-specific items. It is the bedrock of MBT-G.
4 Validating emotional reactions. This item turned out to be used quite infrequently. It is now included in the more general item “Focus on emotions.”
5 Focus on transference and the relation to the therapist and Use of countertransference. These items are collapsed into one item: “Focus on the relationship
between therapists and patients.”
6 Checking one’s understanding and correcting misunderstandings. This item used
to have low reliability. The content has been integrated in the items “Exploration, curiosity, and not-knowing stance” as well as “Stop and rewind.”
7 Integration of experiences from concurrent group therapy. This item is of
course superfluous in MBT-G.
The remaining ten items from the individual MBT-AQS have been modified for
the MBT-G format. It concerns their theoretical position as well as their practical applications. The clinical examples which illustrate these items in this
manual are all sampled from group therapies. It concerns the following items:
1 Engagement, interest, and warmth
2 Exploration, curiosity, and not-knowing stance
3 Challenging unwarranted beliefs
4 Regulation of tension level
5 Acknowledging good mentalization
6 Handling pretend mode
7 Handling psychic equivalence
8 Focus on emotions
9 Stop and rewind
10 Focus on the relationship between therapists and patients.
The nine group-specific items are the following:
1 Managing group boundaries
2 Regulating group phases

RATING PROCEDURES FOR MBT-G-AQS

3 Initiating and fulfilling turntaking
4 Engaging group members in mentalizing external events
5 Identifying and mentalizing events in the group
6 Caring for the group and each member
7 Managing authority
8 Stimulating discussions on group norms
9 Cooperation between therapists.
The nine group-specific items were identified and operationally defined through
a project that started when the manual for individual MBT was finished. Also
this time there was collaboration between the present author, Anthony Bateman, and the Nordic MBT group. The criteria for selecting items were (1) that
they should reflect significant motives for group psychotherapy interventions in
a more general sense, and (2) that they also reflected treatment needs according
to the theory and practice of MBT. A larger criteria pool was assembled and critically reviewed. Those that survived the scrutiny were further defined and clarified through clinical trials. We studied video recordings of group sessions from
Norway, Sweden, Denmark, and the United Kingdom.
The items relate to the domains defined by Chapman and coworkers (2010) as
follows:
◆

◆

◆

Structuring the group: Managing group boundaries; regulating group phases;
and initiating and fulfilling turntaking.
Facilitating verbal interaction: Engaging group members in mentalizing external events; identifying and mentalizing events in the group; exploration,
curiosity, and not-knowing stance; challenging unwarranted beliefs; acknowledging good mentalization; handling pretend mode; focus on emotions; stop and rewind; and focus on the relationship between therapists and
patients.
Creating and maintaining a therapeutic emotional climate: Caring for the
group and each member; managing authority; stimulating discussions on
group norms; cooperation between therapists; regulation of tension level;
and handling of psychic equivalence.

Rating procedures for the MBT-G-AQS
Rating of occurrence
Scoring sheets and detailed procedures can be downloaded from the websites of
the MBT quality laboratory or the Norwegian Institute for Mentalizing. The
Google search engine will provide correct website addresses by searching for

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“MBT kvalitetslaboratorium” or “Institutt for mentalisering.” Go to the English
tab on the website.
Each intervention which complies with the item definition should be marked
by a short line in the appropriate item box on the scoring sheet. An intervention
is defined as an utterance which is delineated by an utterance from another person or by a longer pause. We do not differentiate between short and long interventions. However, short utterances should convey a meaningful and relevant
statement. Short statements like “Hmm,” or “Uh,” or “Well . . .” do not count. A
short statement like “Yes” will count if it is a response to an item-relevant answer
from a patient: “Are you frustrated by me?” “Yes.”
One and the same intervention may be rated as valid for several items.
Example: “it is unclear to me what kinds of feelings were evoked in you Lise,
when Peter just spoke. Perhaps it is clearer for others in the group?” This intervention should be rated as exploration, focus on emotions, and engaging group
members in mentalizing events in the group.
The following items are not rated for occurrence: Care (6), Authority (7),
Engagement (10), Regulating arousal (13), and Pretend mode (15).
The rating for each item is equal to the sum of recorded interventions for that
item. Number of ratings per item will typically vary between 0 and 30.
There will be several interventions that do not comply with item definitions.
These interventions do not receive any rating. For example, “Where did he
live?” “What is the name of your boyfriend?” “Shouldn’t you speak with the
rehabilitation authorities about this?” “Do you use any medication these days?”
There is nothing wrong with such interventions. However, they are generic constituents of any kind of clarifying discourse and not specific for MBT. And most
importantly, they do not address mental states. MBT interventions should by
definition address mental states and interpersonal processes.
The fact that only certain interventions qualify for a MBT-G-AQS rating imply
that the absolute number of rated interventions is an indication of compliance to
the treatment model. We discuss this below when addressing the overall rating.

Rating of quality
For this purpose, we use a 1–7 Likert scale where 1 is “very poor” and 7 is “excellent.” A zero denotes “not applicable,” for example, that the intervention was not
observed.
It will often be the case that relevant phenomena occur (e.g., unwarranted
opinions about self and others), but that the therapists do not comment upon
them. In such cases, the item should be rated 0 for occurrence. One might argue
that there should be no rating for quality in such cases, as one cannot qualify
something that does not exist (i.e., therapist interventions). However, the fact
that the therapists do not intervene attests to poor competence with respect to

RATING PROCEDURES FOR MBT-G-AQS

the item in question. Therefore: No intervention when relevant phenomena are
displayed should be rated by low quality (e.g., 3, 2, or 1), dependent on the seriousness of the omission.
The rater judges the quality according to the guidelines for each item. Three
quality levels 1–3, 4, and 5–7 are described for each item. The descriptions are
item specifications that are adjusted to the following general scale constructed
as a continuum from very poor to excellent:
0

Not applicable

The intervention was not observed

1

Very poor

The therapists handled the item content in a very poor way

2

Poor

The therapists handled the item content poorly (e.g., by
significant lack of expertise, understanding, competence,
engagement, timing, or unclear language)

3

Acceptable

The therapists handled the item content in an acceptable way,
but poorer than average

4

Adequate

The therapists handled the item content in ways typical for an
average “good enough” therapist

5

Good

The therapists handled the item content in ways that were
somewhat better than average

6

Very good

The therapists demonstrated significant skills and expertise in
handling the item content

7

Extremely good
(“excellent”)

The therapists demonstrated very high levels of skills and
expertise in handling the item content

MBT-G will often be conducted by co-therapists. The therapists may display
a markedly different style. Should they be rated separately? According to this
manual they should not. This is a rating scale for MB group therapy, not for MB
group therapists. One should rate the conjoint efforts of the therapists. Co-­
therapists often develop a kind of cooperation based upon (conscious or unconscious) sharing of tasks. Raters usually have no information about what kind of
(if any) deliberations have been undertaken between the therapists with respect
to role differentiation. In any case, raters may observe a practice which is asymmetric, for example, that one therapist is more active than the other, or that one
therapist performs more of a certain kind of intervention compared to the
other. Such differences might be important and relevant for many research
questions, but they are outside the scope of this manual. The purpose of the
MBT-G-AQS is to measure the actual interventions that are delivered to patients
in a given group, regardless of whether they originate from the one therapist or the
other. The raters cannot have any sound opinion about how the individual therapists would behave if he/she conducted the group alone.

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Rating of overall occurrence and quality
In addition to ratings on each item, there should be overall ratings for occurrence and quality. The overall rating should be based upon a global comprehension, that is, it should not be an arithmetic mean. The rating scale is not
constructed in a way which gives each of the items an “equal weight.” The therapists should demonstrate an active and engaged therapeutic style which is
coined by a mentalizing stance (cf. the first section in Chapter 4). The raters
should therefore ask themselves the following question: Is it the case that the
therapists by and large focus on the mental states of the group members; do they
stimulate the participants to explore these states and do they do it in a warm, yet
authoritative way which is adjusted to the participants’ level of mentalizing, and
do they in this process challenge unwarranted opinions, pretend modes and psychic equivalence and strive to keep an optimal emotional temperature?
Here there is less reliance on the formal features, for example, if there is
organized turntaking, since well-functioning groups can be excellent training
grounds for mentalizing without this particular feature. However, if one
observes chaotic and poorly functioning groups, the absence of phase regulation and organized turntaking should count in a negative way.

Rater training and reliability
In Norway, we have established a MBT quality laboratory which rates and comments on MBT sessions performed in established MBT programs. Raters in the
lab are practicing MBT therapists, having been trained by the Norwegian Institute for Mentalizing. Accordingly they are well versed in the theory and practice
of MBT before they are trained in rating according to the MBT-AQS. We have
performed two formal reliability tests. The first displayed moderate agreement
(Karterud et al., 2012), while the second yielded high reliabilities, in the range
of 0.90 (ICC-2). Raters need a couple of hours of instruction in rating procedures. Thereafter they rate two verbatim transcripts and their ratings are compared to a gold standard. Good enough reliability is usually obtained after
rating of eight to ten video recordings.
A reliability study of the MBT-G-AQS is underway. We have trained raters
who already are reliable with respect to the individual scale. All raters are practicing MBT group therapists with a good command of the theory and practice
of MBT-G. The procedure is the same. After discussions of rating procedure,
they rate two verbatim transcripts of MBT-G and their ratings are compared to
a gold standard. The formal reliability test will include 16 group sessions. The
results so far are most promising and will be published during 2015.

Chapter 4

The items of the MBT-G-AQS

Introduction: The mentalizing stance
MBT-G is a therapeutic approach where the therapists seek to enhance the
patients’ ability to mentalize through the therapeutic process, more specifically,
through the group discourse, including the relationships between patients and
therapists.
The actual process is therefore more important than “the content” (what
patients in the group talk about). This does not mean that such content is unimportant. The main themes for MBT are those which involve a person’s own
mind, other people’s minds, and the person’s relationships to other significant
people. MBT does not emphasize “insight” in such matters if “insight” implies
something like the following:
“I have low self-esteem.”
“I have low self-esteem because I was harassed and treated badly when I grew up.”
“I have a problem with aggression.”
“I often have a depressive way of thinking. I was left to fend for myself when I was
a child and then I lost all hope.”
“My mother neglected me because she drank.”

The main issue for MBT is how a person thinks and feels about their own and
about other people’s backgrounds, about their own and other people’s minds,
and about how social processes influence all involved parties. In MBT-G, the
therapists are interested in experiences of self and others and engage each member and the group in exploring such issues. “The process” is the way in which
this is done.
The most important sign of a successful MBT group session is when patients
become engaged in a mentalizing group dialogue. What characterizes such a
dialogue is firstly the content of the subject matter. That is what the group is
talking about. The group should be talking about mental states. Secondly, there
is the way of talking in the group. In a good mentalizing dialogue, images, constructs, feelings, or intersubjective transactions will be dealt with in ways that
lead to new, sometimes surprising and refreshing perspectives. An observer
gets the impression that something new has happened to the group members
through this kind of group discourse. Mental phenomena are thought about a

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little differently. In contrast, we have supportive group therapies where members listen to, acknowledge, support, and encourage each other, but where new
thoughts about mental processes are seldom developed. Low MBT adherence
implies that therapists do not actively explore mental phenomena, but concentrate on, for example, problem-solving, behavioral management, and psychosocial support or engage in interpretations to facilitate pseudomentalizing
“insight.”
“To enhance mentalization through the process,” was a separate item in the
rating scale for MBT individual therapy. In MBT-G, we consider this element so
central and overriding that representing it as a separate therapeutic-technical
item among several others, would be misleading. It is woven into a general
therapeutic attitude which permeates all items. This attitude should be expressed
as a general strategy in and for the group. Besides, all interventions from the
therapists should, in principle, have two aims. On one hand, they should address
a certain issue (which might be a single-member phenomenon). At the same
time the therapists must be aware that everything that is said in a group influences the group process. Optimally, an intervention should highlight both a
member’s state of mind and at the same time make other members curious
about such a state of mind and its implications.
High MBT-G competence implies that the therapists pose relevant questions
which are formulated (using simple, straightforward, and “ordinary” words) so
that they stimulate further reflection and afterthought, and that this is followed
up in longer sequences which optimally contain thoughts, notions, feelings,
relations, intersubjective transactions, and “here-and-now” phenomena. Indicators that patients are engaged in a mentalizing process can be utterances, for
example:
“Well, possibly . . . ”
“When I think about it . . . it might well be that . . . ”
“I have never thought about that before, but it makes sense in a way . . . ”
“It strikes me when I’m listening to you, that I experienced something similar
recently when my sister . . . ”
“Could it be that you were afraid of hurting him?”
“But tell me, what exactly went on in your mind when . . . ?”
“Your story makes me feel sad, in a good way actually.”
“Wait a minute, could it be that . . . ?”

If patients seem reluctant to engage in group explorative dialogues, the therapists’
interventions should be carefully scrutinized. Are the interventions not open or
inviting enough? Are they properly attuned to the patient’s level of mentalizing
(neither too “sophisticated” nor too elementary)? Or are the interventions in
themselves appropriate, but does some overriding group issue block the process?

Introduction: The mentalizing stance

When rating therapists’ overall adherence and quality, the extent to which the
interventions are imbued by such a general mentalizing stance which stimulates
the group process, should be taken into account. It is therefore important that the
therapists do not themselves do the job of mentalization on behalf of the
patients!
We mentioned earlier that a mentalizing stance should take into account and
adjust to the patients’ current level of mentalizing. The term “level of mentalizing” refers to the reflective function (RF) scale which is an operationalization of
mentalization. RF scores are based on the AAI (Fonagy et al., 1998). A patient’s
level of RF is rated repeatedly throughout the interview on a −1 to +9 scale.
Level 5 is considered “good enough.” For most people, RF will vary depending
on the themes which are elaborated in the attachment interview. Scores along
the interview may vary between, for example, 3 and 7 and in such a case the
patient’s (average) mentalizing level would be around 5. The average mentalization level for patients with BPD has been found in several studies to be around
2.5–3 (Fonagy et al., 1996; Gullestad et al., 2012). In addition to normal everyday fluctuations around one’s average level, the level might decline considerably
during emotional arousal and involvement in interpersonal conflicts. The therapists must therefore adjust to each patient’s typical style and in addition be
prepared for further adjustment when emotions get high.
One should also consider the treatment phase of the patient. In an early
phase, the therapeutic alliance might be vulnerable, and the patient can at this
stage be unaccustomed to the special discourse of MBT-G. Merely being in a
group (which focuses on mental states) might be provoking. Many patients will
initially be in a “fight–flight” mode, where emotional outbursts are easily
triggered.
Therapists should have an opinion about the patient’s approximate current
level of mentalizing. It is useful to have the RF scale in mind. A simplified version for clinical purposes can be downloaded from the MBT quality laboratory
homepage.
At level −1, patients have bizarre beliefs about themselves or others, or they
dismiss psychological perspectives with threatening hostility. At level 1, patients
are characterized by non-mentalizing beliefs and attitudes. Behavior and social
events are attributed to mechanical and nonpsychological factors instead of
intrinsic motives. At level 3, patients have an understanding of the relationship
between behavior and motives, but this relation is often implausible, excessive,
clichéd, peripheral, incomplete, and so on. At level 5, patients have an adequate,
but rather simple, understanding of the relationship between behavior and
motives. At level 7, it is sophisticated, and at level 9, it is exceptionally good. A
high level of mentalization is characterized by beliefs that behavior is being

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caused by different and complex motives which again are influenced by personal history, family and cultural background, and current interpersonal,
familial, and sociocultural contexts.
Adjustment to the patient’s level of mentalizing implies being “in tune” with
the patient. Therapists can overestimate their patients and speak above their
level of comprehension, talk “over their heads.” Therapists can also underestimate patients. Examples of the latter include being excessively supportive, not
challenging enough, or even being infantilizing, “talking down.”
Therapists most often tend to be too “sophisticated.” In the initial phase in
particular, interventions should be short and concise. Lengthy explanations,
use of complicated language, and references to unconscious phenomena should
be avoided. When the therapists to some extent do embark on more extensive
explanations, they should check carefully with the patients that they are being
understood. Many patients will often pretend that they understand—partly in
order not to disappoint the therapists and partly not to appear “ignorant.”
Another variant is that the patient has acquired a strategy of pseudomentalizing
where words have a life of their own, detached from feelings and the depths of
the mind. The patient “understands” in a more superficial or theoretical way.
Furthermore (especially in the initial phase), therapists should be careful in
using metaphors, allegories, and symbols.
Adjustment to the level of mentalization also implies an adjustment to the
group as a whole. The therapists’ level of activity should be related to how well
the group is acclimatized to the MBT group structure and discourse (the maturity of the group). How much can the group as a whole regulate itself? Does the
group take responsibility for a reasonable allocation of time and attention
between members? Do the patients share relevant events spontaneously?
To be aware of and correct misunderstandings is part of the mentalizing
approach. In addition, therapists should, if they are uncertain, check whether
they have been understood. As previously mentioned, it is a central premise of
MBT that mental phenomena are opaque, and that it requires a sort of mental
work in order to bring mental phenomena into verbal discourse, whether it
concerns the patient’s inner sensations or conceiving the minds of others. Mental states are not visible to the naked eye. Mental states have to be interpreted.
Interpretation of mental states can be more or less precise (or correct,
adequate, apt). Misunderstandings can happen at any time. It is a hallmark of
good mentalizing that the person is sensitive to inner and outer signs which
indicate such misunderstanding, that he/she checks if this is the case, and that
he/she is able to readjust if his/her interpretation did not correspond well with
the subject matter. This ability corresponds to what we conceive as capacity for
reality testing.

Introduction: The mentalizing stance

All therapists make mistakes and they misunderstand from time to time. This
raises questions about what should be done when something goes wrong and
about what has caused the misunderstanding. Therapists’ mistakes vary of
course, from minor errors to the more serious. Here, we limit our topic to a discussion of “minor” misunderstandings, omitting severe boundary violations.
Therapist errors offer opportunities to re-explore the event in question and to
learn more about the context, experiences, and feelings which affected all parties during the therapeutic process. Handling misunderstandings are thus
excellent topics for “training in mentalizing.” In MBT-G, therapists should be
good role models for the patients by checking their own perceptions and correcting their misunderstandings. Such incidents also allow for “corrective emotional experiences.” Borderline patients usually have in their baggage a lot of
memories from rigid and unpleasant encounters, where no honest attempts
occurred to clarify the transactions.
The group format has several advantages over individual therapy, for example,
that witnesses are present in the group. When misunderstandings happen, therapists should “rewind” and involve fellow group members. What happened
exactly? How did you fellow members interpret it? This is an excellent exercise
in mentalization and it requires that the therapists are thoughtful and
unpretentious.
Therapists with a poor allegiance to the mentalizing stance usually make no
or only superficial attempts to check if their interpretation of a patient’s state
of mind corresponds with the patient’s experience. Even when there are signs
of a misunderstanding, it is not explored or corrected. On the contrary, therapists may insist that their understanding is the correct one, and that disagreements reside in deficient “insight” on the part of the patient. A mentalizing
stance implies an openness to one’s own fallibility, a willingness to explore and
seriously consider comments from others who have witnessed the events in
question.
Example: The group has reached the last third of the session. Grethe has shared a
sequence with her sister which has caused much amusement. Åse seems to be in a world
of her own. She is looking down and shaking her leg. The sequence with Grethe is
brought to an end and the therapists turn to Åse. Åse covers her face with her hands and
says she cannot bear to think. She says she can barely manage to breathe. A brief silence
follows, in which the group has to shift gear from vitality, joking, and laughter in order
to attune to Åse who is struggling to keep control. The therapist asks gently if her reaction has anything to do with something in the sequence with Grethe. No! Does it have
anything to do with the fact that the group session is approaching the end? No, not that
either. “It was that you [the therapist] misunderstood what I said at the beginning of the
session.” The therapist “rewinds” and involves the other group members in recapitulating what had happened. After a sequence of recap and exploration, the therapist sums

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up by saying that it is possible to understand that what he had said might be interpreted
in the way Åse did, but he emphasizes that he in no way had any intention of characterizing Åse as a racist. Åse recovers herself in the course of this sequence and becomes
able to participate in the group conversation again in a more constructive way.

Item 1: Managing group boundaries
This item is not specific for MBT, but is included because it concerns fundamental preconditions for conducting group psychotherapy in a professional
manner. Failures in this area are likely to influence the group dynamics and
inhibit mentalization in the group. As previously mentioned, the group therapists are responsible for arranging the physical framework in a good way. This
includes the group therapy location, that it has good enough light, is clean and
tidy, has a comfortable temperature, and that the correct number of chairs are
in place. It also includes circumstances outside the group room, for example, that
the entrance door is open, that the reception is available, that payment systems
are functioning, and that messages are passed on to the therapists. Furthermore, the group must be informed about forthcoming boundary events within
the group, such as the arrival of a new group member, that group sessions are to
be videoed for supervision or research purposes, that one of the therapists will
be absent next time, and so on. It also concerns therapists starting and ending
group sessions punctually. Therapists do not need to comment upon the group’s
boundaries when all this is functioning properly and when no out-­of-theordinary incidents crop up.
The most common boundary violation is that one or more group members
are absent. All groups should have a system to ensure that therapists receive
messages before the session starts. Patients’ compliance to their obligations of
notification will of course vary. In MBT-G, it is quite common that one or more
patients are absent. Some will have notified the therapists and given a reason,
some may have left a message that was not received, and some will not have
given any notice. These seemingly trivial transgressions have to be addressed.
When a situation arises which concerns the group boundaries, the therapists
should comment on it, clarify their own responsibility, and explore the significance of the event.
An example of good management:
It is the first group session with a new co-therapist. She shakes hands with group
members who she does not know from before. The other therapist comments that
this is an important group event. They should set aside time for talking about what
this means. Otherwise, the therapist conveys information to the group from two
absent members who had left messages. One of the messages is commented on
briefly. Thereafter, the therapist says that Lisa and Hilde were absent last time. The

Item 1: Managing group boundaries

reasons are repeated and commented on. The therapist asks if there is anything Lisa
and Hilde should be informed about from the previous session. There is a short
discussion about what happened last session with special reference to Kari who was
“in the limelight.” Kari talks a little about her experience in the group and what
happened afterwards, but adds that she might elaborate on this later on. Basically
it had been OK but now would other topics perhaps be more important?

An example of poor management:
The group has five members. The therapists sit in the group room, having a premeeting there and are drinking coffee. Four minutes ahead of time, Else arrives and
enters the room. The therapists seem a little surprised, but say hello, turn towards
her and ask how things are going. They continue drinking coffee. Else tells them
that she has had a lot of trouble with different people and services. Five minutes
late, Grethe now enters the room. She rapidly updates herself on Else’s experiences
and takes on a dominating role of questioning and consulting Else. After 15 minutes, Hanne comes in. It takes a while before she becomes included in the conversation. There are no references to the last group session and no comments about
latecomers or discussion about what this means for the group as a whole.

Guidelines for rating of occurrence
Boundary-relevant events need not occur in a group session. If so, occurrence
is rated with no intervention. If the boundaries are functioning properly (in the
background) it indicates that the therapists have done their job “silently” and
they should be given a quality rating = 4 (good enough). If there are relevant
events which the therapists address, each intervention should be marked on the
rating sheet. Examples of relevant interventions are:
“You were absent last time, Einar. We didn’t receive any message so we are curious
about the reasons.”
“Nice that you came today, Elsa, even if it was 20 minutes late. We’re curious to
know what held you up.”
“We have a new patient starting next time. Are there any thoughts or feelings concerning that?”
“I’m sorry it is so hot in here today, but we can’t get the window opened.”
“Next time we will video a session again. Any comments on that?”
“Next time I will be absent and the co-therapist will conduct the group. Are there
any comments on that?”

Guidelines for rating of quality
Low (1–3): Clear boundary relevant events are observed which the therapists do
not address, for example, people are arriving late, the wrong number of chairs
have been set up, and there are missing group members. The therapists do not
take responsibility for group boundaries or minimize and convert clear boundary problems into psychological problems of some group members.

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Adequate (4): The group is functioning smoothly with respect to boundary
issues. The therapists identify boundary-relevant events and comment and deal
with them in ways which seem appropriate and clarifying for the group as a whole.
High (5–7): The therapists address the event(s), acknowledge their own
responsibility, explore the significance of the event(s) for the group as a whole
or for especially involved patients in ways that facilitates mentalizing, and give
the event(s) the attention which is appropriate according to its severity.

Item 2: Regulating group phases
This item is about therapists taking explicit responsibility for (1) the opening
phase, (2) the middle phase, and (3) the closing phase.
As previously described, the opening phase is influenced by the therapists’
reflections immediately after the previous group session, the writing of a group
session summary, their processing during the week, and their meeting and planning immediately before the current group session. Managing group boundaries
is an issue of the opening phase, but it has also been singled out as a separate item.
The opening phase covers more than boundary regulation. It is about the dynamic
management of the continuity of the group and structuring of the upcoming session. It concerns minding the group and its members. The therapists convey
thoughts about what happened last time, with references to each member, and, in
this light, the challenges that might be expected in the current session. This can
seem demanding for some therapists. We have observed a tendency to skip this
part. Some therapists take a more supportive stance by initiating a kind of round
where group members report on “how they are doing.” Consequently the opening phase tends to become overtly long. This qualifies for a low rating. Others go
directly to the structuring part: “Do we have any topics?” It seems more difficult
to convey what the therapists have been thinking since the last session.
The therapists should convey their thoughts in ways which invite commentary
and supplementing perspectives and which engage the members in a discussion
of priorities for the present session. The opening phase should also result in a
conclusion about who, or which theme, one should start with and who/which
theme has to wait. There are many considerations here and the therapists must
make sure that the group members get engaged. As always, complicated words
should be avoided. One example of difficult words (in Norwegian!) could be:
“What is on the agenda?” One must remember not to start exploring the different themes in this phase. The therapists must also be disciplined and not let this
phase last too long—about 5–10 minutes is usually thought to be sufficient.
In the middle phase, the group should work in accordance with the guidelines described in Chapter 2. It concerns external events that the patients have
suggested in the opening phase, external events from earlier sessions(s), and

Item 2: Regulating group phases

current internal events, happening as the group proceeds. We underline that
events from previous sessions are regarded as external events. Current events
are happening in the here and now. The therapists should display the ability to
round off sequences and start up new themes.
At some time-point in the middle phase, inevitable time limitations will
become noticeable and problematic. The therapists should comment on this
and invite the group to reflect upon this fact.
Finally, the therapists should assist the group in finding an appropriate way to
close the group session.
An example of a fair regulation:
The therapist opens the session by accounting for the absence of Eva. The group
has five members and Vera asks if any new group members have been scheduled.
The therapist answers “No,” but adds that there most probably will be some new
members within a month or two. Kine asks if they are soon “going to get on with
this session.” The therapist comments that it sounds like that she has something she
needs to talk about. “Yes!” The therapist acknowledges her initiative, but adds that
perhaps one should start with the disagreement (or perhaps a conflict) from the last
session between Irene and Beate. “I wonder if this is something we should talk a bit
more about.” Silence. “What do you think?” Again, some reluctance. Irene then
confirms that she has thought a lot about this since the last session, and that she
has had a very difficult week. In the following 30 minutes, the conflict is recapitulated and clarified. This includes thoughts and feelings which the other group members had after the last session. Then Kine breaks in and says that her ex-boyfriend
makes her “mad.” The therapist nods and conveys his understanding but adds that
he would like firstly to know if the conflict from the last session has been reasonably
reviewed and worked through. Group members nod and seem to agree and say
they are ready to hear more about Kine’s problem with her ex-boyfriend. Several
have a similar kind of trouble and would like to hear what this is about. A long and
engaged sequence follows on a fairly high level of mentalizing. The therapist
inquires after a while: What do the group members think? Should they carry on
with this theme to the end, or are there other things which should be given attention? “No, no, now we are doing what we really should have been doing for a long
time. This is important!” By the end, several commented that it had been “a very
good session.” The therapist largely shared this point of view, but was a little uncertain concerning his own role. He became quite passive while the group proceeded.
The group did most of the job on its own. He thought he mainly provided some
space, but was this maybe good enough?

An example of poor regulation:
Four members are present, and it is the first time for one of them, Mona. Three are
absent and two have not left any messages. The co-therapist is also absent. The
therapist opens the group by wishing Mona welcome and adds some brief comments on the aim of the group, the structure, and the group rules. There are no

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references to the previous session. Åse is obviously uneasy and says impatiently that
there is something she has to talk about. She tells, in a somewhat breathless and
fumbling way, that she had a nasty kind of attack during a concert last week. Trine
responds by becoming very engaged and quite dominating. She explains partly
theoretically, partly based on examples from her own experiences with panic
attacks, what panic attacks are about and how they can be managed. Trine is also
a fairly new member. It is her third group session, and the therapist says afterwards
that she was not sure how vulnerable Trine was. The therapist is therefore initially
reluctant to intervene while Trine insists on her kind of “individual therapy in the
group.” After a while, the therapist comes in again and takes over the lead. She
helps Åse explore some of the background for her reaction. At the same time she
has to manage Trine who, it turns out, carries with her a considerable traumatic
baggage. The therapist runs the rest of the group by her more standard version of
“individual therapy in group.”
Mona, who is new, has not said a word. When there are only a few minutes left,
the therapist turns to Mona and asks how the group has been for her. “Well, hard, but
also interesting.” The therapist adds then that she forgot to say anything about the
three absent members, but that Lena had left a message saying she has caught a cold.

In this case, the group gets too carried away with itself. The therapist gives away
control and leadership, regains it after a while and keeps it in a rigid individual
therapy-type manner. She is constantly lagging behind because she has not
organized the group in the opening phase and does not take the event of having
a new group member seriously enough (which might be relevant to Trine’s
agitation).

Guidelines for rating of occurrence
The observer notes all explicit phase regulatory interventions. Interventions
which count for this item are, for example:
“Since the last group session, I have thought . . .”
“Last time you, Nora, talked about the relation to your mother and how difficult it
was for you to state your own opinion, and you Peter . . . ”
“You, Eric, were not here last time and have therefore missed a lot of things. What
can we do about that? . . . Should Eric be updated in any way?”
“What do we have on the schedule today ?”
“It seems like many of you have something on your minds today, how shall we deal
with that?”
“OK, shall we start with you then, Knut?”
“I wonder if we should stop there, or what do you think? We have several other
things we also should talk about.”
“What do we do now, we have 25 minutes left. Terje and Kari have things they want
to talk about. In addition, we have the issue about how directly we can speak to each
other here.”

Item 3: Initiating and fulfilling turntaking

“There is now only a couple of minutes left, how does it feel for you now, Tone, to
leave the group after what you have been through?”

Guidelines for rating of quality
The quality concerns the therapists’ abilities to report on their own reflections,
to handle here-and-now disturbances and to mentalize the members’ current
motivations. It should be done in a flexible way while also inviting the group
members to join in the considerations of group regulation. It also has to do with
timing and relevance and a consistent mentalizing stance.
Low (1–3): There are no or too few explicit phase regulatory interventions.
Interventions are too technical or too bound to the written manual at the cost
of stimulating greater responsibility and metacognition about commitment
and group membership.
Adequate (4): At least two phases are addressed in a way that engages members to reflect upon the possibilities and choices they have.
High (5–7): The therapists are sensitive to the members’ comments around
phase issues and give their contributions and reflections on time and impact. At
the same time, the opening phase does not end up as a pseudo-democracy. The
therapists take active responsibility for organizing the session. During the middle phase, the therapists stimulate reflections on the group’s and some members’ dilemmas concerning time, attention, and conflicting priorities. During
the closing phase, when the group meets its final boundary, it is marked by the
therapists, who allow for a new round of reflections.

Item 3: Initiating and fulfilling turntaking
This item is about taking the initiative in stimulating as well as facilitating mentalizing turntaking. Thereby interpersonal events are given the highest priority
in the group, and particularly the emotional aspects of such events. This item
therefore replaces the corresponding item in the manual for MBT individual
therapy, “a focus upon emotions and interpersonal events.”
The present manual emphasizes not only that emotions are important, but
that they have a special function as “steering elements” in the continuous process of interpersonal interactions. A high capacity for mentalizing implies being
able to let oneself be influenced by emotional reactions. To relate authentically
and flexibly to other people requires an openness about one’s own emotional
reactions while at the same time having cognitive control, in contrast to losing
oneself by having to pretend, subdue, or not heed one’s feelings.
Patients will often report that they feel “miserable,” “depressed,” or “out of balance,” that they have more symptoms again, being on the verge of self-mutilation,

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having more suicidal ideation, and so forth. It is a challenge to link such “unexplainable” emotional reactions to interpersonal events.
Through the therapeutic discourse, patients are trained to attend to, explore,
feel, understand, and manage previously unnoticed or denied emotional intersubjective interactions.
Mentalizing turntaking is an important part of the organizing principles of
the group. It directs the focus towards problematic interpersonal interactions
and ensures that all members are considered in this respect, for example, by
being explicitly thought about and discussed with regard to their process and
group participation. The therapists should take initiatives so that each member
has the possibility of sharing their own personal issues. In practice, this does
not annihilate differences between members’ level of activity in the group.
Some members will notoriously be more dominant and some more subordinate. However, it ensures that the theme of responsible participation is continuously on the agenda as well as the inevitable group theme of justice: Who is
getting the largest part of the pie? The principle of turntaking guarantees to
some degree that dominant members don’t exploit every meeting and that the
subordinate ones don’t stay in the shadows forever. However, it does not block
the interpersonal style of the individual member. It does not cover up significant tendencies in dominant behavior. There will remain more than enough
material to work on.
The therapists’ initiatives make it clear to everybody that the main task of
the group concerns exploration of interpersonal transactions, and there is an
invitation for each member to engage him/herself in this process. However,
the interpersonal focus must not be handled in a mechanical way. Although
interpersonal themes have precedence, they should not be at the cost of relevant intrapsychic themes. Thus patients will often be concerned with thoughts
set in motion by experiences from previous sessions. Needless to say, these
are highly relevant, not necessarily for a deeper understanding of the precipitating event, but as tools for expanding one’s capacity for imagination
(Bogdan, 2013).
When somebody in the group has “got on stage,” the therapist must take care
of the initiative and protect the space. How much attention each member takes
up (and receives) varies a lot. Some have issues that only need a short time and
can be rounded off after 5–10 minutes, while others can keep going for the rest
of the session. The most important “steering principles” for the therapist are:
◆
◆

that the patient gets a feeling of “owning” a sequence
that other members are not allowed to “steal” the person’s position as the
center of the group’s attention

Item 3: Initiating and fulfilling turntaking

◆

◆

that therapists and patients hold on to a mentalizing perspective on the issues that the member brings up
that the sequence is closed in a marked fashion.

Closing comments can be something like “Is it OK to round off here?” “Shall we
stop there, is that ok?” “How is it, was this helpful for you?” or “We have to move on,
Peter has also announced that he has something to share, is that OK now?” Patients
often take initiatives to round off themselves. The therapists must then decide
whether this should be taken at face value, or if they should explore the sequence
further based on the hypothesis that the patient is withdrawing defensively.
The optimal time for closure is dependent on whether the members of the
group have “done their job.” One part of this is to organize turntaking so that a
group member gets time and attention in the group to talk about something
that concerns him/her, and thereafter leave the scene for another group member. What matters more is what the time and attention are used for. Carrying
out the principle of turntaking should be done in a “mentalizing way.” As previously mentioned, this requires that the group is interested and engaged in clarifying a sequence of events (creating a narrative). Thereafter, the object of
concern is to find out which mental state was problematic, and how this was
influenced by the social context and the interpersonal transactions which
occurred. Which feelings were involved and what happens with the understanding of the situation while talking about it here and now?
This item is about giving space to the individual patient, ensuring that this space
is protected, and that the space is used for a mentalizing exploration. The other
group members’ presence and engagement is an inherent part of the whole process. How the therapist should proceed to engage other members is a separate
item. In well-functioning groups, the therapist does not need to take such a firm
grip on the group structure as described in these first three items of this manual.
Well-functioning groups will be more self-regulating. The patients take more
appropriate initiatives and the regulation of time and attention can be integrated in
the ongoing group process. If the therapists do not believe it will be at the expense
of other important themes, they can leave the group free to start by its own initiative. The therapists’ adherence to the principles of MBT-G will then depend on
how they follow up the patients’ own initiatives by focusing on emotions and interpersonal transactions, by integrating this focus with the here-and-now dynamics
and by engaging the other group members in mentalizing explorations.
An example of a well-carried out turntaking:
Several of the members have announced personal themes in the opening phase.
Grethe is one of them. After the group has updated a member who has missed two
group sessions and thereby included her in a way, the therapist asks: “Well, several

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of you have announced yourselves, what do we do?” Some of the group members
point at Grethe and say it is her turn. Grethe starts crying and says that she has started to stammer again, and that it is really awful. Several group members engage in
clarification: “What has happened?” “How did you notice it?” “When did you
notice it?” “Did you stammer before?” Grethe explains the current circumstances,
about an encounter with a former girlfriend at the tram. She also tells about a difficult period with considerable parental neglect when she was a child, when the
whole thing started. She receives sympathetic comments about the tough time as a
child when she had nobody to turn to—it is not surprising that she stammered. The
therapist asks for more details about the stammer and says that it was a bit surprising to hear as there now seem to be few signs of such problems in her way of
speech. “Should it, strictly speaking, be described as stammering?” “No, not really,
it is more like stuttering.” Several other members nod and say they can recognize
that one can stutter when one is having a tough time and is not feeling safe. Therapist: “Could we return to that situation you just described on the tram? Could you
tell us what happened in more detail?”
Several patients participate in the exploration of the situation, about the former
girlfriend she met on the tram, what Grethe thought and felt, what was at stake,
what happened inside her, and so on. Grethe finally takes the initiative to speculate
on why this insecurity turned up again now. Could it have anything to do with the
fact that she had got so much better, and was “heading full speed back to the world
again,” but that this at the same time was frightening? More explicitly, that it was
easier to hide behind a wall of depression and binge eating and that she now
encountered a kind of performance anxiety in herself, when meeting that girl? The
group engaged in a round of good reflection about these issues. Grethe closed the
sequence by saying that “It’s OK, it’s been useful. Earlier on, such incidents would
have put me out completely, but now I am more able to see how things can be
related to each other and that things have meanings and then it’s not that frightening. I don’t think I will be stuck in this, I think it will pass.”

An example of poorly carried out turntaking:
Bente says she has something she would like to talk about. It concerns last week.
Her mother was going to receive an award and a lot of friends and relatives would
be present. Bente turned up at the ceremony, even though she would have preferred not to go. She noticed that she was very tense, had raised shoulders, felt
stressed and agitated, but really made an effort to be nice. What she in fact wanted
to talk about in the group was that she noticed she became very suspicious: What
did other people think about her now, did they think she was odd, did they notice
that she was struggling to keep up? That somebody did this or that, was it because
of her? She got through it all in some way, until after the formal dinner. Then things
went a bit off the rails. No catastrophe, but she drank too much. Started out chattering too much and ended up falling asleep in a chair.
Bente described the situation adequately, with far more details than reported
here, and the therapists finally had to interrupt her by saying “Shall we now hear
what the others think about this?”

Item 3: Initiating and fulfilling turntaking

The other group members are reluctant. One says that “I also become suspicious in that way. It’s hard.” And another confirms this by nodding. There are a
few other comments. Bente expands her story a bit, but mainly by adding details
that do not bring in anything new with respect to her mentalizing problems. The
therapists comment: “One thing is a general tendency of suspiciousness, but
what about the circumstances here, the context with mother and lots of family
and friends?” For some reason or other, this comment did not interest or engage
the group very much. None of the usual interest, enquiry, and exploration developed in the group. Usually group members might ask questions like “What does
your mother do?” “What was the award for?” “Did you think it was well
deserved?” “What did you think in advance?” “Was there anything you were
especially afraid of?” “Was your boyfriend there as well?” And so on. The therapists tried some questions in that direction based on the knowledge (that also was
known to the rest of the group) that Bente’s relationship with her parents was
quite difficult. But no group member followed up. The sequence became rather
static, approximating a kind of individual therapy in group. The sequence was
closed by reference to the fact that other themes also should be given space.
Bente felt it was “OK that others had similar experiences.”
The therapists were later told that the same event had been worked through in
her individual therapy an hour before the group started. Bente had not mentioned
this. At the team meeting, the therapists discussed that perhaps the sequence was
an effort to “be a good patient.” She “did her lesson,” that is, brought up a relevant incident, but did it in a submissive way. This was only vaguely perceived by the
therapists during the session. They had noticed the low level of engagement in the
group (which they had not commented on) and retrospectively, they now wondered
if the group’s lack of engagement could be connected to Bente’s way of reporting
the incident, for example, without any really desire to explore it. They thought that
a comment like “Bente, what is it in this story, that you want to find out more
about,” might have been helpful. At a later time point, this could have been followed up by a comment including the individual therapy: “Have you discussed the
same incident in the individual therapy? If so, is there something you did not finish
there, something you feel you need to find out more about here in the group? What
then?” This might have stimulated a meta-reflection and could possibly have
brought her and the group into a more vital discourse. The sequence reminded the
therapists that encouraging patients towards mentalizing turntaking also has pitfalls. It can stimulate dismissiveness and a striving to be a “good patient.”

Guidelines for rating of occurrence
This item might cover a great deal of the therapists’ activity if they follow this
manual. It concerns interventions which directly invite members to take turns,
interventions that clarify and search for a workable scene, and interventions that
close the sequence. Practical trials have demonstrated that the ­reliability is high
for rating interventions that invite turntaking and for interventions that close it,
but not for interventions that facilitate the turntaking process. Raters simply

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cannot agree to a sufficient degree on exactly which interventions during a
sequence actually facilitate a mentalizing process, and which do not (or are
“neutral”). We therefore have come to the conclusion that occurrence and quality for this item should cover somewhat different terrains. Ratings of occurrence
should be limited to the initiating and closing remarks as well as the (few) interventions that clearly define the scene, while quality should concern the sequence
as a whole, that is, to which degree the sequence in question actually followed
MBT principles. It is quite possible, and actually it happens quite often, that therapists organize (and terminate) a turntaking sequence, without focusing on
mental states and intersubjective transactions. If so, they might achieve a reasonable occurrence rating, but a low quality rating. The opposite might also happen. If the group is well established and active, it will organize itself and
spontaneously work with interpersonal sequences that unfold in turns. The
therapist will then receive a low rating on occurrence, but might be rated high on
competence if he/she behaves according to MBT principles during the sequence.
As for occurrence, interventions that count are along the following lines:
“Is it a long time since you have brought up something in the group, Erik?”
“OK, shall we start with Knut then?”
“Erling, you had something on your mind last time, which we did not find time for.
How are you today?”
“You brought in something last time, Peter, which I got the impression that we did
not finish. How is it going?”
“Is that something which you might explore now?”
“Yes, I think that is a fine topic, just go ahead.”
“How is it, Turid? Has this sequence been useful for you? Is there anything that has
been especially important?”
“Is it OK for you if we close this now and proceed with other things?”

Guidelines for rating of quality
According to the clarification above, quality concerns the way the therapists conduct the turntaking sequence. The following examples give some indications:
“I don’t really know if I have quite understood what happened, what it was that X
said to you?”
“You were quite irritated then, is that how it was? . . . When did it start? . . . So it was
the meeting in the corridor with group member Y that provoked you . . . What
happened between the two of you? . . . You felt she ignored you, did you? . . . What
did she do or not do that made you feel that way? . . . How did you react then? . . .
Do you have any thoughts about why she behaved as she did?”
“I suggest that we go through this episode from yesterday morning in more detail.
Tell us what happened right from the beginning . . . All right, you were talking to
each other on the phone. . . . Then your mother made the remark ‘but, surely, you
do know that’ which made you react. . . . As far as I understand, this really upset

Item 4: Engaging group members in mentalizing external events

you, made you feel irritated, disappointed, and hopeless . . . a lot of different feelings. Such feelings used to make you withdraw, but this time, you confronted her.
How was that? What was different this time?”
“You tell us that it is hard to bear the thought that others are irritated or angry with
you. What does that thought do to you?”
“If I have understood you correctly, you got the feeling of being mean? . . . Let’s go
back to what happened between you and your brother last Monday. Can you tell us
more about what happened?”

Low (1–3): The therapists take little or no initiative for turntaking. When the
group’s attention towards a single member prevails over time, the therapists
contribute very little to ensure that the focus is on emotions, mental states, and
interpersonal interactions. The therapists take little responsibility for the development of the sequence and construction of scenes that can be worked with.
The closure of the sequence is somewhat arbitrary, lacking a distinct marking or
any attempt to summarize how it has been for the protagonist.
Adequate (4): The therapists themselves take the initiative and they also follow up patients’ initiatives for turntaking. They contribute to the unfolding of
the story and identification of relevant scenes, intervene in ways that facilitate a
comprehensive narrative and keep a focus on emotions, mental states, and
interpersonal interactions.
High (5–7): The therapists are especially creative and skilled in facilitating a
mentalizing exploration of sequences which become elaborated in the group.
They facilitate the narrative, explore which scenes are the most relevant, make
pertinent comments about the significance of the event for the protagonist in
light of current knowledge about his/her personality problems, and terminate
the sequence in a thoughtful and respectful manner.

Item 4: Engaging group members in mentalizing
external events
The therapists’ most important tasks are to maintain the group’s structure and
dynamic focus, and then, to engage the group members in a mentalizing exploration of events brought up in the group. Events can be external or internal.
External events are of the “there and then type.” Internal events are “here and
now.” Events from previous group sessions are by definition classified as external events. Item 4 is a crucial item. Without it the group process would relapse
into “individual therapy in group.”
With the structure we recommend, there is a permanent risk for such a
relapse, and therapists must therefore take precautions. After all, we clearly recommend that therapists speak directly to individual group members (not selfevident within group analysis), and we also recommend turntaking.

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How then can we avoid a development in the direction of individual therapy
in group, and so creating a dependency group where all knowledge and skill resides in the therapists? Firstly, therapists have to be extremely aware of this issue
and it should continuously be discussed between the therapists in their meetings
before and after group sessions. Secondly, therapists should cultivate a therapeutic style where interventions have a “double message,” remembering that
when speaking to a single group member they also speak to the group as a whole.
Because of this reality, that when speaking to the one, all members are simultaneously addressed, interventions towards single members should also contain an
implicit invitation to the other members to join the dialogue. At any time point,
the other members should be encouraged to respond. MBT-G might well contain
long sequences with many verbal exchanges (e.g., five to ten) between one member and the therapists. This does not matter as long as the other group members
feel free to participate. It becomes problematic if the therapists want “ownership”
of such sequences, and find it disturbing if other members join in.
An example of good engagement:
Relapse of substance abuse is a typical event. Reidar tells the group, a bit nervously,
that he was absent last group session, that he also had difficulties coming this time,
that he did not go to the last individual appointment either, and that it all had to do
with his first relapse in 2 years. It happened last Friday afternoon. He felt restless,
simply picked up his mobile, called a dealer, and then had it going on. A few short
questions clarified the circumstances. Therapist: “Ok. Let’s go back to that Friday.
What happened inside you?” Reidar: “I don’t know. I was uneasy, somehow.” Therapist: “What do the rest of you think? Friday afternoon, uneasiness, what can that
be?” Erik: “I don’t know either, but if it had been me, I might have been feeling
lonely.” Reidar: “Yes, probably something like that. The old boys, you know, they’re
gone. I know people here, though, but not in the same way. Yes, I suppose I probably was a bit lonely.” The members exchange experiences and thoughts about
loneliness. Therapist: “Last time you were here in the group, you talked about
things that had been really tough for you, and there was some talk about how
much you had endured on your own. Could that have made you feel lonely in some
way?” Reidar: “Yes, when you say so. Thought about it afterwards, how much I
have struggled with thoughts and things, much distress, and then sometimes I just
can’t bear it anymore, got to have a break, somehow, but that just made things
much worse, I got into vicious circles.” Erik: “But last time, there were a lot of good
things after a while, you remembered good things.” Reidar: “Yes, but I wonder if it
only made it worse. Can’t really understand it, but when somebody is kind to me,
it’s as if an alarm goes off. Had some things going on with girls, lately. But when
they say something nice, and show that they’re quite keen on me, I just back out.”
Hilde: “That’s odd. Why do you do that?” Reidar: “I’ve had some funny explanations, but I don’t really get it.” Therapist: “It’s important to find out more about
this, what do you others think?”

Item 4: Engaging group members in mentalizing external events

The therapist is here siding with the other group members, taking an overriding
“scenography” position. He first addresses Friday night and invites the group to
reflect upon the mental state of Reidar that afternoon. Then, he addresses the therapy process, through the last session, and thereafter, the phenomenon that Reidar
backs out when somebody is affectionate and interested. The other members are
well attuned. Comments from the therapist and the group members alternate and
complement each other, focus on Reidar’s mental states, and succeed in activating
his own interest in the perspectives raised by the group.

An example of poor engagement:
Brita is quick to take an initiative, starting before the opening phase has finished,
before all members have had a chance to briefly present their issues. She insists on
speaking at once. She wants to talk about several things, but especially the event last
week which upset her. Last week she came to the department and left a message saying that she was not able to attend the group session because something had happened which required her presence. It was the way the group therapist had responded
to her, when she met him in the corridor, which upset her, and which was aggravated
when the department sent her a bill for not having shown up. Yes, she had been very
agitated, but the therapist did not show any understanding or concern.
In the group, the therapist tries to clarify what had happened and their different
experiences, in a calm and questioning manner, but as Brita continues by presenting
new issues and new reproaches, one after the other, the therapist becomes more
defensive, by giving overly detailed explanations and partly by apologizing. Comments from the other group members do not change the process. Brita does not
accept explicit and implicit invitations to reflect or try to see things from different
perspectives. The group atmosphere grows tense and Brita takes on an offended,
irreconcilable stance. After three-quarters of an hour, Sissel becomes increasingly
uneasy. This is addressed and she leaves the room. The co-therapist goes after her
and persuades her to come back in again. The group situation has reminded Sissel
of persisting rows and relentlessness back home when she was a child. This is
worked on in a good way and after a while Brita assures Sissel that she is not “dangerous” and that she “does not attack people.” However, nobody comments any
more on Brita’s rigid psychic equivalent position. It remains in the group as an
unclosed gestalt which everybody avoids.
Plausible reasons for this development are (1) that Brita was allowed to highjack
the group by aborting the opening phase and thereby overriding the other group
members, and (2) that the therapist took too much responsibility for handling the
offended group member, Brita (because the other group members already were
devalued?). The dialog became “too intimate” and the therapist was dragged more
and more into Brita’s narrow, rigid way of thinking (psychic equivalence), and lost
the ability to maneuver out and create a space for reflection. There was too little
focus on the here and now, on current affects, and the therapists did not manage
to engage the other group members efficiently to work on the events which took
place both at the department last week and in the present session.

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Another example of poor engagement:
Hilde is talking about her job in the opening phase. She says she wants to talk about
a few small incidents at her workplace, “and then there is also a lot of poor mentalizing going on in relation to a man I am seeing.” When it is her turn in the group,
she continues: “Yes, I have started dating again, but I am really very uncertain. It is
so tiresome. He lives in Hamar [a Norwegian city 150 km north of Oslo] and that
does not make things any better, it means a lot of phone calls, text messages, and
e-mails. Molehills become mountains. Oh, it’s like swinging from heaven to hell. I
can be completely ice-cold, as if I couldn’t care less, and then I can be warm, my
heart is beating loudly, and I really want him to be here all the time. I’m really crazy.
Should I just switch off?” The group responds with several practical questions, why
Hamar, how often do they meet, and so on. Hilde answers briefly, and then she adds
that a girlfriend of hers has been very supportive, saying that it’s always like that in
the beginning. This is confirmed by Trude: “Yes, aren’t all crushes like that really, if
they mean anything?” Kristian: “I think you seem very reflective about this, actually.
And these things take time. You are coming here to try to change your ways of
thinking about things, but I think you’re getting on well.” Hilde then gives an
example from a telephone conversation where she had reacted strongly. “But the
next day, I understood how outrageous I had been, the things I had said, really . . .
” Astri: “But that’s good, Hilde. You see your own part in it. Otherwise, I don’t think
you should excuse yourself as if you were weak or ill. Just be yourself.” Sigrid: “Take
your time, at your own pace. I think you are doing very well.” Therapist: “It is
through the meeting with others that one’s own personal issues come up again and
relationships are difficult, you know. But, now you have a fine opportunity to work
on it. It is important how you manage this and that you don’t act out.” Hilde: “Yes,
well, OK . . . Well, then, I think I’ve finished, that’s enough for now.”
The problem with this sequence is that the therapist resigns. Initially, the group
does its job, finding issues and taking turns, and Hilde brings in an extremely relevant event and this is explored a bit, but then the process comes to a halt. The group
members lapse into supportive statements and the therapist says that “she has a
fine opportunity to work on it.” The problem is that it is exactly this work which is
missing. The process lacks a transition from support and declarations about what
the group is meant to do, to doing the actual job. In short, there is no effort at
exploring the details of the transactions. Nobody tries to identify the obvious failures
of mentalizing. What does they consist of? It has to be specified. What was actually
said in the telephone conversation which Hilde referred to? What did she say, what
did he say? Why? How did she understand it? And how did she understand him?
When such exploration of subjectivity is lacking, one is left with general information
and risks lapsing into pseudomentalization. The therapists’ task is to lead the group
members on, when the process ends up in a supportive stance. Support is fine, but
in this case it blocks a further understanding of Hilde’s inner scenarios.

The therapists’ dilemma is that in a group setting, they should not do the job of
mentalizing by themselves in dialogue with the protagonist. They should try to
identify the failure of mentalization, but at the same time hold back the impulse

Item 4: Engaging group members in mentalizing external events

to go into it fully and instead attend to how the other group members manage the
situation and help them to practice a mentalizing stance. The example illustrates
how a supportive group psychotherapy style implies avoidance of this vital task.

Guidelines for rating of occurrence
Technically we recommend that interventions have frequent references to the
group as a whole, by using “we” and “us” about those present. This means that
the therapists define themselves as part of the group:
“Have we understood this?”
“What shall we do now?”
“Shall we go on?”

The first task is to contribute to a clarification of events. Interventions which
aim at engaging others in this clarification will be variants of the following:
“This is a bit unclear to me; I think it is important that this aspect/sequence become
clearer, what about the rest of you—do you agree with me?”
“Do we understand what happened?”

When a narrative is reasonably clarified (who did what and when and what was
the outcome?), one should chose a particular scene. Interventions that count
are of the following type:
“Which aspect of this story do you [the group members] feel is most important to
address?”
“Are feelings the main problem here, in that case, whose feelings?”
“What do you think, Clara, about what was going on here?”
“It seems like you become engaged by this story, Fred. What do you think about
these feelings? Are they unclear, too strong, too weak, difficult to own, difficult to
express? Are they reasonable?”
“How do you others react to this story?”

As in all dynamic group therapy, when other members do this in a clarifying,
explorative, empathic, and even a more challenging way, the therapists can stay in
the background. In situations where the group members hold back, become passive, pursue issues which do not have anything to do with mental states, or give in
to psychic equivalence or pseudomentalization, the therapist should intervene with
the repertoire of interventions which are described later in the present manual.

Guidelines for rating of quality
Low (1–3): The therapists take over (too much) and lapse into individual therapy in the group, or do not contribute to clarifying the events so that the group
has to deal with extremely unclear scenarios, or that they do not contribute to
finding a focus which involves problematic mental states.

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Adequate (4): The therapists invite the other group members, implicitly or
explicitly, to clarify relevant events and engage members to participate in a collective exploration of the mental states involved therein.
High (5–7): The therapists display high level of expertise in engaging other
members in clarifying the narrative, identifying appropriate scenes, and exploring with the members a wide range of perspectives on the scenes.

Item 5: Identifying and mentalizing events in the group
“Events” in the here and now are defined as an act by somebody that attracts
attention because of its emotional content or latent significance. When ten people come together, lots of things will inevitably happen all the time. People react
with the protomental/primary emotion core of themselves and they continuously interpret each other’s actions and mental states. The reactions are contextualized by the established group matrix, but most of these transactions take
place outside awareness or are vaguely registered as sweeping thoughts that
pass away. However, from time to time, tensions will surface. Somebody does or
says something that provokes a conscious experience. When becoming more
intense, it gets more difficult to hide and at some point, it gets noticed by others.
When noticed by the therapists, they should act.
Formally, there is a clear distinction between external events and events which
happen in the group here and now. However, in practice they are often interwoven. Any story about external events will evoke some kind of here-and-now
response, such as interest, caring, acknowledgement, rejection, or irritation.
When should the therapist focus on the external story and when on the accompanying unfolding of the ramifications of the story in the here and now? It is not
possible to state any firm rules about this because the context is so important, but
generally, it might be said that one should “go where the temperature is highest.”
This does not contradict the principle about keeping affects moderate when
working through issues in the group. The therapists need to find out where and
if the temperature is high, since “small fires” have to be tamed before one can
deal with other issues. If an external event has evoked strong feelings in the
group, these must first be worked through, before one goes back to “the story out
there.” A skilled therapist will shift between “there and then” and “here and now.”
What happens here and now is most often highly relevant to the understanding
of the story being told from “out there.” It also concerns vitality and engagement.
If the story is laden with feelings, stay there. If the story seems too composed,
superficial, or “flat” (lacks feelings), then go to the “here and now.”
Working with events in the here and now has special significance for the phenomenon of projective identification, that is, the tendency to suck other people
into (most often) malignant roles that correspond to (part-) object relations in

Item 5: Identifying and mentalizing events in the group

the inner world of the protagonist. It’s hard to work on projective identification
when it unfolds in real-life events since the protagonist will be identified with
the innocent victim side of the story. In the here and now it is different. Distortions may be more easily identified and corrected and other perspectives may
be introduced and accepted before the sequence escalates in a malign direction.
We will return to these issues in “Item 16: Handling psychic equivalence.”
Events in the here and now can be explicitly identified by the therapist “marking” something by stopping and commenting on it. Implicit identification
means that somebody else in the group reacts in a way which changes the focus
to here and now, and that the therapist tacitly accepts it.
Mentalizing an event means that it is talked about and explored with respect
to its emotional meaning and intersubjective and systemic (for the group)
implications. What happens can be that a story reminds a group member about
something emotional from the past. Or it can be that he/she has identified with
something in the story or reacts emotionally to the story teller:
“I can’t stand listening to this, it’s so destructive . . . ”
“It reminds me of something I did myself, but I just can’t bear thinking about it.”

When working on events in the group, the full meaning of the group being a
“training ground for mentalization” becomes realized. Something has happened
in the here and now and has become a matter of interest. How? Who saw or heard
what? How was it interpreted? Does this match the protagonist’s own experience? Can different perspectives exist side by side? Is it possible to establish an
exploratory dialogue about the event? Which feelings are involved and why? Is it
possible to “stay in these feelings” and talk about them at the same time?
The following is an example where other aspects of the story than the actual
content turned out to be important. The main person becomes engaged in the
group process by telling a personal story and this involvement in itself becomes
the here-and-now event which the therapists encourage the group to reflect upon:
Kari (23) has been a group member for approximately 4 months. She has a mixed (A/C)
attachment pattern. She can become chaotic, overinvolved, and self-destructive in romantic relationships, but is critical and reserved in relation to authorities, like the therapists.
She has been skeptical of the treatment program, as she is of health authorities in general.
In her opinion, existence itself is meaningless. To her, this is a fact and not a personality
feature (e.g., a consequence of a pessimistic attitude or of being depressive). In the group,
she has taken on the role of being the skeptical listener, the outsider, and has only as a
matter of duty participated in sharing anecdotal events from her own life. She has (perhaps) been a bit more active during the last few sessions.
At the beginning of the present group session she quickly conveys that she has something she wishes to talk about and that she would like it to be the first item. She then tells
the group about a drive to her home town the previous weekend, and how they became
involved in a rear-end collision. A car drove into them from behind and then just drove

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off. The other group members listen attentively from the start, and their commentaries
make the story move forward and expand into other stories (about negative experiences
from the health services). The comments range from more technical questions about
insurance matters, to how she coped afterwards emotionally. The therapists think that her
story is being told quite ambivalently. She speaks rapidly, is rather unarticulated, difficult
to understand sometimes, as if she wishes to be finished quickly, and that it really does not
matter if she is understood or not. But, this does not seem to affect her slightly older, fellow group members. They ask a lot of questions and are obviously engaged by her, and also
compliment her on how she handled the car crash situation.
The therapists thought that this here-and-now situation was important and filled in with
some comments which helped keep the exploration going, but eventually became more
interested in the actual group process. Their minds were filled with thoughts about the
previous mutual suspicion in the group which was now less apparent, about a possible
relief over this, about a wish to include Kari as a “real” group member and her wish to be
included (although ambivalently), about mature women who take to a younger, delinquent
member, that it might be easier for Kari to attach to peers than authorities, and so on.
After half an hour, one of the therapists comments that this was the longest conversation about Kari’s life which she could remember. “Yes, I am sure it is.” “And how has it
been?” Several members exclaim that it had been very satisfactory. And for Kari? “Well,
not bad.” “Not bad? How should we understand that?” “Not so bad is not so bad!” “It
seems that you are a bit irritated now, is that right Kari?” “Yes!” “And what is that all
about?” “You become so intrusive!” “OK. What do you mean?” After a while the other
group members join in and a discussion about caring for others develops. Some say that
“parents can spoil things by caring too much.” Sometimes, “one must be allowed to just do
things on one’s own.” Kari nods and says that it was like that, it felt OK to talk about the car
crash and afterwards about the hospital admission. But “when I was forced by the therapists to say it was OK, it all went wrong.” “The therapists wanting you to say it was OK?
Where did you get that idea from?” “No, maybe it was more like, when one says that something is OK, then it suddenly isn’t OK any more. You suddenly realize what you’re up to.”
Therapist: “Can it also be that as one says that something is OK, then suddenly things are
no longer meaningless?” “Well, yes, possibly, no, it’s difficult . . . ”
The group continued this discussion about how good things can be destroyed and if the
therapists actually did that in this session, or if Kari had misunderstood, or if the therapists were not sensitive enough, or . . . The sequence lasted for about 1 hour.

For another example of good performance we refer to item 16, “Handling psychic equivalence.” The example concerns Grethe, who reacts to the therapists
videoing the group session.
As an example of poor performance we refer to item 7, “Managing authority.”
The example is about how Valborg, a patient, devaluates the therapist.

Guidelines for rating of occurrence
This item concerns all kinds of interventions which aim to make group members aware of something happening in the here and now, and to help them

Item 6: Caring for the group and each member

explore the phenomenon. Events may be marked by the therapists by interventions such as:
“Can we stop a bit here? It looks like Jonas has reacted to something.”
“Did something happen just now, between you, Petter, and you, Kari?”
“It seems that something happens with you while you are telling this story?”
“You seem quite uneasy today Jessica.”
“Wait a minute, I haven’t got it. Was it when you, Kari, said X, that you, Rita, felt . . . ?”
“Are there any thoughts about what just happened between Kari and Rita?”
“This seems to engage you, Tom. What are your thoughts?”

Guidelines for rating of quality
General interpretations of the kind “It seems there is a lot of irritation going on
in the group today,” can lead to concrete exploration, but can just as well lead to
pseudomentalizing. The question here is how the therapists follow up such an
interpretation. Interventions should be as simple as possible and mark identifiable occurrences.
Low (1–3): The therapists ignore obvious events in the group, or only comment on them superficially, or do not work consistently in engaging the members in a collective exploration.
Adequate (4): The therapists identify some important events in the group and
engage group members in a collective exploration which seems meaningful and
clarifying.
High (5–7): The therapists identify several important events in the group and
engage members in a collective exploration which is profound both regarding
relevance for the group as a whole and for the individuals. Therapists and
patients are cooperating actively and vitally about the understanding of the
intersubjective transactions in the here and now, about feelings which are
involved, and about the implications for the involved subjects.

Item 6: Caring for the group and each member
The theory of mentalization is related to attachment theory. John Bowlby
coined the metaphor “a secure base,” referring to the physical and mental home
which takes care of the child’s needs for safety. Referring to both mentalization
and attachment theory, we would say that for the group to become a good
training ground for mentalization, it requires that the group becomes, and is
experienced as, a secure base. Explicitly and implicitly, the group process activates the attachment system (explicitly: “You should try to attach to the group
and its members”; implicitly: “You can share your worries and concerns in the
group”).

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Since the attachment system will become activated, one has to ensure that
members’ attachment behavior is met in a respectful and professional manner.
This is most important for patients whose attachment is profoundly insecure or,
in the worst cases, have a disorganized attachment pattern, which makes them
confused in close relations. When the attachment system becomes activated, a
lot of doubt and uncertainty will be aroused in these patients, as a consequence
of their early poor attachment experiences. It is then even more important that
retraumatization does not occur in the group.
The ideal about the group as a secure base has references to families as groups.
Within a good enough family, feelings are regulated by parents and siblings,
confirmed but also challenged; the family provides the members with opportunities to talk about life outside the family and about what happens within the
family, in addition to playmates. Children who grow up in healthy families who
have continuous and curious conversations about relations with other people,
develop better social competence than children who grow up in insecure families with high levels of conflict (Gergely & Unoka, 2008). In a sound family,
parents protect the family boundaries, respect the family member’s integrity,
teach the children healthy norms and social skills, contribute to solution of conflicts, and make space for play at the same time as talking and negotiating about
how things should be understood and justified.
These ideals come close to the group therapist’s care for the group. We notice
that this item partly overlaps with taking responsibility for the group’s boundaries and the regulation of the group’s phases. It also overlaps somewhat with
the item about turntaking which makes sure that all members get their share of
time and attention. In addition to taking responsibility for turntaking, the
group therapist should in each group session make sure that the attention is
“balanced” so that it includes all group members. Everybody should be mentioned and commented on in the course of a meeting and if someone is conspicuously quiet, this is an “event.” How come? What is it about?
The most important negative examples are related to destructive group
behavior. This has most often to do with patients who treat other patients badly,
here and now, or who in other ways behave destructively towards the group as
a whole. It is the therapist’s duty to actively intervene and stop such behavior. And
to justify why. It is not only destructive for an individual to be harassed, threatened, and yelled at—it is harmful for the group as a whole if this is allowed. It
undermines members’ confidence in the group as a whole, the confidence that
an authority, a parental figure, is watching out for them, looking after what is
happening, and that he/she will intervene if necessary when somebody’s feelings get out of hand. To take care of the group as a whole, it is sometimes necessary for the therapists to expel destructive patients who are unable to change.

Item 6: Caring for the group and each member

An example of taking care of the group:
Lise had great expectations of the group therapy component of the MBT program,
in particular because the group was conducted by an “expert.” From the start, she
was talkative, dominating, almost a bit like a co-therapist. She was interested in
other group members and gave a lot of advice and recommendations. Early on, she
highlighted similarities between the therapist and her father, and at the same time
she complained that her relationship with her father was “terribly difficult” because
he had never “seen” her. It was difficult for the therapist to successfully stimulate
any reflection concerning Lise and her contributions to the group. When the therapist said: “Lise, can we stop a little here and . . . ,” she replied, “now you are interrupting me again. It is terribly irritating, exactly like my father, I want to finish
speaking.” If the therapist tried to say “Yes, but . . . ,” she interrupted again by
raising her voice above his. When the therapist finally got a word in, she was quick
to object and respond that it was actually the therapist who had a problem. For
some reason or other, “he was after her.” The confrontations with Lise turned competitive, and Lise was always trying to get the last word. The individual therapist was
informed and asked to work on this in her individual therapy. This, however, had no
effect on her group behavior. The controversies intensified and after a while they
came to dominate the entire group process, until the group therapist, after about
eight sessions, decided, with justification why he could not have Lise in the group
any longer. The treatment was unproductive. What was happening in the group
was far from what could be labelled “therapy,” and for the group as a whole it was
destructive. Lise continued in individual therapy. An attempt at reconciliation after
some weeks failed and she was not taken into group again.

An example of taking care of a member:
Sissel had had an issue for a long time about a complicated court trial which was
coming up. She was a central witness. She tells the group that she has been called
in for cross-examination the next week. At the same time she rather inconspicuously adds that she is going to have an operation that same morning. The therapists
stop and wonder if it is possible to have an operation and to be cross-examined as
a witness on the same day. Sissel tells them that she just has to. “I have had to do
worse things than that.” The other group members also realize the unreasonableness of the situation. In the following discussion, the therapists comment upon her
childhood story of gross neglect. The theme of caring for oneself develops. Sissel
finds that the issue of the trial is “peanuts” compared to what she has been through
before, and that it is only a matter of “pulling oneself together.” In addition, there
had been considerable pressure to bring this case to court as soon as possible. The
group therapist says that she has difficulties with accepting this and offers to call the
lawyer and explain Sissel’s situation to him. The other group members are obviously
relieved. The issue of taking care of oneself becomes supplemented with the issue
of parental care. Sissel starts to reflect on how she tends to completely disregard her
own needs.

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An example of a failed effort to explore group events:
In the opening round, the therapist says that he has been wondering if there is
“some conflict going on between you, Erna, Knut, and Kari? Is something going
on? There have been some small incidents lately, some disagreements, comments.
Perhaps there is something we should look more into here?” Trine: “I find it really
unpleasant that you mention this. I don’t know what this is about, or if anybody is
feeling uncomfortable, but just now it is unpleasant.” Siri: “It is OK for me. I’m in
my own world these days. I don’t really notice how others react.” Knut: “I think it’s
quite difficult. But a lot of things have been hard lately. I feel as if I could explode.”
After a round on Knut’s anger towards health authorities, the therapist returns to
the conflict issue and Erna takes the floor: “Yes. I can start. When it came to the last
session, I did not understand what Kari was talking about. Nor the session before.
It was not a lack of interest, it’s just that I faded out, you know, and then I pulled
myself together again. It is something with your manners, Kari, so many words, and
I don’t really know if they hang together, and then you have some very strong statements within this fog of speech, which I don’t get, and then last time you suddenly
talked about me, that you were convinced you could change me somehow, if you
only got the chance, and then I thought, well, now . . . who are you and what do
you know of me, to change me from the outside, when I have known myself from
the inside for 35 years! I couldn’t just sit and listen to that, it was really quite cheeky,
but I have learnt some things in this group, after all, I’ve been coming here much
longer than you have, so I thought, I’ll answer that one. In the old days I just would
have taken it in and kept silent, never dared to oppose, really. But I’m doing it now.
I can’t put up with things in the same way any longer. It is feedback which is the
main point in this group, so I did say to you then, exactly what I thought about such
statements like yours.”
With some short comments from Trine, Knut, and the therapist, Erna keeps up
her monologue for approximately 10–12 minutes, where she talks more about Kari
than to her. Kari then says: “I‘ve been listening to this for a quarter of an hour, and
I must say that I am present in this room too, you know. I just wonder if you’re soon
going to ask me a question, or what this really is about. There are limits to what I
can take. I can see that you have taken up the sword, but I don’t like just sitting here
receiving attack after attack from you. I knew at once when the therapist mentioned it, that I was the one to be ‘taken’ today.”
The same kind of “dialogue” continues, with plain offensive comments and
more indirect hints, mutual insults, exaggerations, and misunderstandings. No unified understanding or reconciliation happens during the group session.
There is a lot to address here. On a superficial level, the therapist makes some
“correct” moves. He mentions a group issue in the opening phase and says it should
be talked about. Thereafter, a lot goes wrong. The therapist underestimates the
emotions associated with the theme and he overestimates the mentalizing capacities of the group members. This allows Erna to overrule Kari. Most people would
find Erna’s flow of words insulting. The therapist should have listened more to the

Item 6: Caring for the group and each member

hints which were apparent from the beginning, hints about this being “really
unpleasant,” and explored that. Kari had also felt that immediately: “that I was the
one to be ‘taken’ today.” By finding out more about what the unpleasantness was
all about, the current affect, one could have kept a more metacognitive stance later:
“This is obviously difficult—how shall we deal with this?”
When this example is mentioned under item 6, “Caring for the group and each
member,” it is because the main point is that the therapists let a patient overrule
another member without intervening and stopping it. It is a scenario, where a member (Kari), is picked out and talked about derogatively over a prolonged sequence
of time, while other members are listening. Erna appeals to the others, almost as if
she is talking on behalf of the members in the group. It is a scapegoat scenario. Kari,
however, is not necessarily an innocent part of it. She may have contributed to the
scene by projective identification. She even says afterwards that she “knew” that
she “would be taken.” Whatever the contribution of underlying mechanisms, such
scenarios must be stopped. It has to do with caring for the group as a whole as for
its members.
As mentioned, the therapists should try to live up to an ideal of caring for parents in a family which can accept that a lot is troublesome, but which try to mentalize together about things that are difficult and unpleasant. It is far from the ideal if
a parent allows a member of the family to attack somebody else in the family without intervening. At some time point, this will result in a retraumatization, as yet
another experience that nobody cares and that all in all, it is best to be on the lookout, offensive, and that in the end the only person one can trust is oneself. The right
intervention in this case would have been a variant of “Hey, slow down there, Erna,
this is going too fast for me, I can’t quite follow you. We’d better take it a bit more
calmly. How is it for the rest of you? How are you doing, Kari?” Thereafter continuing with a more controlled exploration where each involved member is stopped
if needs be, and made responsible for their unclear statements, feelings, and
misunderstandings.

An example of a patient who experienced a panic attack in the group:
Louise (23) is an attractive young woman who has dropped out of secondary school
and only just manages to make ends meet by working as a part-time shop assistant.
She gets a lot of attention from men, but does not manage longer-lasting relationships, and is not interested in them either. She has a dismissive attachment pattern
and keeps other people at an emotional distance. She has no close friends and does
not feel comfortable when a person she knows asks her how she is doing. This kind
of talk, and especially in groups, “gives her the creeps.” The group therapy component of MBT was therefore troublesome and quite provoking for her. She felt sick
when she entered the group, and in the beginning, she only managed to give brief
answers to straightforward questions. During the fourth group session, she had a
panic attack and left the room. The group therapist followed her and found her
sitting on a bench in the corridor, trembling and hyperventilating. He sat down
beside her, held her hand, and talked calmly to her. After 10 minutes the attack was

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over. She composed herself and joined the therapist back in the group. She
explained that she had simply felt scared stiff in the group. She had appreciated that
the therapist came out, that he cared, and that he managed to calm her down by
staying with her. Later, in the course of treatment, when Louise had managed to
adjust and use the group constructively, she often returned to this incident, saying
how important it had been for her that the therapist took care of her and did not
leave her on her own.

Guidelines for rating of occurrence
When therapists do their job in accordance with this manual, caring aspects
will most often be implicit in the group dynamics. They do not stand out as separate phenomena, but are part of the foundation of the group. Since many interventions may have this implicit feature of caring, it is difficult based on “external”
signs to operationalize what would characterize a caring intervention. This item
is therefore not rated on occurrence. However, the rater should note on the
working sheet when explicit caring interventions do occur.
In an “ordinary” group session, without particular positive or negative events,
the quality is set to 4 (good enough).

Guidelines for rating of quality
Low (1–3): The therapists let group members treat one another in a derogatory
or insulting way or they handle such situations superficially.
Adequate (4): At this level, the group process is on an even keel when it comes
to care. The therapists seem to have an awareness regarding negative comments
between group members and are quick to intervene in such situations.
High (5–7): The therapists are very well emotionally attuned to interactions
between members and to issues that have to do with disappointments, insults,
rejections, and withdrawals here and now, as well as failing abilities to care for oneself, and they are active in mentalizing seemingly “small” incidents in the group.

Item 7: Managing authority
The therapists should not only take care of the group and its members in the
sense of caring, but also by their authority as the leaders of the group. This item
marks a distinct and different attitude towards leadership as compared to group
analysis. The latter defines a distinct leadership of administrative issues (the
therapist takes responsible for time, place, and physical matters) but group
analysis, as recommended by S. H. Foulkes, does not define the therapist as the
dynamic leader of the group. The therapist is instead labelled a “conductor” (as
in an orchestra). In MBT-G, we clearly define the therapist as the leader of the
group. He/she not only has responsibility for physical arrangements, but he/she
has also invited the group members to join a specially designed project with

Item 7: Managing authority

specific aims and rules. Within group analysis, one can to some extent profess
that the group members “own the group,” meaning that in many ways it’s their
product. The group analyst should act more like the group’s “midwife.” Within
MBT-G, group members are also active participants, but the terms and premises for the group are nevertheless decided by the therapist.
Managing authority implies that the therapists are active, that they explicate
and model the goals of the group and ways of achieving the goals. They should
explain the rationale and structure in a convincing way and demonstrate in
practice what it implies. They should be open, curious, and explorative, but at
the same time able to maintain consistent boundaries. The group should be a
training ground for mentalization, not an arena for acting out personal aggression, self-destructiveness, or antisocial features. The therapist should monitor
how the group keeps to its primary task and sensitively interrupt issues which
do not belong to this setting. When the therapist’s authority is tested by devaluating and aggressive patients, it is important that they are able to handle their
own countertransference.
In particular, one should be aware of potential conflicts between the obligation of managing authority and taking a not-knowing stance. Quite recently we
(Inderhaug & Karterud, 2015; Karterud, 2015) conducted an observational
study on three consecutive MBT-G sessions at a MHC in Norway. We found
that the group dynamics were out of control. The main reason was that the therapists downplayed their authority role and overplayed the not-knowing stance.
They appeared not-knowing with respect to knowledge about borderline pathology as well as group dynamics. The result was chaos. Readers should be
reminded that the principle of not-knowing refers to the content of the mind in
particular circumstances. We are not experts on what people are feeling and
thinking in particular situations. However, we are experts on how to conduct
MBT-G, in general, for borderline patients.
An example of good management: See the example about Lise in “Item 6: Caring for the group and each member.” Lise made repeated frontal attacks on the
therapist who at first answered by ordinary therapeutic techniques. When this
did not lead to any change, the treatment was terminated.
An example of poor management:
It had become acceptable in the group to speak to the therapists in a rude and
derogatory manner without any consequences. In this session, the group used the
first hour to say goodbye to Reidun who had been a group member for about 3
years. There was a lot of focus on how Reidun was feeling these days, and on her
plans after ending the treatment. There was little focus on what it actually felt like,
that this was her last group session, here and now. Reidun had improved and when
asked what she thought had helped, she answered that it was probably the medication. Nobody in the group commented on this any further. Nobody asked how

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Reidun thought the group might have contributed to her improvement. The therapist cringed, but he could not bring himself to say anything in this situation. This
sequence of Reidun’s last session became emotionally flat.
After this sequence, one of the group members commented that she had problems with Kine and Valborg in the group. It seemed to her as though these two were
sticking together in some way. She felt a bit suspicious about what they were talking about, whether it was something critical, behind her back, and she thought she
had to bring it up in the group. This led to a heated, quarrelsome atmosphere.
People interrupted each other, were quick to feel attacked and to counterattack.
The therapist tried after a while to stop this by saying something and moving his
hand, but was overlooked and not heard. After a while, he tried again, but was
overlooked once more. On the third attempt, he finally succeeded in capturing the
group’s attention. Although the therapist then said the “right” things—about an
important issue and that the temperature had become a bit high in the group—it
became somewhat drawn-out, and in the end he was interrupted by Valborg who
turned to someone else and just continued as if the therapist’s intervention had not
taken place. The therapist let this happen. After a while, Valborg’s rather weighty
style is commented on by another group member and her interruption of the therapist is mentioned. Valborg then says “Well, yes, but therapist X just keeps going on
and on. Usually nothing comes out of what he says, anyway. You’re quite right, I do
become impatient. But I think that’s just healthy.” Another group member comments: “You know, I think you’re brave.” The group continues and Valborg’s
devaluation is not mentioned again.

In the following example, the therapist did not manage to handle a hostile patient:
Bente had for a long time been very reluctant to speak about herself. In the opening
phase in this meeting, the therapist turns to Bente and asks: “How about you,
Bente?” The therapist has a Bergen accent [a Norwegian west coast town] and
Bente answers in a mocking way, repeating her words using the therapist’s accent.
The therapist is startled and exclaims in a rather surprised way, “What was that?”
She is answered in the same way, but now even more accentuated. The therapist
feels humiliated and remarks, in an irritated way, that “Well, it’s about time we get
to hear something from you, now.” Bente does not answer. Therapist: “No? OK
then,” and continues, turning her attention to the others. Bente does not say anything more in this session. During the next session, the therapist tries to bring up the
incident again, but is not answered. Some weeks later, she gets a note from Bente,
saying that both she and the group need a break from each other. During supervision, the therapist explains that she has for a long time felt almost “terrorized” by
Bente and that this has made her avoidant and helpless. Retrospectively, it’s easy to
see that the therapist in this particular session should not have turned to the other
patients, but kept to this incident and made it a main group issue for that session,
talked about her own feelings, and asked her co-therapist and the group for help.

See also the example from Chapter 2 (“Clarification of events”) where Lise
arrives late for her last but one group session, when she more or less “empties”

Item 8: Stimulating discussions about group norms

herself, and talks in a flow of incoherent themes, where the therapists give in,
abdicating from their role as authoritative group therapists.

Guidelines for rating of occurrence
This item is also difficult to operationalize at the level of distinct and explicit
commentaries. Therapists manage their authority by a range of different means.
This item is therefore not rated for occurrence.

Guidelines for rating of quality
Low (1–3): The therapists let derogatory comments about their characteristics
and unwarranted beliefs and opinions about themselves pass by. They do not
stand up for or defend the group’s basic values as something inherently linked
to their own role. The therapists seem unconfident or hesitant, or they manage
their authority in an unnecessarily harsh or rigid manner.
Adequate (4): The therapists seem calm and confident as MBT-G therapists.
In theory and practice they stand up for the group’s basic values.
High (5–7): The therapists manage difficult challenges from individuals and
from the group as a whole that have to do with the group’s basic values. They do
this in a convincing way, firmly determined when necessary, but at the same
time keeping a mentalizing attitude.

Item 8: Stimulating discussions about group norms
This item is about the necessary discussion group members have to perform in
order to make the group’s generalized project concretely their own. It is mainly
about establishing norms. Even if therapists in MBT-G repeatedly indicate the
goals of the group, this does not necessarily mean that group members really get
the point, internalize it, and make the group norms their own. The therapist’s
recommendations will necessarily be a bit general and abstract and not always
straightforward or understandable. It is a major task for the group to find out
what these recommendations mean for the practical week-to-week work of the
group. This may account for procedures, such as how do we receive a new member? Should members introduce themselves? What and how much should they
say? It may also account for the opening phase. How long time should it take?
Must everybody have something to say? What is an event? But mostly, it accounts
for principles about being open, frank, managing defenses and resistances,
handling feelings, and principles about how active (or passive) one should be. Is
it right to push people? In that case, how much? How frank can one be? What
about if people become hurt? Is anger allowed in the group? How active should the
therapists be? If one keeps silent, should one then be asked? And so on. For a more

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profound introduction to the theme of establishing group norms, we refer to
other literature (e.g., Karterud, 1999, p. 338).
The issue of norms turns up in all types of groups. Some groups regulate this by
communicating a set of principles and rules as to what is allowed and not allowed
with respect to content and ways of expressing oneself. In dynamic groups, where
the establishment of norms is part of the therapeutic group process, the therapists should facilitate discussions about norm establishment. This is done by
“marking” certain problems and making them topics for general discussions:
”It seems that you, Kristian, felt a bit devalued by Eva, just now. It seems that you
got things straightened out, though. It brings out the question of how careful or
conversely how persuasive or confrontational one can be towards each other in the
group. Any thoughts about that?”

Norms which are accepted and shared after such conflicts have been termed
“group solutions” (Whitaker, 1981). Group solutions can be restrictive or enabling. Restrictive group solutions aim at controlling anxiety. A restrictive solution to the above mentioned conflict could be the following: “Everybody in the
group is really fragile and vulnerable. It’s important that we are very careful with
each other and make sure we don’t hurt anybody.” Restrictive group solutions
indicate high levels of anxiety. Therapists should not accept restrictive group
solutions. However, at times the therapist might think that this is the most the
group can manage at the given time point. In that case, the therapists should
make a plan for how they can make the group develop in a more liberating direction. This is described in detail by Karterud (1999). An enabling solution to
the above mentioned group conflict could be:
“Everybody in the group has inhibitory, anxious features which restrict life. To get
on in life we have to challenge each other. It’s important to keep on discussing how
this can be done.”

By this item we want to emphasize that the therapists should stimulate (1) by
taking initiatives, or actively being engaged in group relevant discussions which
spontaneously occur, in order to underline that this is important, and (2) by
challenging restrictive group solutions and favor enabling solutions.
An example of a too directive leadership style:
Brita is a new member in the group. This fact probably accounted for some reluctance in the opening phase. The therapist saves the day by saying: “Well, then we
usually introduce ourselves.” A better variant would have been: “Yes, now we have
a new group member today. How are we going to handle this?”

As an example of poor performance on this item we refer to the passage about
Berit and Lisa under “Item 5: Identifying and mentalizing events in the group.”

Item 9: Cooperation between co-therapists

Lisa makes the group choose a restrictive group solution which the therapists
do not challenge.

Guidelines for rating of occurrence
This item concerns interventions where the therapists take the initiative, support, and engage in discussions about issues that are important for how the
group functions as a group:
“Being angry in the group is perhaps not so easy. How shall we handle that?”
“It is a dilemma when someone is getting on well with an event and we at the same
time know that several others also have things to talk about. How shall we handle
that?”
“This discussion about latecomers is important. How can we find a balance
between making requirements about commitment without lapsing into military
discipline?”
“Should things become a bit stricter now, by not allowing people to interrupt when
somebody is talking?”

Guidelines for rating of quality
Low (1–3): The therapists are either too directive and try to make rules in an
authoritarian manner, or they neglect obvious group conflicts so that these are
not brought up for group discussions in order to establish enabling group solutions, or they do not engage in the discussions between patients on norms and
the making of norms.
Adequate (4): The therapists take the initiative to norm discussions, engage in an
interested way in spontaneous discussions, and try to modify restrictive group solutions which are being made, if these are not challenged by other group members.
High (5–7): The therapists are obviously sensitive to group conflicts, participate in making the group aware of these, and formulate them in words which
seem relevant and vitalizing for the group. At the same time they give the issues
meaning, in the context of the group’s main goal as a training ground for mentalization, and thereby help the group to negotiate group conflicts in enabling
directions.

Item 9: Cooperation between co-therapists
A noteworthy difference between individual and group therapy is the presence
of a co-therapist, which is frequently seen in group therapy. It is of course
important that the different therapists cooperate in an efficient manner. In
MBT-G, they should do this in a manner that models mentalizing dialogues.
We have previously written about how co-therapists should cooperate before
and after each group session to ensure meaning and continuity of the group

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process. In the group, they have to assist each other. It is most important when
the mentalizing capacity of one of the therapists has been weakened by something in the group. In such situations, co-therapy can demonstrate here and
now how one can make use of other perspectives and regain mentalizing capacity. This requires that the therapists speak to each other during the group sessions. Instead of wondering what the co-therapist might have thought about a
subject, it is recommended that therapists ask each other directly, and also, that
therapists are open about feelings of uncertainty: “I must admit that I don’t
quite know how to understand this. What do you think, therapist B?”
Talking directly to each other contributes to making the therapy process less
obscure. An efficient cooperation requires free and open (transparent) communication. Being open demonstrates that therapists are not omnipotent and that
they also sometimes mentalize poorly. On the other hand, they might become
models for how it is possible to regain mentalizing capacity. Being open also
models good parenthood. It is possible (and preferable) for parents to speak to
each other frankly about difficult situations with the rest of the family present.
Such frankness requires a confident relationship between the co-therapists. We
do not encourage therapists to expose aggressive feelings or contempt for each
other. If this is the case, it should be dealt with after the group session or in
supervision. If co-therapists, over time, do not manage to achieve a confident
cooperative relationship, they should not continue to work together. Patients
rapidly perceive such tensions and if a bad co-therapist relationship was pointed
out in the group, the co-therapists would be in difficulties. If they deny it, which
might well happen, they undermine the project of MBT. Sensitive observations
from patients are actually pieces of good mentalizing. To deny that would be
destructive. On the other hand, if therapists should admit to a bad co-therapist
relationship, this would open up a far greater transparency than most therapists
can handle here and now in a group.
An example of good cooperation:
Therapist A made an intervention which was followed by total silence. Therapist B
felt confused because she did not hear what had been said and wondered if the
same had happened with the patients. Instead of leaving it to the patients to find
out about this, she actively intervened. Therapist B: “While you were talking, I
found it a bit difficult to understand what you actually meant. Could you repeat it
please, or perhaps put it differently?”(An alternative intervention is to ask the group
what the members have experienced, but then there is a risk that a problem which
the therapists are responsible for becomes attributed to the group.) Therapist A:
“Yes, I see that this was a bit fuzzy. Perhaps it was because I was not clear enough
in my own head. I tried to say something about the group having trouble with listening. The way I talked, it seemed I made things even worse!” Therapist B: “Yes,

Item 9: Cooperation between co-therapists

I was really struggling to follow you and to understand what you were saying. Is
there anything in the group making you so vague?” Therapist A: “Good point. I
think it may have to do with the disagreement last week between Truls and Katrine.
We have not referred to it today, but I think it is important. I have been thinking a
great deal about what happened and can’t understand what really led to such a
heated discussion. Assisted by therapist B’s question, therapist A now points to a
manageable issue for the group. It is time to round off the dialogue between the
therapists and to open up exploration which includes the patients. Therapist B:
“Has anybody else had thoughts about the disagreement last week? Perhaps you
also became a bit apprehensive?”

In this manual, most of the examples of poor group processes are also examples
of poor cooperation between therapists. When a therapist does something
which has a bad effect on the group’s development (or does not do something),
it is the other therapist’s duty to intervene in order to re-establish the group’s
collective capacity to reflect. It is understandable that one therapist temporarily
loses some capacity for mentalization. It is more unfortunate if both simultaneously lose this capacity.

Guidelines for rating of occurrence
This item concerns all types of interventions where therapists talk to each other
or refer to each other:
“Are you or I going to start, therapist X?”
“Now, I’m a bit uncertain, what do you think, therapist X?”
“In addition to what therapist X has said, I would like to add . . . ”
“I just want to say that I feel a bit confused here. I don’t know what this means. Do
you understand, therapist X?”

It is possible for therapists to have a good and confident therapeutic cooperation without communicating to each other verbally. Interventions can follow
each other smoothly and creatively without any explicit dialogue. It is therefore
possible to have a low rating of occurrence (even 0) and at the same time receive
an adequate score on competence.

Guidelines for rating of quality
Low (1–3): There is no verbal communication between the co-therapists. They
also cooperate badly by not following each other’s interventions, and pull in
opposite directions. In the worst case, therapists contradict each other and
show signs of irritation or dissatisfaction.
Adequate (4): There seems to be a confident relationship between the therapists, their interventions are complementary, and they communicate with each
other with open, reflective comments.

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High (5–7): The therapists have an open dialogue between themselves which
functions as a model for mentalizing and contributes to clarifying difficult situations in the group.

Item 10: Engagement, interest, and warmth
This item is not unique to MBT-G. It is highly valued in most psychotherapies.
The key terms engagement, interest, and warmth could be supplemented with
the terms authenticity, empathy, and caring. Their opposites are cold, disinterested, uncaring, reserved, and distanced. This item is meant to reflect perhaps
the most important general factor in psychotherapy. It refers to a therapist who
“cares” and who is able to communicate this in a manner so that patients feel
welcomed, respected, important, listened to, and taken seriously. This requires
a far more active therapeutic style than is customary in group analytic psychotherapy. The therapist should be interpersonally “present” and take initiatives.
He/she should not be distant with the individual members and wait for “the
group to take the initiative.”
The item reflects MBT’s and mentalization theory’s roots in the attachment
tradition. The ability to mentalize grows out of an experience of being understood. Through this experience the individual will find culturally acceptable
verbal means of expressing his/her state of mind. The therapist’s role, as previously mentioned, is somewhat similar to that of a parent. It is a matter of “minding minds.” It requires an interest in and involvement on the part of the parent/
therapist to find out what is in the child/patient’s “mind,” an interest that is
sustained by a desire to be helpful. For parents, this is a natural response in relation to one’s offspring and is linked to the emotional system of “CARE” (Panksepp, 1998). For the therapist, it is a cultivated response that is sustained by the
emotional systems of care and SEEK.
The idea here is not of overwhelming warmth bordering on invasiveness,
which is likely to be harmful to patients with BPD, but more about a balanced
friendliness. It should be genuine, not superficial. Although this item is generic
for the psychotherapies, the MBT version of it contains a specific quality of
authenticity. The mentalizing therapist needs to make their mental processes
transparent to the patient as they try to understand them, openly deliberating
while “marking” their statements carefully. This requires directness, honesty,
authenticity, and personal ownership that might seem problematic partly
because of the dangers of boundary violations in the treatment of BPD. Our
emphasis on the need for authenticity is not a license to overstep boundaries of
therapy or to develop a “real” relationship; we are merely stressing that the therapist needs to make themself mentally available to the patient and must demonstrate an ability to balance uncertainty and doubt with a continued struggle to

Item 10: Engagement, interest, and warmth

understand. This becomes particularly important when patients correctly identify feelings and thoughts experienced by the therapist. The therapist needs to
be prepared for questions that put them on the defensive – “You’re bored with
me,” “You don’t like me much either do you,” etc. Such challenges to the therapist can arise suddenly and without warning and the therapist needs to be able to
answer with authenticity. If they do not do so the patient will become more
insistent and evoke the very experience they is complaining of, if indeed the
therapist was not already feeling it at the time.
The therapist need not like all aspects of a patient, but the patient must arouse
a positive involvement on the part of the therapist. Positive involvement may be
challenged and threatened by the therapist’s countertransference, but unless the
therapist has an initial positive attitude toward a patient, then he/she should
refer the patient to another therapist.
Engagement, interest, and warmth are factors that should pervade the therapy as a whole, and it is therefore less relevant to link this item to specific interventions. This is the reason why this item is not scored for adherence. It is more
a sort of a precondition for the other interventions, such as “Exploration, curiosity, and not-knowing stance.” Even though it refers more to a general attitude
than to specific interventions, but certainly involves nonverbal signals (e.g.,
smiling, a friendly facial expression, body language, etc.), a number of phrases
clearly communicate interest and involvement, such as “I have thought about
you since we last met” (“holding mind in mind”), or “I’m sorry to hear that”
(empathy), or “Too bad,” or “That sounds good,” in addition to questions such
as “How was it?” “What were you feeling then?” and “What did you think?”
Humor belongs to this item. Psychotherapists should have a good sense of
humor. It testifies to an ability of having different perspectives in mind which
might counteract the grave seriousness of psychic equivalence. It is easier to
joke in group therapy and it is a fact that people do laugh more often in group
settings. The therapists should be a part of this. However, the humor should be
warm and inclusive, not cold or cynical.

Guidelines for rating of occurrence
This item is not rated for occurrence

Guidelines for rating of quality
Low (1–3): At the lowest level, the therapists appear cold, uninvolved, and uninterested, with a reserved body language. They give the impression of having
little or no empathy. Questions are delivered in a mechanical manner. On a
somewhat higher level, they do not appear directly cold and uninterested, but
more reserved and distanced. The therapists act and react with little vitality and

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spontaneity, and the therapeutic process seems slow and lethargic. At level 3,
there are sequences in which the therapists seem more involved, but the overall
impression is still one of reservation and distance. It is also possible to be overly
involved and blinded by one’s own therapeutic focus and thus overlook the
patients’ points of view.
Adequate (4): The therapists appear genuinely warm and interested in each
member and the group as a whole. The rater gets the impression that the therapists care in a positive way. Several interventions and their stance indicate this.
High (5–7): The therapists seem definitely genuinely interested and involved,
and they express their empathetic attitude in a natural and spontaneous way as
well as a capacity for authenticity. At the highest level, the therapists’ involvement is dynamic with flashes of disarming humor, but without this undermining the feeling of a genuinely empathetic stance.

Item 11: Exploration, curiosity, and not-knowing stance
This item also refers to an underlying attitude that should characterize the
entire therapy process. It is a most crucial item for MBT. It may of course occur
in other psychotherapies as well, but hardly as consistently. Earlier versions of
the assessment scale differentiated between a not-knowing stance and promoting exploration and curiosity. Practice has shown, however, that these phenomena are so closely related that they practically never occur independently of
each other. This is also consistent with a conceptual analysis. Exploration and
curiosity arise out of a state of not knowing and of a desire to find out. Exploration and curiosity are linked to the primary emotional system SEEK. It is usually associated with a scrutiny of the surroundings, of unfamiliar others, and a
search for food, resources, sex, and so forth. The unique aspect here is that it is
applied for the exploration of the inner world. The starting point is that the
patient has poor mentalizing abilities to find out about and understand mental
phenomena, or that these abilities are temporarily shut down due to emotional
hyperactivation. The essence in MBT is that patients need to develop their ability to mentalize through the therapeutic process. The therapist must therefore
be consistent, clear, and pedagogical with respect to the following fundamental
principles:
1 Even though mental states and mental phenomena are not transparent, they
are not incomprehensible
2 They can be made more understandable via exploration
3 This type of exploration requires inquisitiveness and a not-knowing
attitude.

Item 11: Exploration, curiosity, and not-knowing stance

The therapists’ most important task is therefore to be tolerant companions in an
exploratory process and not all-knowing experts who think they have privileged access to other people’s inner worlds or to “what really goes on in the
group.” Like companions on a journey, the therapists should engage patients in
common efforts to find out about certain phenomena. The therapists must
communicate the attitude that they cannot simply see into the patient’s inner
world, but that they depend on the patients’ assistance. Mental states are not
transparent, but they can become apparent through dialogue. The therapists
must accept that both they and the patients experience things only impressionistically and that neither of them has primacy of knowledge about the other or
about what has happened. This is more easily said than done. Both patients and
therapists may behave as if they are sure about what the other is thinking or
feeling. The therapists should refrain from statements or interpretations that
have a conclusive character in relation to patients’ or others’ mental states without having first arrived at a common understanding with the patient based on
an abundance of information.
This item emphasizes the importance of awakening/stimulating patients’
interest in mental states and motives in themselves and in others. An interest in
other people’s motives is a precondition for conducting the necessary work that
is needed to find out other people’s mental landscape and what drives them. The
therapists must have activated their own seeking system and, by way of genuine
curiosity for the patients’ minds, they hopefully stimulate the patients’ own
curiosity.
The beauty of the not-knowing stance is that it reminds the therapists that
they do not need to understand what patients are saying or to struggle to
make sense of it within another framework such as a patient’s traumatic past
or their maladaptive cognitive schemas. MBT therapists eschew their need to
understand. The therapists should not feel under obligation to understand the
nonunderstandable. Patients with BPD become muddled as they talk about
themselves and others when they become aroused, as do people in general.
But feelings disrupt mentalizing more rapidly in patients with BPD and, as the
mentalizing processes of the patient derail, the therapists are likely to understand less and less. This is a moment for the therapist to intervene, most simply by saying “I am not sure that I understand this. Can you, or someone else,
help me do so”? The cardinal error under these circumstances is for therapists
to take over the mentalizing and to try harder and harder to make sense of
what the patient says and subsequently to deliver their understanding.
Relieved of having to understand, the novice therapist is in a more confident
position. It allows them to be less fearful of making errors.

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Curiosity, exploration, and not-knowing stance concerns also the group as
a whole as well as what happens between the group members during the session. Interpersonal transactions are usually spontaneous and fast. Interventions belonging to this item will therefore often be linked to interventions
aimed at calming down, and stop and rewind: “Let’s go back and find out what
happened.”
In the section on group-specific items we underlined how important it is for
therapists to elicit how other patients understand what the group is talking
about. It means that therapists have to contain and practice a kind of double
not-knowing position! They have to be curious about what particular individuals talk about and how they enact their story here and now, and at the same
time wonder how other group members interpret the same phenomena.
Low occurrence of this item means that the therapists are not particularly
interested in understanding mental phenomena, but are more concerned about
behavior, support, problem-solving, or, for example, manipulating mental phenomena with medication. The opposite of an open, seeking, curious, and nonknowing attitude is a closed, convinced, and assertive attitude. A therapist with
a “closed” attitude often establishes an idea about what “really” is the patient’s
problem, what he/she “really” is afraid of, what he/she “really” is feeling, or what
the patient’s closest relations “really” have in terms of hidden agendas. Such a
therapist’s objective is then to convince or persuade the patient to accept his/her
view. The same attitude may prevail towards what happens in the group. These
kinds of interventions are not covered by this rating system. The rater should
still make notes on the worksheet about when and to what degree such interventions occur. It might be that the therapists in some sequences are assertive
and persuasive and that in other sequences they are more open and exploring.
In such a case, the persuasive section will decrease the quality score.
Most of the clinical illustrations in this manual contain interventions that
comply with this item. In the example of “What counts as an event?” (Chapter 2), the therapists explore what is “impossible” for Marianne by staying with
her parents over Easter. In the example with Grethe under “Item 3: Initiating
and fulfilling turntaking,” the therapists explore the event that triggered her
stuttering.

Guidelines for rating of occurrence
The target here is interventions that convey curiosity about motives and mental
states and not curiosity about facts or systems. In the course of a 1.5-hour group
session, a large number of people will have been mentioned and a lot will have
happened here and now. Low occurrence implies that the therapists do not pose

Item 11: Exploration, curiosity, and not-knowing stance

questions about these people’s mental states or motives and their intersubjective
transactions. The patient’s explicit and implicit perceptions and interpretations
are quietly accepted. With high occurrence, many questions are posed that promote seeking and curiosity about the patient’s own motives as well as those of
others:
“What do you others think about this?”
“What kind of feelings do you get by listening to this story?”
“What do you think made her say that?”
“Why did he do that, do you think?”
“Yes, I hear what you are saying, but I wonder why you said it in exactly that way?”
“It is possible he said it to hurt you, but might there be other reasons as well?”
“Based on what you have told me, is it possible that your mother often overlooked
you. Why did she do that, do you believe?”
“How is it for you, Elisabeth, to hear that the other group members do worry
about you?”
“What has been in your thoughts about this matter since the last group session,
Peter?”
“It seems like something is going on between you two, Eva and Louise. Can we find
out what it is about?”

Guidelines for rating of quality
Quality concerns to what degree the therapists follow up questions like those
above, in detail and depth:
“Yes, that makes sense, but how does it relate to X, do you think?”
“Is it possible to find out how Trudy reacted to your story?”
“Am I right in thinking from what you’ve been telling me that you believed she just
was acting in order to deceive people?”
“Why? Are you suggesting that it was because Y was present?”

By way of similar questions, motives may become understood within broader
interpersonal and social contexts.
In general, therapists should be careful in suggesting possible motives that
may be driving patients or others, unless the case is explored in depth. MBT is
not an insight-oriented therapy. The goal is to develop the patient’s own abilities to mentalize. However, if one encounters mental blockages of any type of
exploration, the therapist might make suggestions, such as in the following
example:
“I understand that you have difficulties understanding why X behaved as he did. It
is not easy for me to understand it either. I do not know him other than through
what you have told me. But could he simply have been exhausted?”

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The following are examples of low quality:
”You have been traumatized and that is why you can’t stand such situations.”
”You are doing this because of your unconscious guilt complex.”

Low (1–3): The therapists do not pose questions about mental states. Or, they
make assertive claims about the patient’s or some other person’s motives. The
therapist’s questions about motives are poorly formulated, mechanical, and
superficial. They may also be poorly timed and appear like ruptures in the
ongoing conversation. The therapists accept responses that sound like clichés.
The therapists leave it to the group to explore narratives and interpersonal
events. The therapists display little interest in the process of finding out and
seem more interested in “causes.”
Adequate (4): The therapists pose appropriate questions designed to promote exploration of the patient’s and other’s mental states, motives, and
emotions and communicate a genuine interest in finding out more about
them.
High (5–7): The therapists pose adequate questions about the patient’s and
others’ mental states, motives, and emotions. They are posed in a friendly and
welcoming manner. The questions are followed up with respect to details
and they invite an in-depth exploration of interpersonal and social contexts
without relapsing into individual therapy in group.

Item 12: Challenging unwarranted beliefs
Patients often have unwarranted opinions about themselves and others and
about relationships between people. Such unwarranted opinions are in themselves signs of poor mentalizing. They should be challenged, but in a friendly
and sensitive manner; not in a categorical or unsympathetic manner, but consistent with a curious and not-knowing stance.
Typical unwarranted opinions about oneself have been well documented in
the cognitive literature. Patients may describe themselves as dumb, ugly, less
worthy than others, not deserving anything good, deserving punishment, or
being helpless victims of bad life conditions. We also encounter the opposite,
when patients state they are better than others, more intelligent, deserving of
special treatment, and so on.
Unwarranted opinions about others often appear as fixed, rather clichéd-like
ideas about others’ supposedly inflexible personality characteristics, for
example, that others are dumb, lazy, ruthless, nice, envious, jealous, unsympathetic, greedy, bad, etc. It may involve attitudes about groups expressed in general terms: “Health system bureaucrats don’t care at all about us patients” or
“Estate agents are just greedy.”

Item 12: Challenging unwarranted beliefs

Or it can be about specific people: “She never cared about me” or “My mother
was always nice.”
It may concern other people’s motives in specific contexts: “He did it to punish me” or “Yes, I hit her; she asked for it.”
It can also be about relationships between people: “My parents’ relationship
was always good. Never an angry word was spoken between them” or “Yes,
there is a lot of hitting, kicking, and arguing, but I don’t think the relationship
between us is worse compared to most people.”
Therapists may suspect an opinion to be unwarranted when it is overly onesided, rigid and fixed, global (applies to the entire person or everyone in a category of persons), lacks empirical proof, seems improbable, or seems overly
exaggerated.

Guidelines for rating of occurrence
Interventions that belong to this item often take the following forms:
“I noticed that you described yourself as dumb, and I also heard that earlier. I wonder what you mean by that? . . . Any thoughts about this in the group?”
“You say that you experience yourself as less worthy than others. But last session
you said that you felt OK. It seems like your self-confidence fluctuates. Do you have
any thoughts about why your self-confidence may be down today?”
“A while ago you said that everybody at the unemployment office was an idiot. I am
unsure about how I should interpret that statement; is it a manner of speech, is it
because you were upset, or is it because you really meant it?”
“You said that your mother was always nice. I don’t know exactly how I should
interpret this statement. Can you explain it a bit more?”
“Based on what you have told the group, it is quite possible that he did it to punish
you; but could there be other reasons as well?”
“You say that she asked for it. For me it is difficult to understand how someone
could want to be beaten up. It seems like Robert has some comments about this.
What are your thoughts, Robert?”

Guidelines for rating of quality
When it comes to this item, it may be that unwarranted opinions about oneself
and/or others do occur in the session, but that the therapists do not comment
on it. The adherence rating will then be zero. Some would argue that there
should not then be any rating of quality. One cannot assess the quality of something that does not occur. However, as explained in previous paragraphs, the
fact that therapists do not intervene when the phenomenon actually is present
indicates poor skills on the part of the therapists with respect to the item. No
reaction when appropriate target behavior in fact occurs should receive a low competence score (e.g., 2 or 1).

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Examples of low quality would be the following:
“How on earth could you think that?”
“That is the craziest thing I’ve ever heard.”
“That sounds like an incredible exaggeration.”
“I don’t believe that at all. You can’t mean that!”
“What a load of rubbish.”

Low (1–3): The therapists do not react to obvious unwarranted opinions. The
therapists confront patient in unsuitable manners. Therapists intervene rather
superficially by accepting clichéd-like responses or abandon the topic without a
more careful examination.
Adequate (4): The therapists confront and challenge unwarranted opinions
about oneself or others in an appropriate manner.
High (5–7): High-competence interventions are formulated in a friendly and
slightly provocative manner. The therapists do not accept clichéd-like answers,
but find new ways to move on without seeming to be condescending. They find
acceptable ways to end the sequence if the patient insists on his or her perceptions, for example, by accepting the patient’s view but at the same time clarifying their own position, as in the following: “I understand that you see this in a
specific way. I see it a bit differently, however. How do you feel about us having
different views on this subject?”

Item 13: Regulating emotional arousal
Treatment should take place in an atmosphere of optimal emotional arousal. As
already mentioned in “Item 2: Regulating group phases,” therapists should work
to prime and activate the patient’s emotional system for exploration/seeking/
engagement. Often this will be accompanied by a feeling of vitality. With a
friendly and caring attitude on the part of the therapists, one should expect that
the patient’s fear system should gradually be downregulated. However, the therapists’ constant focus on emotions may likely activate fear. A range of emotions
may be hard to accept and own and integrate. It concerns the primary emotions
of anger, separation anxiety, lust, love, and joy, as well as more complex social
emotions such as jealousy, envy, guilt, shame, and so forth. The therapists have
an important task with respect to regulating the level of emotional arousal (corresponding to parents’ regulating function in relation to their children). The
level must not be too high so that it overwhelms the patient (confuses him/her,
puts him/her off, leading to uncontrolled emotional outbursts, seriously impairing mentalizing ability, etc.); nor should it be so low that the treatment becomes
just words, that is, pseudomentalizing.
It is important to be aware that the treatment system by itself might destabilize patients’ mentalizing abilities by stimulating their attachment system. When

Item 13: Regulating emotional arousal

therapists explore and pose questions about emotions, patients may become
anxious. Therapists as well as fellow patients will naturally come closer emotionally to a protagonist during a session. However, MBT therapists should
monitor the level of mentalizing. When they see signs of decline, they should
retreat and become more distant in order to curb the emotional arousal.
Here we encounter a clinically significant paradox. Just when therapists do
have a natural inclination to be even closer, we ask them to retreat. Most people
who speak with somebody who is about to lose control will display a tendency
to become even more empathic and caring. They will likely speak more quietly
and softly and try to demonstrate their understanding of the other’s difficulties.
However, this strategy might only provide extra stimuli for the attachment system and provoke even more decline of mentalizing ability. This is particularly
valid for borderline patients who have a hypersensitive attachment system.
Accordingly, we advise therapists to resist the natural inclination to become
more empathic and caring when patients become emotional. When their mentalizing capacity is regained, therapists may involve themselves again, becoming more emotionally attuned. However, one should not be surprised to
experience a new round when getting closer. Therapists should therefore have a
vigilant focus on level of emotional arousal and do their best to monitor it. We
do not recommend that therapists become careless and cold. However, we warn
against care expressed through tenderness, worry, and sympathy in situations
of strong emotional turmoil since it may fuel the fire and activate deep and
unsatiated attachment needs. It might diminish patients’ mental resources
when they need to have them most urgently.
Therapists help regulate the level of emotional arousal in groups through
their general attitudes (interest, warmth, friendliness, engagement, and focus
on emotions), through nonverbal communication and through specific
interventions. Typical challenges are “the agitated member,” “the withdrawn
member,” “the quarrelling couple,” and “the devaluating subgroup,” when the
group as a whole is in fight–flight mode, or the group is emotionally flat. How
to deal with such group situations are described by the examples which
accompany most of the items in this manual. Therapists have to use different
techniques, adjusted to where the problems reside.
In MBT, therapists follow a general principle that the greater the emotional
arousal of the patient, the less complex the intervention should be. Supportive
comments, gentle exploration of a problem, and clarification require less mental
effort on behalf of the patient and so are considered “safe” interventions during
high states of arousal. In contrast, interpretive mentalizing and mentalizing the
transference heighten arousal and so carry the danger of stimulating either
hyperactivation, leading to over-arousal of the patient or deactivation, inducing
pretend mode, both of which decrease mentalizing. We therefore suggest that

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these interventions are used with care. They are likely to be of most benefit when
the patient is optimally aroused, that is, able to remain within a feeling while
continuing to explore its context—so-called mentalized affectivity (Jurist, 2005).
Groups with borderline patients will always exist on the brink of fight–flight
mode. It is a vital competence of MBT-G therapists to be able to regulate this
kind of dynamics. However, therapists (like patients) have different tolerances
for emotional tension. If one is uncertain about the limits, one may well ask:
“How is it? Is it too hot in this group now, or is it tolerable?”
“How about you, Janet? It this about to be too tough, or can you manage?”

The most important emotion in this respect is RAGE (anger and aggression).
One should remember that the group should be a training ground also for this
emotion. Patients have to express anger in appropriate ways and they should
learn to handle anger from others, including group members. It is therefore
important that MBT groups don’t become organized around restrictive group
solutions that forbid anger here and now. On the other hand, MBT groups
should not encourage aggressive acting out.
It is important that therapists carefully monitor the level of anger in the group,
for example, by interventions like those mentioned above. When therapists
consider the “emotional temperature” to be too high, the first commandment is
to stop the ongoing interaction. It might concern two or more members, it may
pertain to the group as a whole, and may also include therapists. If therapists are
part of the turmoil: stop challenging! Shift gear. Otherwise, one should go
straight to the heart of the matter:
“Stop. This is going too fast/becoming too hot/getting too tough . . . I cannot follow
it. We need to slow down . . . ”

In such cases, it is important that the therapists have gained a position of authority in the group. Their words should be respected (Inderhaug & Karterud,
2015). It should not be necessary to shout in order to be heard. However, it is
important to be stern and authoritative. When therapists stop ongoing interaction in this way, it is because they want to establish another mode of communication which is more reflective and containing. The main target for reflection
should be: What happened since we got to the point where people started
shouting at each other?
Too high arousal is of course not restricted to anger. Separation distress may
also become overwhelming. Some patients will submit to grief and intense crying. Some will dissociate. And fear is often turned on. Sometime we witness
panic attacks. We may succeed in regulating some patients while they stay in the
group. At other times, patients have to leave the group. When they have calmed
down, they should return and reflect upon what triggered the fear.

Item 13: Regulating emotional arousal

It may help to redirect the focus of the regressed patient, for example, from
here and now towards the mind of another “out there.” The purpose of such a
strategy is to help patients regain a modicum of mentalization by supporting
their thinking about the motives of others, when the opposite perspective is too
overwhelming, that is, thinking and reflection on one’s own mind. This strategy
is labelled “contrary moves” (Bateman & Fonagy, 2012). It advocates moving
“outwardly” when patients become overly self-focused and moving “inwardly”
when they become overly focused on others. If self-reflection turns to repetitive
and rigid bouts of negative, shameful, and self-derogative accusations, it might
be better to turn the attention towards others:
“How do you think this affected him?”
“What do you believe made her do that?”

Patients may answer that they just do not have a clue and jump back to their
unproductive preoccupation with own state of mind. Therapists may insist a
little harder:
“You have to bear with me, but in fact I do wonder how you understood what happened to him since he responded in that way.”

Moving in the opposite direction might be necessary when patients are obsessed
by understanding others, why they behaved as they did:
“But what are your feelings about this?”
“How do you understand your own reaction?”

The fact that many items contain examples which also could have been included
in this item, illustrates the central position of “Regulation of emotional arousal.”
We refer, for example, to the vignette about Erna and Kari in “Item 6: Caring for
the group and each member” which describes poor regulation. Patients express
fear prior to the subsequent confrontation, but they are overruled. Later Erna is
allowed to ventilate her feelings uncontrollably and a reflective stance is not
achieved.
Interventions that count as regulating emotional arousal are often as follows:
“Hey, wait a minute. I believe we have to stop. The one word triggers another and
to me this does not sound constructive. How should we handle this?”
“Hey, Pete and Joan. It seems like things are getting rather heated between you. It
might be wise to hear comments from other group members.”
“I see that you feel sad. We touched on a sensitive topic. Take your time . . . Are you
doing ok? Is it still just as painful? . . . Is it possible to take a closer look at what it is
exactly about this story that overwhelms you?”
“It’s clear that something is upsetting you. I am not quite sure what it is. It might be
something I said or the very subject we are discussing. Maybe you need some time

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for yourself before we try to find out about the reason behind your reaction, what
do you think?”
“I understand that this makes you angry. How distressing is it for you? Are you
furious inside? Is it OK to be where you are right now, or would it be better for you
to take a moment and wind down a bit? Earlier it helped if you . . . ”
“Hi, Trine. Are you doing OK? Did your thoughts wander off a bit just now? We
have been discussing a difficult topic. Maybe you need some time to collect your
thoughts?”
“It’s OK, John, to leave the group. It’s OK to calm down. Do you need someone to
accompany you?”

It is more difficult for therapists to have to up-regulate patients who seem to have
closed down their emotional states. Patients become monosyllabic, fail to
respond to comments from the therapists by elaboration, and appear disinterested. Interventions that aim at raising the temperature might be something like:
“How are you doing, any feelings about what we’ve been talking about just now?”
“Earlier in the session I got the impression that you were really interested in what
we were talking about. Now it seems you’ve lost interest. Did we lose focus or was
it me who moved it away from the important things?”
“I am a bit unsure how important what we are talking about right now is for you.”

An example of low competence:
“I see that it really pisses you off. That’s an honest reaction. It’s important to get in
touch with your feelings. Let it out!”

Guidelines for rating of occurrence
As the examples above indicate, it is perfectly possible to identify interventions
that explicitly address the here-and-now emotional temperature. However,
numerous trials have shown that therapists most often regulate the temperature
through their general therapeutic style. We might thus encounter groups that
are well regulated while at the same time do not contain many specific interventions. For this reason we do not rate occurrence for this item, just competence.

Guidelines for rating of quality
Low (1–3): Therapists do nothing (or little) to regulate the emotional arousal
when one or more patients, or the group as a whole, become overactivated during the session and it results in strong emotional outbursts. In contrast, therapists may say or do things that fire up already excessively activated feelings.
Alternatively, the session is emotionally flat, dull, and without emotional involvement from anyone, and the therapists do nothing to “raise the temperature.”
Adequate (4): The therapists play an active role in terms of maintaining emotional arousal at an optimal level (not too high so that patients lose their ability

Item 14: Acknowledging good mentalization

to mentalize and not too low so that the session becomes meaningless
emotionally).
High (5–7): In addition to skills described for level 4, therapists use a wide
range of interventions which may partly be geared towards specific patients,
and partly towards the group as a whole. Raters get the impression that emotional regulation is a domain of high priority and that therapists are quite conscious about their goals in this respect.

Item 14: Acknowledging good mentalization
The therapists should support and gently praise patients when they have dealt
with a situation in ways that attest to good mentalization. It also concerns the
group as a whole. It is important pedagogically, as an illustration of what the
therapists mean by good mentalization. It will also strengthen the alliance, and
it has importance for patients’ self-esteem. They receive recognition for mastering an activity that is a valued objective for the joint therapeutic project. In
addition, the therapists’ praise has effects through positive reinforcement. For
the group as a whole it implies acknowledgement when the group does its job in
an exemplary manner.
Examples of good mentalization might be situations in which patients have
mastered their emotional arousal through reflection, in contrast to previous
reactions such as emotional outbursts, confusion, dissociation, withdrawal,
self-destructive behavior, overeating, intoxication, or suicidal gestures. It may,
for example, involve situations where patients deal with problems on their own,
such as when they decide to “sleep on” an incident, instead of calling the boyfriend or girlfriend late at night and indulge in destructively arguing. Or it
might be an interaction that is dealt with in a new and better way, a conversation, a constructive argument, an earlier unbearable feeling, or a sequence in
therapy in which the patient has dared to address a sensitive topic without
collapsing.
Acknowledging particular individuals in a group is a double-edged sword
that should be used with some caution since it can provoke envy and jealousy.
However, years of clinical experience proves that this seldom occurs when the
item is practiced with care and consideration. Also, patients have the capacity
to appreciate progress among fellow beings! This item is therefore significant
for the curative mechanism of “installation of hope” (Yalom, 1995). However,
one should take care not to favor particular patients. Regardless of their level of
functioning, there should be moments of praise for everyone. It should be delivered as fairly as possible. One should acknowledge small steps among more
poorly functioning patients, and not always acclaim “star patients.”

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Acknowledging good mentalization should be done in a “mentalizing manner.” This means that therapists check as they go along whether their evaluation
is consistent with the patient’s own assessment, and that the therapists encourage patients to reflect about the event in the here and now:
“How is it for you now when you think back on it? . . . What was different this time,
do you think? . . . How is it for you that we appreciate this?”

As an example, we refer to the vignette about Kristin in the section on “Starting
the group” (Chapter 2). Kristin tells how she, with help from the group, has found
different perspectives on her parents, their interaction, and the significance for
herself. The therapists approve her reflections in a warm and smiling way.

Guidelines for rating of occurrence
This item concerns interventions where therapists acknowledge and give their
approval not just with a smile or a confirmatory nod or “mm,” but also verbally.
The following types of intervention count:
“What you are telling me about what happened yesterday evening is a bit new, isn’t
it? . . . Isn’t it the type of situation where you previously would have done X? . . . It
is perhaps an example of what we have been talking about in therapy, about trying
to control your feelings and reflect on them and trying to understand things in new
ways. . . . It seems that you dealt better with the situation this time. . . . How is it for
you now when you think back on it?”
“It seems that the conversation that you had with your mother yesterday evening
took a different path than the usual one between the two of you. If that’s the case,
then it sounds positive. What was different do you think?”
“It seems that you enjoyed the encounters with your friends more on this trip. It seems
as if you were more involved and enthusiastic. You have told us about similar trips
before where you felt lonely, ignored, and unhappy. What was different this time?”
“That was good to hear. I am happy for you that it went so well. It meant a lot for
you. It was a difficult situation, but you managed it without having to take any
medicine or getting stoned or high. It seems that you were able to contain the painful feelings without collapsing and you managed to uphold your ability to think. It
must have felt like a victory. Or am I exaggerating?”

There does not need to be several occurrences of this type of dialogue for it to
count as an adequate degree of adherence. One occurrence is sufficient if it is of
a reasonable scope. If there are obvious incidents that the therapist overlooks,
however, then the absence of interventions should be scored as low quality.

Guidelines for rating of quality
Low (1–3): There are obvious examples of good mentalization that are overlooked, neglected, or misunderstood. Low quality also includes comments that

Item 15: Handling pretend mode

are short and delivered with little empathy or conviction, almost as if they are
forced in order to adhere to the manual; or if therapists say something like
“sounds good” without leaving an opening for reflection.
Adequate (4): The therapists identify and explore good mentalization and this
is accompanied by approving words or judicious praise.
High (5–7): The therapists identify, explore, and support good mentalization
in ways that are consistent with patients’ and the group’s mentalizing capacity
and stimulate longer reflections that add further dimensions to the events and
current group processes.

Item 15: Handling pretend mode
The expressions “pretend mode” and “pseudomentalizing” are often used as if
they are interchangeable. There is a difference though. Pretend mode (or pretend play) is also the label for a normal and healthy way of being and thinking
during child development, at its height during 3–4 years of age. Adults also
need this ability to play and pretend, and “Homo ludens” is an ideal for many
people. However, when we talk about pretend mode in adulthood, it is not this
creative mode of being we are referring to. The word pseudomentalizing is more
straightforward since it (“pseudo-”) refers to something negative or dysfunctional. Pseudomentalizing is also better suited for delineated utterances, while
pretend mode refers more to a “mode” or mental state, not merely expressing
oneself in a clichéd-like manner about a subject matter. This distinction is quite
important for interactions in groups and that is why we prefer the expression
pretend mode for certain phenomena that occur in groups. One will also often
encounter statements that have a flavor of pseudomentalizing in groups. There
is no need to worry about this. It is part of vernacular speech and life itself. The
critical point is what other group members are doing with it. Is the statement
accepted as a reasonable way of speaking and do other members follow in the
same vein? If so, the group may enter the route of pretend mode and the therapist will need to prepare some kind of intervention. However, we often see that
the statement is followed by responses which are more grounded in real life and
imbued with more emotions and vitality which takes the conversation “back on
track.” In that case, therapists do not need to intervene.
Pretend mode (and pseudomentalizing) is a mode of discourse in which
patients speak about a topic in a superficial, emotionally flat, but often detailed
way so that one gets the impression that it is “just talk.” It is a manner of dialogue
with a monologue-like form where the person doesn’t check out whether what
he/she is saying provides any meaning to the conversation partner, or where the
person uses words and concepts that seem to have a psychological content, but

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are used in an exaggerated, distorted, or clichéd-like manner so that the content
is lost. In pretend mode, the patient’s contact with social reality is poor. He/she
is relating to a pseudo-reality consisting of words, concepts, and perceptions
that are poorly grounded. The term intellectualizing covers part of this phenomenon. Other relevant associations are “The Emperor’s New Clothes” and
the term “bullshit” as it now is used within the social sciences (Frankfurt, 2005).
In pretend mode, the person is running on idle. No development takes place
in pretend mode. It’s wasting time here and now. However, for some patients it
is a kind of discourse that is meaningfully based on that person’s history. It is a
way of relating to others that might make relationships possible, albeit in a distanced and abstract way. Pseudomentalization might work as a distancing strategy. The person may have many acquaintances, but no close friends. It is a poor
strategy for intimacy with respect to feelings and being open to one’s own vulnerability. The latter requires a mentalizing approach and not a pseudomentalizing manner of speech.
The following are examples of speech in pretend mode:
“Most people simply do not interest me. They have an aura reflecting an inability to
process the complexities that exist between people. I need an input of energy that
hits my chakra so that the totality of the existence may reveal itself in the shape of
an immediacy that makes it possible to endure our world, which is on the verge of
destruction.”
patient: “I realize that my problems were created by my upbringing.”
therapist: “Tell me more about what makes you say that?”
patient: “Well, my relationship with my mother was good for some of the time
and bad at other times. I became a sort of nonperson who was destined to be neurotic and the black sheep of the family. Yes, that is it. I was the black sheep of the
family. The black sheep. So I became the person who was not going anywhere,
without any direction, just drifting. I float around like a piece of flotsam in the
ocean and never know what’s going to happen next. It might have been my father
too. He didn’t give me a sense of being. I got no grounding which I could use for my
development.”

Pretend mode is often accompanied by typical countertransference reactions.
When listening to empty and aimless talk, therapists will often experience boredom and lose interest. Listening to “bullshit” may also be irritating because of
pompous exaggerations, or simply because therapists do not fathom what the
patient is talking about. There is a risk that therapists collude with pretend
mode, by joining the patient and the group in a kind of talk which provides
masquerading “insight” into the patient’s situation. Believing that the patient is
making progress, therapists may continue this kind of discourse without realizing that it has no links with the patient’s emotional life or reality. This might lead
to endless inconsequential talk. In group sessions where pretend mode

Item 15: Handling pretend mode

develops and therapists are reluctant to intervene and let the group carry on, an
assistant “therapist” from the rank of fellow group members is often recruited.
Patients with histrionic features are particularly apt for such roles. They rapidly
feel “close” to other people and their empathy is easily activated. One problem
is that boundaries between self and others are often blurred: “I know exactly
how you feel.” Such patients are very “understanding” and they will sometimes
experience the same-sex co-therapist as a rival. In the group literature, such
characters are known as “helpful Hannahs” (Bogdanoff & Elbaum, 1978).
Pseudomentalization poses many dilemmas for the therapists. A group session lasting for 1.5 hours will of course vary with respect to vitality and intensity. Some sequences are merely “transport legs” which carry the group from
one theme to another. Some comments are superficial while others are more
challenging. Some are more cliché-laden and intellectualizing while other come
more “from the heart.” Therapists should tolerate troughs. Everything cannot
be a peak. If therapists were to comment on all defensive utterances, the conversation would become so fragmented that the very life, the lush undercurrent of
the group would get lost. We are now touching on the essence of a dynamic
therapeutic group. In individual therapy, the patient and therapist might be in a
constant intersubjective exchange where every speech act may be explored with
respect to its meaning and implication. The other wonders, does not quite
understand, gets touched or provoked, etc. In groups, all members relate to
each other, to the group as a whole and to the topics in question. What does not
make much sense for the therapists may be experienced as very meaningful for
other group members. Foulkes used the phrase “resonance.” It connotes the
reaction of each individual person in the group to what is being said and done.
Each mind is a soundboard or resonance chamber for other minds. What people react to, the string that starts to vibrate inside them, does not necessarily
concern the primary level of the speech. It might be a reaction to the “subtitles”
(Gullestad & Killingmo, 2005). Such phenomena justify a more tolerant therapist attitude.
On the other hand, sequences will occur that clearly are superficial and which
need to be challenged. Simple interventions may suffice:
“Are we a bit superficial now, and reluctant to dig deeper into the matter?”

Or:
“Are there some emotions in this?”

More troublesome are sequences of pseudotherapy in groups. That is, sequences
where one or more members try to “solve” the problems of a designated
“patient.” Such situations might be difficult to handle since the involvement
often is well intentioned and since patients who offer themselves as problem

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targets often feel understood and cared for. Therapists may feel uncomfortable
when they intervene in such situations. They should find a plausible reason to
call a halt. One could ask for comments from more passive onlookers, refer to
the purpose of the group, or go back to what led to the sequence in question:
“Can we have a pause here? I wonder where the other members are.”
“I hear much advice and recommendations as to what you could do, Mary. But
have we lost our focus on emotions and thoughts?”
“I wonder if we have got a bit away from what initiated this sequence, that you,
Paul . . . ”

The following example illustrates pretend mode at the group level:
The session has lasted for a while. A sequence emerges with somewhat general talk
about “stress.” Veronica starts to say that she is stressed because of too little money.
It’s awful and she feels down. She adds that her self-esteem is bound up with
money. She feels miserable without or with little money, but feels great when it’s
there. It also affects her lifestyle. She gets pissed off when having to worry about
every cent and to reflect and plan carefully. Having money she might find herself in
a kind of shopping euphoria. She loses control. It’s great when it’s happening, but
she experiences a backlash afterwards.
The theme gets hold of the group. Other members join in and say how lousy it
is to be poor and attest to the almost intoxicating feeling of having money in their
hands. Irony and laughter fills the group. Therapist: “What is the connection
between self-esteem and money?” The question leads to more of the same. Short
episodes are being told which illustrate the theme, again followed by some laughter
and jokes, and possibly a subcurrent of shame which is not explored. “The nice
thing with money is that everything becomes available.” One member comments
that “the pleasure is shortlived, then.” Another compares it with bulimia: “There is
strict control and then suddenly it explodes in an orgy.” “Buying, eating, and forgetting everything.” The next person explains how he “is broke half of the month
and have to borrow from people, and just now I have to sneak on the tube. When
I get money I become like a devil. Hell, I also deserve some joy. Then I am broke
again, and there is a new round.”
This conversation is not detached from reality. Hard realities are the very backdrop. The sequence is not emotionally flat—there is laughter and excitement. The
problem resides in the very discourse. It’s unbinding. One short episode follows
another, accompanied with nonsense comments about “short-lived pleasures.”
However, the group does not really explore the events. Members do not penetrate
the surface. General opinions and clichés are accepted and small sins are confessed.
The (video) observer is reminded of Bion’s descriptions of the pairing group. It concerns a group mode where the main point is to sustain hope, but in a way that is
remote from mental realities. In this case, it is money that evokes hopes of joy and
permanent happiness. People tell their stories of being at the gate of heaven, having a glimpse of it, and the brutal experience of being thrown back. The whole

Item 15: Handling pretend mode

sequence is marked by pairing and pseudomentalization. The group is partly on the
brink, and partly down in the mire. We note that the therapists have to take their
own share of responsibility. To pose a question about the “connection between
self-esteem and money” is to ask for pseudomentalization.

Guidelines for rating of occurrence
Group sessions vary in terms of involvement, interest, and vitality and the
therapists must tolerate sequences of confusion and floundering. It is a question of judgment when such a rollercoaster ride takes on the form of clinically
significant pretend mode. Nor is it the case that all therapy sessions are characterized by clinically significant pretend mode. When therapists notice this tendency, they should implement MBT strategies such as posing exploratory
questions, adapting a focus on emotions, regulating the emotional arousal, and
so on. If such attempts do not have the desired effect and patients continue
with a flat or pompous style, then this should be challenged. In order for it to
be rated, however, the episode must be long enough so that the observer
becomes aware of it, which often means that he/she becomes a bit impatient
and gets the impression that the group is wasting time or that the conversational style prevents exploratory mentalization. Examples of such interventions
include the following:
“Earlier in the session I got the impression that we were rather focused on what we
were talking about. Now it seems that some of that focus is gone. Have we lost our
direction?”
“In the past 10 minutes it seems like we have jumped from one thing to the other,
without really catching on to any one thing. Do you agree that it has been like that?”
“I am not quite sure that I understand what you mean by waves of energy between
people. Is it possible to explain this by giving a concrete example?”
“I must admit that I could not follow you in your train of thought here. Earlier we
talked about your tendency to use words and expressions that make it difficult for
me to understand what you are talking about. I think we are in that mode of conversation now, or what do you think?”

Examples of poor competence include:
“The words are getting the better of you. It’s boring me.”
“These are just empty words.”
“Now you are intellectualizing.”

Guidelines for rating of quality
Low (1–3): The therapists ignore clear and clinically significant sequences of
pretend mode. They follow up on patients’ pseudomentalizing mode of speech
with seemingly interested questions and comments, and sequences take on a

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character of pseudotherapy. Alternatively, the therapists confront patients in
insensitive or humiliating ways.
Adequate (4): The therapists identify pretend mode sequences and intervene
to improve mentalizing capacity.
High (5–7): The therapists point out pretend mode sequences in a friendly
and sensitive manner, and do this by using various words and examples if the
first intervention does not succeed. They invite a reflection on the phenomenon, for example, on when and why it started. If therapists do not succeed in
obtaining a reflection on the pretend mode activity, they try other strategies
(e.g., challenge) in order to establish a more meaningful dialogue.

Item 16: Handling psychic equivalence
Psychic equivalence is a term for a prementalistic form of thinking in which the
individual has a tendency to equate mental phenomena with objective phenomena and vice versa. There is little difference between fantasy and reality. A perception about the world is mistaken for the world itself. Other people are supposed
to think and experience things in the same way as that of the protagonist. Thinking about oneself and others is characterized by unwarranted generalizations and
one-sided categories, such as “He is always bad” or “She is always good.”
Clinicians often characterize psychic equivalence as concreteness of thought:
what is thought is real. Patients with BPD have an overriding sense of certainty
in relation to their subjective experience. Experienced in the psychic-­
equivalence mode, even a passing thought feels real; no alternative perspectives
are possible. Thoughts therefore have to be acted upon. Psychic equivalence
suspends the “as-if ” mode of experience. Everything imagined, sometimes
frighteningly, appears to be “for real.” This experience can add drama as well as
risk to interpersonal relationships, and patients’ exaggerated emotional reactions are justified by the seriousness with which they suddenly experience their
own and others’ thoughts and feelings. The vividness and bizarreness of psychic
equivalent subjective experience can appear as quasi-psychotic symptoms
As with pretend mode, this is a mode of thinking and relating that may characterize individuals to a greater or lesser extent, or it may be a mode that individuals resort to when feeling stressed or in an emotionally aroused state. In the
latter case, interventions aimed at regulating psychic equivalence should target
the emotional arousal level. In a state of emotional arousal, we all have a tendency to resort to psychic equivalence: “I am a failure . . .,” “Everyone is stupid . . .,” “Life is terrible . . .,” or “The entire world is just horrible . . . ” Nuances,
alternative interpretations, and the possibility of other perspectives are lost.
Similar to pretend mode, psychic equivalence is a position where no psychological development takes place. Patients must therefore be helped to get out of

Item 16: Handling psychic equivalence

this mode. This is easier said than done since psychic equivalence is a state governed by intense emotions. It is also a state of mind that can arise from—or
approximate to—a psychosis. All therapists know that it is useless to challenge
(in the sense of reality testing) a person in a state of paranoid delusions. Challenging psychic equivalence therefore requires great skill and empathy.
Psychic equivalence may be accompanied by attitudes of self-righteousness,
absolute certainness, and arrogance that can be provoking. Therapists must be
careful not to let their interventions be influenced by countertransference.
Psychic equivalence flourishes in therapeutic groups with poorly functioning
patients and it is a major task to deal with this tendency appropriately. If
assumptions based on psychic equivalence are not challenged, they tend to
multiply or create more or less hidden alliances and subgroups. Taboos will
develop. The group will behave as if there are catastrophes linked to certain
individuals or previous events or themes in the group. Similar phenomena are
described by Volkan (1998) for natural groups. They might carry a “chosen historical trauma” which becomes part of their identity formation. According to
Volkan, the battle of Kosovo in 1389 carries such significance for devoted Serbs.
Opinions about this battle are sanctioned. To challenge these opinions is a highrisk enterprise, not to mention the risk entailed in making caricatures of the
prophet Muhammed. In therapeutic groups, it is as if group members know
intuitively that certain phenomena are particularly rigid and guarded by vehement emotions and that one should better stay away from them. However, therapists should have the courage to approach the unspeakable and demonstrate
that, when brought into the light of day, most episodes lose their power to scare.
An example of good handling of psychic equivalence:
Grethe turns up some minutes late. She realizes that the therapists have turned on
the video camera for a recording for supervision purposes. In the opening phase, the
therapists remark that Grethe in earlier sessions had signaled the need to talk in the
group, but that other issues had been prioritized. Accordingly, she should have the
first go. Grethe says yes, surely it’s her turn, there are a lot of issues she had prepared
herself to talk about, but now we should just forget it, it’s impossible with the camera running. She displays pain and almost despairs, twists her body, waves her arms,
and tries to cover her face. She catches the group’s attention. Some fellow patients
seem more comfortable with the routines of video recording. They acknowledge
that it can be stressful, but they have accepted it and it has “to be lived with.” They
wonder what the most difficult part is for Grethe. She answers “that is obvious”
and “it’s just impossible.” “It’s impossible to talk when the camera is on.”
The therapists and other patients try, using different kinds of questions, to find
out more about what this “impossible” is about. The therapists repeat previous
information about video recordings and supervision and who the members of the
supervision group are. Some patients say they understand how frustrating this is for

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her since “she previously had given her time to others” and now was eager to get
her share. One of the therapists says that she is tempted to turn off the camera. On
the other hand, she says, the very purpose of the group is to understand and master
strong emotional reactions to frustrating events in daily life. “And there’s where we
are now, isn’t it? So, how can we understand it and help to master it?” Grethe
responds, “No way!” The other therapist comments that Grethe is obviously in
great emotional pain. However, it is as if she has got stuck in a corner, remains sitting there, and rejects all offers at help. He adds that there have previously been
several similar scenes with Grethe in the group, and that it is important, not only for
her, but also for the group, to find out what this is about so that she might be able
to handle similar situations in the future in a better way. Grethe: “Yes, I’m like a
4-year-old. I’m stuck in my corner and I cannot get out of it.” Some other patients
share experiences of being stubborn during their childhood and that they can recognize this rejection of others while at the same time just wanting to be included,
to be in the warmth again, but that they could not manage it. “When that is the
case, parents must not give in too!” someone says. Through listening to the experiences, images, and metaphors of fellow patients, Grethe seems to recover her ability to think and speak. She straightens herself up in the chair and gets engaged in
the group discussion. After a while she takes the lead and starts to talk about her
biggest problem with the group, which is her own strong reaction when perceiving
signs from other group members that they aren’t listening to her, don’t like her, or
don’t understand what she is talking about. By further exploration she explains that
the main problem is not perhaps that she misinterprets other group members, but
that she cannot accept different points of view, in particular if they have a “negative” valency. It’s “unbearable” that people might get bored while she talks. Therapist: “What is so unbearable about that?” There follows a lengthy discussion in the
group with many illustrations from the group as well as to the video camera “which
she cannot control.” The sequence ends by Grethe explaining, in different ways,
that she has to train herself to endure the reality that other people can view things
quite differently than herself and that they even may dislike what she is saying. She
regards this session as some kind of “breakthrough” in this respect, “but it’s hard.”
The sequence lasts for around 40 minutes.

In the example above, the other group members behaved as constructive “team
players” with the therapists. At other times they may join ranks with “the weak”
and express feeling such as “We should stop this; it’s just painful; can’t we just
move on?” Or they can support a defensive maneuver, as in the following case:
Janet picks up on her theme of suspiciousness. There was a new episode this weekend.
Somebody rang the doorbell at home and she believed it to be a friend of her son. However, it was a neighbor who was delivering the key to their joint bicycle shelter. She
believed she was caught off-guard, talked too fast and strangely, and thereafter she
thought: “Jesus, how stupid I was. Now he can see how far out I am and the neighbors will
talk even more about me.” She describes a “bottomless” despair by having made a fool of
herself once more, feeling hopeless and panic-ridden. In order just to do something, she

Item 16: Handling psychic equivalence

started to clean the floor violently. Later that night she asked her husband if they could not
just move to their summer house for the season, it used to be so nice. When saying this she
knew that she just wanted to escape from the neighbors.
Two group members acclaim: “Yes, that is a good idea, Janet.” “You are tired and
need a break.” “Well,” the therapist comments, “it might be nice at the summer house
during the season, but aren’t we talking about Janet’s emotional problems? Can we
reach a better understanding of these problems here?” The group “stops and rewinds”
and goes back to the scene at home: What happened exactly and why did Janet react
as she did? The story gets more detailed and nuanced compared to previous episodes
told in the group—the episodes that had provoked “unexplainable panic attacks.” The
group members, as well as Janet, regard this as progress. Janet describes movingly
how terrible it feels “to fall down in the cellar,” to lose the capacity to think and
becoming beset by the thought of “getting away.” The other group members express
their understanding and recognition and they discuss ways to tolerate and regulate
strong emotions.

Another example of good handling:
Vera asks for attention. “I have an appointment with my individual therapist on
Wednesday, but I have to talk about it here. I can’t stand it.” She tells a story, accompanied by a lot of tears and display of shame and guilt, about how she had made a
fool of herself since the last session. Her main concern now is that she might
encounter the people in question tomorrow, that they would see straight through
her, and that everything would become public knowledge because she feels unable
to do anything other than reveal her most secret thoughts. The therapists focus on
the belief that other people might “see straight through” somebody and how terrible it might feel if one doesn’t have a private space inside, which is one’s own
property and not available to others. The other group members get engaged and
share similar experiences and Vera gets involved in a lively group exploration of such
experiences and assumptions. Several group members emphasize their “right to
own” their own mind and the importance of being able to contain and protect
one’s most inner thoughts.

The most important factor for the destiny of psychic equivalence in groups is
how the other group members respond. The wished-for course is that fellow
patients, for example, in the aftermath of a therapist intervention, accept and
empathize with the painful state of the protagonist, but challenge his/her
accompanying beliefs. The last example illustrates such a course. On other
occasions, we witness how fellow group members get recruited as supporters
and allies in a crusade against some evil object or in a flight from an overwhelming danger. Theoretically we would then say that the protagonist has succeeded in engaging the group in a fight–flight mode (Karterud, 1989). If one
studies such sequences in detail, one can often see how protagonists present a
series of utterances about self and others, where each utterance is shaped by
slightly unwarranted claims, which many would let pass, but which, taken

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together, lead to conclusions with disastrous consequences. If one lets such a
discourse develop, members might get trapped in a sort of conclusion which
seems “natural,” based upon the (dubious) premises which have silently been
accepted by the group. The previous example of Janet illustrates this. Several
group members seemed to accept the premise that the neighbors were of the
mean and gossipy kind, and that Janet “just had to get away.” The “natural” topic
then became how she could get away. Group therapists have to deconstruct such
discourses and, for example, return to the premises, preferably to concrete
events. It should be said as simply as possible:
“Can we stop here? It seems that there is a big concern about how Janet can get away.
However, the primary task for the group is to explore difficult emotions. Can we
pick up this trajectory and go back to the situation where you, Janet . . . ”

Guidelines for rating of occurrence
This item overlaps with item 12, “Challenging unwarranted beliefs.” All psychic
equivalence involves unwarranted beliefs, but not all unwarranted beliefs are
part of psychic equivalence. Some unwarranted beliefs are due to habitual
thought patterns, lack of information, manners of speech, and so on, which
make them easier to regulate.
Psychic equivalence can be reduced simply by having the patient calm down:
“Now I’m doing a bit better. I can see that I get rather one-sided when I get upset.”

Interventions that qualify for this item should be something more than the
therapist’s ability to calm down patients. They should contain an explicit verbal
statement aimed at a manifestation of here-and-now psychic equivalence:
“You say that no one in the group likes you. That’s strange. What do you base that
impression on?”
“As far as I understood it, it was a comment from Linda at the student house that
got you thinking that no one likes you. Is that right?. . . I agree with you that the
comment, as you present it, sounds critical. But the fact that someone criticizes
you, does that mean that they do not like you?”
“You seem convinced that the same thing will happen again so there is no reason
to try. Can we look at this for a second?. . . Is it that you think you can’t handle situation X? Or that he will not be able to accept Y?”
“I hear that you say that it is impossible. Could you explain to me what the impossible is about?”

Examples of poor handling include:
“I must admit that this is wearing me out. I have suggested both X and Y and Z, but
you just reject all of my suggestions.”

Item 17: Focus on emotions

“I don’t know if I can help you. Whatever I say is wrong.”
“It doesn’t seem like we are getting anywhere with this. Maybe we should talk about
Y instead?”

Guidelines for rating of quality
Low (1–3): There are clear signs of psychic equivalence functioning in the group,
but the therapists deal with it as if it were the case, rather than accepting the
painful emotions and challenging the adjacent beliefs. Alternatively, the therapists challenge psychic equivalence in a superficial or even condescending way.
Adequate (4): The therapists identify psychic equivalence functioning and
intervene to improve mentalizing capacity.
High (5–7): In addition to level 4 competence, therapists keep to the key issues
over time and devote much attention and energy to exploring the case by
recruiting other group members. They intervene with tact, empathy, and creativity, and without signs of negative countertransference.

Item 17: Focus on emotions
All PDs are characterized by some kind of emotional dysregulation, and this is
particularly the case with BPD. Emotion dysregulation concerns problematic
emotional awareness, emotion tolerance, understanding of emotions, and the
ability to adaptively express emotions. It is important to gain an accurate understanding of what the patient’s emotional problems are about. For some, it is
about impaired access to emotions (awareness); for others, it is about the intensity of emotions, possibly combined with a poor tolerance. It could be that dysfunctional emotions are acted upon (e.g., intense feelings of jealousy or envy),
that their inappropriateness is poorly understood, or there may be problems
with finding a culturally accepted outlet.
In MBT-G, emotions are defined as a primary priority focus for the group.
This is thoroughly explained in the psychoeducative group component, in the
pre-group interview, and it is repeated explicitly during the course of the group.
Every member should have received this message in different wrap-ups.
The item favors emotions here and now. “All” emotional reactions should be
noticed, responded to, and explored when necessary. Group members do this
intuitively much of the time. As we have emphasized in previous paragraphs,
particularly significant reactions should be given the status of an “event” in the
group.
We have also emphasized (cf. items 3 and 4) that emotions should be explored
in their interpersonal context.
The item concerns the emotional “atmosphere” in the group. Sometimes this
is clear to everyone, sometimes it is vague and beyond conscious awareness for

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all participants. It is the task of the therapists to identify it and express it in words
in order to make it available for joint exploration. Awareness of the emotional
tone in a group depends on this double ability to read other minds appropriately
and at the same time be aware of the resonance in one’s own mind. Therapists
may start to worry about certain group members, or about the group discourse,
or about their own difficulties with thinking, without knowing exactly what this
is about. Or there may be other kinds of experiences that alert the therapists and
make them search for the underlying emotions. We do not require that therapists have nicely formulated hypotheses in their heads before intervening. They
should express their own experiences, as something that belongs to their own
mind and for which they take responsibility, but which nevertheless resonates
with what is going on in other minds: “Let’s try to find out together!”
Identifying emotions is an important step in MBT-G because it links general
exploratory work, rewinding with clarifications, and challenge to mentalizing
the transference. The aim is “to mentalize the emotions,” that is, to give them a
name, to bring them into a symbolized and reflective space, and to let them have
an influence on the mind in a regulated way and in an intersubjective context.
Identifying emotions links to the concept of “marked response” in mentalization theory (Fonagy et al., 2002). Emotional confusion is ontogenetically rooted
in flawed parental responses, for example, by neglect, incorrect attribution, or
by being overwhelmed by the parental emotional reaction which, so to speak,
“steals” one’s own experience. By a “marked response,” parents clearly point at
the child’s reaction and help in mentalizing it so that the child becomes able to
own it as a proper emotional representation. The same should take place in
MBT-G. The therapists survey the group process and halt and point to emotional events, if no one else does, and help in mentalizing what happened.
As for examples, we refer to the section “Identifying failures in mentalizing”
(Chapter 2) where Terje becomes overwhelmed by emotions when he is helped
to describe what triggered his feeling that “it went to hell.” See also the example
with Beate in the section “Engaging the group members in mentalizing events”
(Chapter 2). Beate’s experience of shame was so pervasive that it could hardly be
owned.

Guidelines for rating of occurrence
Examples of interventions relevant for awareness of emotions include the
following:
“What did you feel when X . . . ?”
“Did this generate other feelings as well?”
“It seems like you are reacting to what we are talking about. Tell me what you are
feeling? . . . Is it difficult to say something about it? Is it primarily a type of

Item 17: Focus on emotions

restlessness? . . . Try to concentrate . . . where do you feel it? . . . What do you associate with this feeling?
“It seems to me that something just happened between you two, Eva and Ruth. Is
that so?”

Examples of interventions relevant for a tolerance of emotions include:
“What does that emotion do to you? . . . Does it make you nervous? . . . Afraid that
it might overwhelm you? . . . What would happen if it became very intense? . . . You
perhaps wonder how people in the group would react?”
“It seems to me that there is a connection between the fact that you were feeling X
last night and that you started drinking. What was it about X that was difficult for
you to accept?”
“How much of your emotions do you believe we can take, here in the group?”

Examples of interventions relevant for understanding emotions include:
“It seems like sadness is a feeling that you try to avoid. It’s as if you quickly have to
get rid of it when you notice it coming over you. You have talked about how it does
something to you that you don’t like. That you feel pathetic. Can we talk a bit more
about that? Sadness is a feeling that most people experience. It is a natural reaction
to losing something.”

Examples of interventions relevant for expressing emotions include:
“What would be a suitable way for you to express these feelings, do you think? . . .
I am thinking in relation to X in particular. How much do you think he/she can
stand?”
“How strong do you believe your emotional message need to be, in order for you
not to be misunderstood?”

Examples of interventions that are relevant for the group as a whole include:
“Is it a bit slow here today?”
“Any thoughts about the mood in the group today?”
“It seems to me that there is some irritation in the air. Is that so?”
“How come there is still some tension between you two, Linda and Peter?”
“What’s it like to talk about this here?”
“Yes, I’m smiling. . . . No, it isn’t because I’m laughing at you. Quite the contrary, I think
it’s nice to listen to you when you talk about things the way you are doing now.”

Of particular importance in this process is working in detail. Therapists should
not accept generalizations about emotions but try to explore the feelings in
detail in relation to the movement in an interpersonal interaction described by
patients. It is not enough, for example, to accept that the patient felt hurt during
an interaction with his/her boyfriend. It is necessary for therapists to explore
exactly what it was that led the patient to have the feeling he/she describes—was
it something about how the boyfriend said it, what he was saying, or was it

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something about what he was saying, for example. The therapist can then move
the patient forward “frame by frame,” as it were, so that important features are
not missed. Clearly this should be done sensitively and the therapist should
desist if the patient is finding it difficult; for example, many patients with BPD
find it hard to identify emotions, but the principle of exploring mental detail in
relation to the interpersonal event should not be lost.
Examples of interventions that are relevant for emotions and interpersonal
transactions include:
“You seem a bit on edge today, I’m wondering how you are doing . . . So you’re quite
irritated then?. . . When did it start?. . . So it was the encounter in the hallway with
patient Y from the group that you reacted to. . . . What happened between the two
of you? . . . You felt that she ignored you, is that what you felt? . . . What was it that
she did or didn’t do that made you feel that way? . . . How did you react then? . . . Do
you have any thoughts about why she behaved the way she did?”
“We should look at the incident that happened yesterday morning in a bit more
detail. Tell me from the start, what happened exactly? . . . You were talking on the
telephone. . . . So it was when your mother said “That’s obvious dear” that you
reacted. . . . As far as I can understand, it made you feel discouraged, disappointed,
and irritated . . . A range of different affects. Previously these feelings have made
you withdraw from the conversation, but this time you tried to deal with what she
said. How was that?”

Since patients with PDs often carry a history of emotional abuse, many will be
quite confused as to what counts as “normal” emotional responses. In groups, it
might transpire that emotions are clarified as well as the intersubjective transactions and the context, while the protagonist still questions whether he/she
had a “right” to such emotions. It concerns the right to own certain feelings or
if one is prohibited from having certain feelings, or if it’s only a waste of time to
feel X or Y, or if one has the right to express feelings X and Y, or if somebody
might be hurt by one’s feelings, and so on.
Such questions, which often become voiced near the end of a sequence, are
good “thought food” for the group. There is seldom any need for the therapists
to introduce any scale of “normality” with respect to emotions. Fellow group
members usually have lots of opinions about such matters. The therapists can
restrict themselves to the job of modifying grossly unwarranted opinions if they
seem to influence the discourse. One should be careful not to confuse the notknowing stance with not-knowing in questions of normality, normal range, and
morality. The answer to the question of if one has the right to feel damaged, in
despair, or mad at being sexually abused, is a clear and simple: “Yes.” It belongs
to a “marked” response that therapists acknowledge that patient’s reactions are
comprehensible, that the therapists take them seriously as valid reactions, and

Item 17: Focus on emotions

that they often are shared by others under similar circumstances, that is, that
they are “normal” in that sense.
Interventions that concern the issue of “normality” might include:
“You ask me about my opinion, if you have the right to feel this way. Let’s first go
through it in detail once more and let’s involve others here in the group, and then
we can return to your question.”
“What do you think? Did Tom have any good reason to react?”
“Yes, I believe we might label this as jealousy. . . . Sounds like it’s a feeling you have
found hard to accept. I can understand it might be unpleasant. On the other hand
it’s part of being human.”
“Yes, I too believe you react somewhat more strongly than most people.”
“You wonder if you react too strongly or not enough. Any thoughts about this in
the group?”
“So, you didn’t feel anything after having kicked her down. Too me that sounds
strange. What are your thoughts about this now?”
“Yes, it seems to me that you have good reasons to react to this.”
“I think most people would become angry in a situation like that.”

Other relevant interventions include:
“Yes, I smile, but’s not because I’m laughing at you. On the contrary, I find it nice
and amusing when you talk the way you do now.”
“I’m not quite sure, but I got the impression that something happened between us
some moments ago, and I wonder if you reacted to something that I said.”
“You, Robert, didn’t turn up last session. . . . Something affecting you from the session before? . . . OK, so you felt ignored and misunderstood. Let’s go back and discuss what happened.”
“You say that you don’t feel welcomed in the group. Can we find out where that’s
located?”

Examples of interventions with low competence include:
“I don’t think you should control those feelings. Tell him straight out what you feel!”
“Yes, I hear and see that you are sad, but what you are actually feeling is a rage
because you were dumped, but you just don’t want to admit it.”
“You are asking whether you were right in feeling ignored in this situation. That is
not easy to answer. It was a rather complex situation and your perspective is just
one of many possibilities. Besides there is a group dynamic going on here . . . ”

Guidelines for rating of quality
Low (1–3): The therapists do not focus on emotions in the group. To the extent
that patients talk about or show emotions in the here and now, it is not noticed
or commented upon. The therapists focus on emotions, but only in a cursory
way. The therapists misunderstand the patients’ emotions or misunderstand the

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kind of problems patients have with particular emotions. The therapists encourage patients to reveal dysfunctional affects. The therapists identify with emotional states rather than mark and explore them, or they display exaggerated
worry about emotional display in the group.
Adequate (4): The interventions focus primarily on emotions—more than on
behavior. The attention is particularly directed at emotions as they are expressed
in the here and now in the group, and particularly in terms of the relationship
between patients and between patients and therapists.
High (5–7): The therapists’ interventions are to a large extent directed at the
patients’ emotions and they cover many aspects of emotional processing: emotional awareness, tolerance, comprehension, expressivity, and intersubjective
transformation. The therapists are able to explore different emotions in multiple contexts, pertaining to the self, to others, to the here and now, to the group,
and the relationships between patients in the group as well as between patients
and therapists.

Item 18: Stop and rewind
“Stop and rewind” has been alluded to in several previous examples. It often
concerns getting more control over the group and the process and it presupposes a modicum of authority. It is a technique that is particularly relevant
when “things are going too fast,” for example, when patients race through a
story, often in an emotionally aroused state of mind, “jump to conclusions,” or
when transactions in the here and now are fast and turbulent. Therapists should
try to slow down the pace of the discourse, both for their own sake and for the
sake of the patients. It is important to try to understand the details in situations
that have taken an unpleasant or destructive course. Therapists should invite
patients to engage in a detailed review of the events. This is particularly important when the therapists observe a decline in mentalization in one or more
patients or in the group as a whole. It might be conflicts, quarrels, or withdrawal
from a former protagonist, or that the group as a whole has adopted a fight–
flight mode, or a decline into pretend mode. The therapists invite the members
to pause, to regain their ability to reflect, and to find out where, when, and how
the discourse deflected.
This item may sound simple, rather banal, and not so significant, but it is very
important and many group therapists would do better if they adopted it more
frequently.
For an example of good performance, see the vignette with Åse in “Introduction: The mentalizing stance” at the start of this chapter. Åse held that the therapists had made her sound like a racist. The therapists rewound and mobilized
the group in a conjoint exploration.

Item 19: Focus on the relationship between therapists and patients

Guidelines for rating of occurrence
Among the interventions that count for this item are the following:
“Please let us stop for a second, this is going a bit too fast for me. Something happened between you, Tom and Clara. What was it?”
“I’m getting a bit breathless and my mind is racing. Can we just go back to . . . ?”
“I’m sorry, but I’m not able to keep up with you now. Everyone is talking at once.
Could we sort this out in a more orderly fashion?”
“I think I lost you. Can we go back to X? Or where was it the entire thing started?
Can we go a bit more slowly now, step by step? So it started when you began scrolling through his mobile telephone, is that right? Or did it start earlier?”
“I see. Now I think I’m beginning to understand a bit more. You had been looking
forward to showing her this video recording that you made on Sunday with the
music that you had composed. What happened then? She simply didn’t want to
look at it? . . . Not at all? Did you hesitate to ask her then? . . . So that was what you
meant when you said that she should have taken the initiative? . . . How did you
know that she didn’t want to look at it?”

Guidelines for rating of quality
Low (1–3): There is at least one incident in which patients react in a maladaptive
way to an interpersonal event without the therapists stopping, trying to slow
down the pace, or trying to recruit the group to look closer into the incident.
The competence is rated somewhat higher if the therapists at least stop and
make an attempt, but then give up too soon.
Adequate (4): The therapists identify at least one incident in which patients
describe interpersonal events in a noncoherent and affected way, try to slow
down the pace, and find out about the event step by step. In a similar way, the
therapists halt events in the group that tend to be destructive and take the initiative to explore the sequence together with the patients.
High (5–7): As above, but in a more convincing and empathetic manner, the
therapist shows a great deal of understanding for the various elements in the
sequences and explores them extensively, taking a lead in keeping the patient
focused.

Item 19: Focus on the relationship between therapists
and patients
In MBT-G, patients are explicitly asked to attach themselves to the group and its
members. This adds to the automatic processes that are set in motion within a
helper–helpseeker relationship. The relationship to the therapists becomes
important and laded with emotions. However, in MBT-G, there is this general
focus on interpersonal transactions, and the relations to fellow group members

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are exploited for all their worth. The relation to the therapists is therefore not as
paramount as it is in individual psychotherapy. One might say that the “transference becomes diluted.” The practical arrangement adds to this “dilution.” In
individual psychotherapy, there are two people who are in a constant intersubjective transaction throughout three-quarters of an hour. In group psychotherapy, the individual members oscillate between participant and spectator roles.
For some patients, relatively few words will be shared with the therapists during
a group session. However, the therapists are under constant surveillance as to
what they do and what they don’t do.
The relationship which each patient develops towards the therapists is characterized by a combination of rational, collaborative elements, and irrational
elements that are remnants of earlier problematic object relations. Patients are
therefore disposed towards experiencing and interpreting the therapists in distorting ways. The latter is what is usually labelled transference. In groups, it is
even more difficult than in individual therapy to determine what counts as
transference in the strong sense, and what are rather plausible reactions in a
complex and ambiguous (group) situation. This adds to the arguments for being
cautious with transference interpretations which aim at generating insight and
connecting the past with the present. Transference interpretations in groups
carry the risk of invalidating the significance of the here and now. What the
patients risk hearing is:
“Attacking me in this way has nothing to do with me or my behavior, it’s because
you are mad at your father.”

Typical transference interpretations in groups for borderline patients may exert
iatrogenic harm. They often sound speculative and risk deactivating the
patients’ competence.
We therefore coined the phrase “mentalizing the transference” which could
equally be termed “mentalizing the relationship.” Mentalizing the transference
is a shorthand term for encouraging patients to think about the relationship
they are in at the current moment (in this case, the therapist relationship) with
the aim of focusing their attention on another mind, the mind of a therapist,
and helping patients to contrast their own perception of themselves with the
way they are perceived by others, by the therapists or indeed by members of the
group.
In short, this means that transference phenomena are not interpreted in light
of the past as in the following example:
“You have difficulties accepting anything good from me because I remind you too
much of your father to whom you are in constant opposition.”

Item 19: Focus on the relationship between therapists and patients

Transference phenomena should be dealt with as current phenomena that are
difficult to understand by themselves:
“Several times recently I have noticed that you have rejected what I have suggested.
You seem to have good arguments, but it seems also as if you have become more
critical of me. Is this an accurate perception? . . . Is it possible to find out more
about that? . . . Can you tell me more about what is irritating you? . . . Is it something
about the way I am expressing myself? . . . If I understand you correctly, you have
got the impression that I am somewhat authoritarian and that I care about you as
though you were a child which you don’t like. Let’s look at the authoritarian aspect
first. What is it about me that you find authoritarian? . . . I understand what you
mean, but is it possible to look at this from a different perspective?”

As evident from the above-mentioned example, transference phenomena are
dealt with the same way as unwarranted beliefs are dealt with (item 12). They
are highlighted in an attempt to establish them as objects of joint attention, and
then explored using MBT approaches.
We have set out a series of steps to be followed although not all of them need
to be present in order to rate this item on a satisfactory level. However, therapists need to demonstrate an ability to explore the patient–therapist relationship,
linking some of the following steps:
Our first step is the validation of transference feelings through exploration.
The danger of the generic approach to transference is that it might implicitly
invalidate the patient’s experience. MBT therapists spend considerable time
within the not-knowing stance, verifying how patients are experiencing whatever they say they are experiencing.
This exploration leads to the next step. As the events which generated the
transference feelings are identified and the behaviors that the thoughts or feelings are tied to are made explicit, sometimes in painful detail, the contribution
of the therapists to these feelings and thoughts will become apparent. Therapists
should acknowledge the ways in which they may have contributed to the
patient’s experience.
Most of the patient’s experiences in the transference are likely to have some
basis in reality, even if they only have a partial connection to it. We refer to previous discussions of the theme “enactment.” It often turns out that therapists
have been drawn into the transference and acted in some way consistent with
the patient’s perception of them. It may be easy to attribute this to the patient
but this would be completely unhelpful. On the contrary, the therapists should
initially explicitly acknowledge even partial enactments of the transference as
inexplicable voluntary actions that need to be explored and for which they
accept agency rather than identifying them as a distortion of the patient.

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Authenticity is required to do this well. If the therapists really cannot identify
some aspects of themselves or their actions that might have been involved in
creating the patient’s experience, then they should suggest that they hold alternative perspectives and that the question remains open for future exploration.
Drawing attention to therapists’ contributions may be particularly significant in
modeling to patients that one can accept agency for involuntary acts, and that
such acts do not invalidate the general attitude which the therapist tries to convey. Only then can distortions be explored.
The final step is collaboration in arriving at an alternative perspective. Mentalizing alternative perspectives about the patient–therapist relationship presuppose the general mentalizing stance which permeates MBT. The metaphor
we use in training is that the therapists should imagine themselves sitting beside
the patients rather than opposite them. Sitting side by side, looking at the
patient’s thoughts and feelings, all parties should try to cooperate by the mentalizing stance.
Exploring the patient–therapist relationship is a demanding task. It is intimate and sensitive. It presupposes a well-established alliance. In MBT-G, the
therapists are initially supportive, pedagogical, and containing. Mentalizing the
transference is something that can be gradually addressed when the therapy is
well underway and the patient is reasonably stable. In the therapy’s early stages,
however, therapists can still comment on what are called “transference traces,”
which is a term that refers to attitudes relating to earlier therapists, health services in general, the treatment program as such, and so forth (Bateman & Fonagy, 2006). Examples of this type of comment include the following:
“You told me that in previous therapies everything used to start out fine, but then
it was as if the therapist would lose interest in you for some reason. You would then
become disappointed and would stop talking about what was most important to
you. Then you would quit. We should be aware of that kind of development, so we
can possibly avoid it this time.”
“You told me that you have often been misunderstood by people in the health services. It is important that you tell me if you feel the same thing is happening here
with me.”

The relationship between patients and therapists includes countertransference, that
is, the therapists’ emotional reactions towards their patients. The technical use of
countertransference in MBT borrows heavily on the work of Racker (1957), who
distinguished between complementary and concordant countertransference.
Complementary countertransferences are emotions that arise out of the
patient’s treatment of the therapist as an object of one of his earlier relationships, and are closely linked to the notion of projective identification. This leads
to countertransference experience of the therapist being considered as part of

Item 19: Focus on the relationship between therapists and patients

the patient’s internal state and technically leads many therapists to place the
experience they themselves are having back with the patient. This is avoided in
MBT. Why? Countertransference experiences are most commonly associated
with turbulence in the patient’s mental state; asking the patient to consider their
feelings in the context of a theoretical projection of emotion onto the therapist
will overwhelm their precarious state of mentalizing just at the time when they
need mental support, as in the following examples:
“I am noticing an increasing frustration over our relationship. I think it may be
because you unconsciously want to undermine the therapy and that you therefore
are behaving in a way aimed at provoking me to say that therapy is getting nowhere
and that we’d better end it now. Then you could leave as a victim, a role that you
seem to be quite comfortable with.”

The therapist, experiencing himself as becoming confused and then bored,
states to the patient:
“It strikes me that you have been feeling confused and are now rather bored. In this
way you escape remaining feeling so confused.”

In contrast, concordant countertransferences are empathic concordant responses,
based on the therapist’s resonances with his patient. Concordant countertransferences therefore link with affective attunement, empathy, mirroring, and a sense
that certain aspects of all relationships are based on emotional identifications that
are not solely projections. Stern’s (1985) “affective attunement” between mother
and baby, and, by extension, between patient and therapist, is a different way of
explaining such interactions, involving as it does the ability of the mother (therapist) to “read” the patient’s behavior and respond in a complementary manner,
which is in turn “read” by the child (patient). Technically, in MBT, countertransference experience is used with this understanding in mind.
Countertransference is stated as the therapist’s experience, that is, it is
“marked.” It is not considered initially as a result of projective identification and
the therapist must identify the experience clearly as theirs. The simplest way to
do this is to state “I” at the beginning of an intervention. Intriguingly this seems
to be hard for therapists who understandably worry about violating boundaries
of therapy. Yet we are not suggesting that therapists start expressing their personal problems or start talking about any feeling that they might have in a session whether relevant to the process or not. Rather we maintain that the
therapists’ current experience of the process of therapy has to be shared openly
to ensure that the complexity of the interactional process can be considered.
Patients need to be aware that their mental processes have an effect on others’
mental states and that those, in turn, will influence the direction of the
interaction.

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There are a number of common countertransference experiences for therapists when treating patients with BPD which are associated with particular
modes of psychological functioning. Gradually therapists need to become comfortable with managing these states of mind and be able to express them constructively in the service of extending the patient–therapist collaboration.
Many non-mentalizing states of mind are indicated by the actual behavior of
the therapist who for a considerable period of time may be unaware that their
actions are changing. Therapists who only grunt as the patient talks and clearly
lose concentration are often being affected by pretend mode functioning in the
patient; therapists who start to give suggestions about how to solve problems or
who tell the patient what to do without exploration are likely to be involved in
teleological process; the confused therapist who nods wisely is more often than
not struggling with understanding what is being said and is trying too hard to
understand psychic equivalent modes of thought. In all circumstances the therapist, once alerted by a change in their behavior, should focus more carefully on
their feelings and identify them.
To reiterate, the expression of the underlying feeling of the therapist is a useful tool in therapy if done openly and carefully marked. It is “owned” by the
therapist to ensure that the patient is not overburdened with emotional responsibility. Implicitly telling the patient that they have created the feelings in the
therapist increases the mental work required from the patient just at the time
when their mentalizing is in danger of being lost, thereby inadvertently increasing the likelihood of this outcome.
When it comes to countertransference, it is important to find a form through
which this can be expressed without humiliating the patient. This applies particularly to negative countertransference. There is no point in uttering: “I get
exhausted listening to you.” Instead, it should be something more like: “I am
beginning to notice that I have lost interest in what you’ve been talking about
the past few minutes. I think we need to stop for a second to find out why.”
The use of countertransference can be an extremely powerful tool. Just as
with transference, it is a tool that the therapist should be careful in using in early
stages in therapy. It will become more appropriate as the course of the therapy
develops.
Managing one’s countertransference is fundamentally important for maintaining one’s own mentalizing ability. In group supervision, when asking why
therapists did not intervene in certain situations, one often hears that they felt
paralyzed and totally occupied with handling their countertransference internally: “I was so perplexed,” “I was just out of my mind,” “I really didn’t know
what to do,” “I got so enraged that I just had to shut up,” “I tried, but everything
sounded weird in my mind and eventually I didn’t even manage to think.” We

Item 19: Focus on the relationship between therapists and patients

know that it is demanding, and particularly since there is no tradition for this,
but we recommend that therapists in situations like this reveal their states of
mind. We believe such a policy has large modeling potentials. In such situations, one may lean on the co-therapist for support and use him/her as a means
to regain one’s mentalizing ability.
The relationship to the therapists is mentioned in several previous examples.
As for poor performance, we refer to the vignette about Brita (“Item 5: Identifying and mentalizing events in the group”) who pours out a stream of complaints,
making the therapists defensive and compliant instead of exploring what happens in the here and now. See also the vignette about Lise (“Item 6: Caring for
the group and each member”). Lise’s transference towards the male therapist
became too strong and “realistic.” The alliance fragmented and the treatment
had to be terminated. As for good performance, see the vignette about Kari
(“Item 5: Identifying and mentalizing events in the group”).
In the following example the therapist acknowledges his own part of a piece
of muddled communication and thereby stimulates the interest of fellow
patients:
The group talks about a hot issue, immigrants and terrorism. Helena is the only member
in the group who has an immigrant background. She is also a quite new member and her
history is poorly known. One of her problems is a tendency to dissociate when interpersonal tensions arise. The therapist addresses her and asks in an overly complex way if the
current theme in the group is more sensitive for her than for the others. She listens and
replies that she doesn’t quite get what the therapist is wondering about. The therapist
repeats himself, again rather clumsily. Helena repeats that she doesn’t understand, but
that it might be because she is not attentive enough, since “she often switches off ” when
people talk. The therapist responds that it might be possible, but this time he believes that
part of the problem resided in him. When talking about it, he realizes that actually he
knew very little about her background and that he might have been vague because he
didn’t want to hurt her by revealing his ignorance. This comment triggers interest among
the other patients. What is her country of origin? Is she a first- or second-generation
immigrant? What about her parents? Does she experience herself as “equally Norwegian”
compared to the other members in the group? Through this sequence, Helena becomes
better integrated in the group.

Guidelines for rating of occurrence
The following types of interventions can be included in this item:
“And now, I get a feeling that I’m pushing you.” “Yes, you are!”
“How are you in the group?”
“Does the same apply here in the group also, in relation to the therapists? . . . No?. . .
What is the difference do you think?”
“At the end of the last group session, things went a bit fast and I got the impression
that you didn’t like how I terminated the group since feelings were still quite

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heated. . . . I’m not sure if I’m right. . . . How do you feel about it now? . . . So you
contemplated not coming to the group. . . . I’m glad you came. . . . What exactly was
the worst part of this?”
“You mentioned a second ago that you think I am disappointed with you. How did
you come to that conclusion?”
“That was nice to hear.”
“If I am disappointed in you? Hmm, . . . no, I don’t think so. I do feel a bit frustrated,
though. I’m frustrated that we weren’t able to find out more together during the last
session. But maybe we both see things a bit more clearly now?”
“This was a tough story. I’m touched by it. What feelings does it stir up in other
people here?”
“I must admit that I’m a bit confused here. What about you, co-therapist?”

Examples of low competence interventions include:
“No, I have a professional attitude about this kind of thing. The fact that people
hurt themselves doesn’t affect me anymore.”
“Maybe it is you who feels bored and that is why I have begun to be bored by the
session.”
“When you were growing up you were used to getting things the way you wanted
by expressing strong emotions. You are now doing the same thing here, but you
probably have noticed that it won’t work.”

Guidelines for rating of quality
Low (1–3): The therapists do not comment on how patients relate to the therapists during the session, even though it would have been relevant. The therapists
ignore obvious transference phenomena, seriously misunderstand transference
phenomena, or interpret transference in a rigid manner as simple repetitions of
the past. The therapists display obvious indications of being emotionally
aroused, or they are exposed to situations where most people would do so, but
don’t comment on their own reactions. On a somewhat higher level, the therapists may comment on the relationship, but in a rather superficial way.
Adequate (4): The therapists comment on and attempt to explore—together
with the patients—how the patients relate to the therapist during the session
and stimulate reflections on alternative perspectives whenever appropriate. The
therapists speak about their own feelings and thoughts, related to the patients,
and in this way they try to engage all parties in mutual exploration.
High (5–7): In addition to level 4, the therapists comment on and explore several aspects of the therapist–patient relationship and link this to themes that are
highly relevant for the patients and the group and this performance is a significant part of the group process.

Chapter 5

Transcript of a mentalizationbased group therapy session

Introduction
In the following chapter, we present a complete transcript of an entire group
session in order to give the reader a better feeling of what MBT-G looks like and
how the rating scale works. All interventions by the therapists (T1 and T2) are
rated for adherence. At the end of each intervention there are one or more notations that indicate the appropriate item: A-1, A-2, etc., means “adherence item
1,” “adherence item 2,” etc. Some interventions do not receive a rating because
either they are too short (e.g., “Hmm”), or they do not comply with any item
(e.g., counseling).
A summary for each item follows the transcript, including ratings of quality,
and finally a rating profile.
The group belonged to a MBT program, implying that the patients also
had received 12 sessions of psychoeducational MBT-G, as well as weekly
individual MBT in the first year. The individual therapy was less frequent in
the second and third years. Mean treatment time in this group was around
2 years.
The group had eight members. Three members were absent from this particular group session; two of them had sent messages to say they’d be absent.
Before the video camera was turned on, the group was told about the absences
and the members signed a declaration of consent for publication. All patients
were female and their fictive initials are: A, C, K, M, and Å. They had been
members in the group for various lengths of time, from 6 to 24 months.
There is a prehistory which the reader should know in order to understand
the content. This session was the second session after the summer break of
2011. At the first session, the group used half of the time to discuss the terrorist
attack in Utøya, Norway, on July 22, 2011, when 69 young Norwegian political
activists were massacred. At this meeting, patient Å said that she found the
mass media reports of the event so terrible that she had to turn off her TV and
could not read any newspapers. She also reported strong fantasies about Utøya,
for example, what she might have done if she were present. T1 was worried

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Transcript of a mentalization-based group therapy session

about patient Å’s reality testing and asked her if these fantasies almost were confused with reality. Patient Å felt misunderstood during this exchange and it is
referred to during a sequence in this group session.

The transcript
t2: Last time we spoke about the disaster of 22 July and other things as well. There
have presumably been some thoughts and feelings in the aftermath? I suppose it
also has been discussed in the individual sessions. (A-2, A-11)
a: I have many feelings around it, not only 22 July, but from the last group session.
t2: So you have something you would like to discuss around this issue? (A-2, A-3)
t2: Someone else? K, there were some you knew . . . (A-2)
k: They are doing fine now.
t2: What about you, Å? (A-2)
c: I had some thoughts when we left, but they have not disturbed me much. We are
different, emotionally.
å: I am embarrassed by who I am, that I’m not like others, it is as if I’m an actor, I
pretend, pretend that I am like other people.
t1: Mm, are you referring to what happened last session? (A-11)
å: It concerns feelings in general, I dismiss them. I know I do. I let them come when
I am alone. I never show them to other people, even if I’m in deep trouble, so
other people will not know.
t1: That’s a theme which is fine to explore here. (A-7)
t2: Then we have two themes here, and you should get some space. (A-2, A-3)
å: And I’m hospitalized again, he, he.
c: Here?
å: No, at another place.
c: You should talk about it. Why, what has happened?
å: Nothing has happened.
t1: Yes, we are curious. (A-11)
c: And I wonder why.
t2: Have you two something else which you want to talk about today? (A-2, A-3)
k: I could talk about anger.
t1: Mm, yes, that’s a good theme. (A-7)
t2: Now I’ve become curious. (A-19)
c: I have some small stuff around flipping out and mentalizing poorly, something
from yesterday, relating to my boyfriend. It’s ok now, through with it in a way,
although I feel . . . It was bad mentalizing, I went from zero to ten within a
second.
		 [Group laughter]
c: Could have tried to stop at five.
t2: What happened? (A-11)

The transcript

t1: Shall we take that later? (A-2, A-7, A-9)
t2: Yes, I realized it could be misunderstood. I wanted to say it could be a theme for
you. (A-3, A-9)
c: It’s about a deep relation. I’ll wait, until after “anger.”
t2: It’s an advantage being in a small group. Everybody will get their time. So, who
will start? (A-2, A-3, A-7)
k: You, A, were the first . . .
a: It’s possibly a bit about anger, I don’t know. It was last session . . . there are so many
feelings on top of each other . . . well . . . I reacted when the two of you said something to me, I don’t quite remember, “You have to understand” or something.
t1: The two of you, who?
c: It was not aimed at you, it concerned understanding . . .
t1: Just to clarify this, the two . . . was it K and . . . ?
a: Å.
t1: OK, what did they say? (A-11)
a: I don’t remember what they said, it was the manner.
å: Yes, but . . .
		 [Patient M comes in]
t1: Hello [greets patient M]. (A-1, A-6)
a: I don’t want to speak about what, that’s insignificant. The point is that both of you
looked at me and said something, “but can’t you understand,” or something like
that. When someone talks to me in that manner, especially if there’s more than
one, I get lost, and that’s the point, not what they said. I only got that feeling, and
then the group was about to end, and then you, T1, said “OK, well . . . ” and was
about to explain something, and I just sat there, ah awful . . . [hides her face in her
hands], and then it was over. I reacted strongly, but it was not recognized.
t1: Ok, so you . . . it was right at the end of the group, and I did not recognize your
feelings, is that what you mean? (A-11, A-17, A-19)
a: Yes, I felt it a bit like that.
t2: Yes.
a: Even if . . . perhaps it was not like that.
t1: Yes, but I think you are right that I overlooked it. (A-14, A-19)
å: I have actually thought about it and I feel bad about it.
a: You should not, since this happens in everyday life, with all kinds of people who
might be irritated at me, or at someone else, and who talk to me in a strained
manner, and then I react. So it is nothing to do with you. You did no wrong. I
must learn to cope with that in a way.
t1: Let’s clarify, you say that when C and Å talk to you in a certain manner, something happens with you, which expression are you using? It’s like . . . you used an
expression . . . (A-5, A-11)
a: I don’t know.
c: Against you in a way.
a: I felt attacked.

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t1: You felt attacked, yes. (A-17).
a: And I know I am not . . . mentally. I am fully aware of what happens in the situation, but I cannot control my feelings, and therefore I often get very angry. When
this happens I can say “but don’t get so angry at me,” but actually I did not believe
that you were angry at me. In this way I can start quarrels.
t1: Yes.
t2: I think you describe it very well. I too remember that episode. It seems that you
have been able to reflect upon it afterwards. You others here, do you feel you
understand what it’s all about? (A-4, A-14)
å: I reacted because I felt that people misunderstood me, and it was tough, because
I felt that I was considered a total idiot. I never speak loud, but then I actually
cracked, because I felt . . . OK . . . listen, I felt that I had tried to say something, but
I was not understood. I never raise my voice, but just then I did.
a: I believe it was why I reacted, because you never act like this. And then you did,
and I felt . . . I actually got very sorry.
å: I’m always in control, but . . .
a: You did not frighten me, but I get sorry when people get angry at me.
t1: Mm, hmm.
a: And then I felt misunderstood, because I did not think it was stupid, I only did
not understand. I tried to pose some questions since I did not quite understand
you. I felt the same as you C, that it was strange that you could think like that,
because I disagree, because I value you a lot, I cannot understand how you can
think like that.
å: Yes . . . there is something inside me in a way, it’s like . . . I believe I also have
another problem, I believe when people say things like that, that they don’t
understand, that they say it only to be nice in a way, and that might irritate me,
when people says nice things to me, because I don’t believe it, and I get like: Ah,
stop this bullshit.
t2: So you were somewhat irritated last session? Because you [looking at A] felt that
people were angry at you. However, it was not quite so, could it be . . . (A-11, A-17)
a: That was not my point. I understood that Å was irritated or angry there and then,
but essentially it does not concern me if people are angry at me or not, the problem is that I perceive it like they hate me, but I want to be able to endure and cope
with people even if they are irritated with me.
t1: Yes, it is convenient to be able to handle such things. Everyday life becomes much
easier. If I had said “Pull yourself together, A,” that would have been . . . (A-7,
A-11, A-17)
a: Yes, if you say it like that.
		 [Group laughter]
t1: [Laughs] Yes, and I would not . . . but you seem very sensitive to criticism and
anger towards yourself. (A-17)
a: After some drinking I often get angry and mad, not violent, but radiating violence maybe. Well, I want to be violent, and I have been it too, and I may . . . well
I don’t know, yes I get very angry if someone does something that . . .

The transcript

t1: How should we help A with these problems? (A-4)
m: Are you talking about the things at Utøya [from July 22]?
t2: Yes, you were a bit late. Can somebody clarify for M what we are talking about?
(A-6)
m: Something from the last session?
c: Yes, from the last session, right at the end.
m: When we talked about those Utøya things.
c: Mm.
m: OK.
c: We are talking about feelings, about reacting when there is disagreement and
feelings when the atmosphere is somewhat . . .
m: OK, I did not perceive at all that somebody was irritated.
c: I did. I was a bit irritated myself. There was a lot that I did not understand.
m: Well, that I can see . . . Anyway . . . I’m with you.
t2: Interesting . . . perhaps we are different with respect to sensitivity for irritation.
T1 also said that he did not perceive that A reacted emotionally towards the end,
and you did not either. Maybe we are different as to how sensitive we are towards
each other in the group. (A-9, A-17, A-19)
m: I can express myself in a rather aggressive manner even though I am not aggressive, so perhaps I’m not very good at picking up the nuances in other’s speech, I’m
not quite sure how well I remember it.
å: I recognize myself . . . like the way you felt it, since it was that which made me,
ugh . . . just . . . yes, then I felt that everybody just hated me.
t1: Here in the group?
å: Yes.
t1: OK . . . well . . . you have announced this as a theme in itself, but let me just clarify
this, I did not hate you. (A-2, A-16, A-17, A-19)
a: Not me either.
c: It is so easy to say, that since you feel that people disagree with you, that they hate
you.
å: Yes, but . . . it is this . . . that I have trouble with displaying feelings, that I laugh
when things get tough. I’m so ashamed by it, actually, but it’s hard to change it,
because I don’t like to display that side of myself. I prefer to hide at home, but
when people don’t understand that I actually have feelings, then I feel like evil, in
a way . . . I feel somehow that I have the feelings inside me, I feel sad and the like,
but . . .
t1: Yes . . . but, should we stick a bit longer with A’s experiences? You are expressing
yourself quite clearly, A. So, the question for us now is, how can we help you with
it? You state quite clearly that you wished you were somewhat more robust, that
you could endure more, isn’t that so? (A-3, A-7, A-11, A-17)
a: Yes, but I do not quite understand why I react with such an insane explosive rage
if anybody, let’s say my boyfriend, gets a bit irritated at me. I can get so angry that
I want to crush him, and then I start a quarrel and respond in an aggressive
voice.

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t1: So you blow it up . . . if anybody gets irritated or aggressive towards you, you
expand on it? So it will spiral upwards instead of you trying to level it out? (A-11,
A-17)
c: Yes, it seems like attack on attack, isn’t it?
a: Yes, that’s in a way the strategy.
t1: So that’s the strategy.
c: Yes.
a: Hit back twice as hard, to crush the enemy.
t2: Yes.
t1: Mm.
c: Instead, perhaps, to halt and take a time-out and try to listen to what he actually
is saying.
a: Yes . . . yeah . . . “Let’s sort this out.”
t1: There you are! (A-14)
t1: [Laughs] It seems to be there, but it’s hard to do it. (A-14)
a: It’s like a reflex.
c: There is a pattern here, a track which you are used to, emotionally.
m: There is something here, I have also trouble with accepting critical remarks,
because I often accept it too much in a way, because I am so self-critical, and can
think that yes, he is right. But I hesitate to accept it, that that’s the case. With me
too, attack can be the best defense, instead of just saying, yes, I agree, see your
point, sorry, or something.
a: But how can one change such reactions, emotionally?
c: Difficult, very difficult.
å: Yes it is, I’m there 80% of the time.
m: Well, I’ve noticed that it is easier to stop it and avoid that impulsive blow out if
things are more orderly around me, in a way, if things are . . . simple things like it
is orderly and clean and if I feel I have control in other areas of life. If everything
is chaotic, I feel that the trigger is more easily pushed.
c: But, does he use your faults against you? Can he say “I feel” when you are selfabsorbed and push your buttons?
a: I don’t know.
c: Because communication is different things, how one decides to use . . .
a: I don’t know, but I try to use that technique myself, that I feel such and such, but
perhaps I say it . . . it can work against one’s intention also.
c: Yes.
a: When it comes to him, it’s like we’re fighting, as if it is a question of being the winner. I had such a childish episode recently this summer. We were in the park,
barbecuing, and then we needed something from the shop, and nobody would go
and get it, and it turned into a kind of competition where nobody could go
because then the other would lose, and it was embarrassing, in front of other
people, it’s like being 4 years old.
a: Instead of saying, OK, I’ll do it . . . it turns to a feeling that the other will be the
winner.

The transcript

t1: Well, the way we think about these matters . . . There are several ways of self-­
development, for example, being able to tolerate more. One way is simply to practice, through exposure, and that’s what you are doing now. In a group like this you
will be exposed to critical remarks, that’s unavoidable, and you can learn to handle it better in this group. (A-7, A-17)
a: I know that, but tell me how I shall cope with it.
t1: Like you are coping with it now, for example, point one, by taking the initiative to
talk about it in this way. (A-14)
c: That you are curious about it.
t1: And by addressing this theme from the end of the last group session, right at the
start of this group, you invited others into it to explore it, that’s a good start. (A-14)
a: Well . . .
t1: You don’t seem . . . (A-11, A-17)
a: No, I am not satisfied with that. I have spoken to other people too, but it doesn’t
help as long as . . . It’s the very situation I do not handle. I can think and speak
about it afterwards, but when my feelings get intense . . . then, I can’t use any
techniques.
c: But you and your boyfriend can make a sort of deal, if you notice that you two are
going in a clinch, make a deal on some kind of time-out.
a: No . . . he bangs his head against the wall, real hard, and he turns almost crazy.
c: That’s him, not you.
a: But, no . . .
t1: I’m not sure if I got it. (A-11)
c: Hmm.
t1: You said something about him hitting his head against the wall? (A-11)
c: He gets angry.
t1: Does he? (A-11, A-17)
a: I’m afraid his head will burst or something, it’s so . . .
t2: Oh. (A-6)
t1: Surely that must be awful? (A-6, A-17)
t1: I’m still not sure if I’ve got it. Is it when he gets angry that he hits his head against
the wall? (A-11, A-17)
a: Yes, a kind of self-injury.
t2: Does it make you afraid of him getting angry? Or, what do you others think?
(A-4, A-11, A-17)
a: I’m not afraid that . . . well, yes . . . no . . . I don’t know. I arrange my day so that he
will not get angry, I do.
c: So when he gets angry, he does it? Every time?
a: It makes me anxious . . . I don’t know. We don’t have to talk about it here.
c: If I had a boyfriend like that, I would also avoid situations that made him angry.
That’s natural.
t1: It created, what shall I say . . . a sort of dramatic new direction here, when you said
about him banging his head. It seems like you are . . . crushed in a way . . . is that
right? (A-5, A-11, A-17)

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a: This morning, when he woke up . . . you know, tonight I’ve planned to have a
friend of mine sleep on the sofa in the dining room, but this scares my boyfriend.
He’d been worrying about it the whole night through, because he has some social
anxiety, and then he woke me up this morning, standing there, trembling like
hell, and he panicked and says “You must not not leave that guy here alone, you
must not, you must not,” and then he banged his head against the wall, really
hard, he is like crazy . . . And I don’t know what to do. I haven’t seen my friend for
a long time, he lives far away, and suddenly I have this problem that I might have
to tell him that he cannot stay with us, that my boyfriend can’t stand having him
here, and a lot of things.
t2: Really difficult. (A-6)
a: And then I get angry, because I find him malevolent, acting it out in this way so
that a visit from a friend turns into a very unpleasant thing . . . I don’t know. But
I’ve now spoken for a long time . . .
c: It seems like you are the one that have to carry his feelings, his anxiety.
a: Yes, I have to protect him.
t1: How did you others react to A’s story? (A-4)
c: It’s a very difficult emotional situation to be in, isn’t it?
a: Yes.
c: Is it healthy for you?
a: What did you say?
c: Is it a healthy relationship?
å: In my former relationship, I was also very considerate, but it was self-­destructive,
to keep that going, that’s my view now.
m: It sounds difficult to be two people with problems in a relationship, since one
must perhaps delete themselves in order to protect the other.
a: That’s the way I do it, but perhaps it is not necessary.
m: Well, listening to this story, I notice that I got really irritated. I don’t know, but if
it had been me, well: “Hello, pull yourself together my friend, go for a walk,” but I
don’t know if that would help.
å: I get really sad since I recognize myself so thoroughly, and I know how destructive it was, to be in a relationship with a lot of problems, even if it was really good
at times. I was very much in love, but I destroyed a lot, lost all my friends and the
like.
m: Shouldn’t he, for his own’s sake and for yours, seek help, it can’t be your responsibility to save him.
a: I have asked for help.
t1: Yes, you said last session that he has contacted an addiction unit.
a: I have.
t1: So you were the one that contacted the unit?
a: Yes.
t1: And how are things going?
a: He is like a little child. He is waiting for an appointment which I have asked for. If
I’m like a mother for him, it works in a way. The addiction clinic has to call me,
and then I’ll inform him, and then supposedly he will turn up.

The transcript

t1:
a:
m:
a:
c:
a:
t1:

Mm.
He will do it for my sake, but he does not take responsibility in his own right.
Sounds immature.
I believe he is frightened to quit.
Quit?
Quit smoking hashish.
Because what happened this morning, that he came in to you, woke you up, and
he was terrified? (A-11, A-17)
a: Yes, he is frightened. Because my friend who is visiting us has been “saved” by
Narcotics Anonymous. He is “happy-sober.”
t1: Happy-sober? (A-11)
		 [Laughter in the group]
c: Yes, that’s a phrase.
t1: OK.
a: Instead of having found Jesus, he’s a strong believer in Narcotics Anonymous.
My boyfriend is an addict, and, I think, terrified at looking at himself in the
mirror. Meeting this “saved” sober guy may be too much; he’s possibly mulled
over this the whole night, trembling with anxiety. He’s not malevolent towards
me, he just does not know how to cope with it. However, he copes badly, and it
frightens me.
c: So his feelings become your feelings then?
a: I have trouble with my boundaries.
m: Is it possible to get out of the situation? I know it’s a tough option, but could you
possibly just go?
a: Well, I have tried somewhat.
m: Just saying: “Sorry, I cannot cope with this.”
a: Yes, he he.
c: It’s difficult to set limits for such kind of things.
m: Of course, but he has to learn . . . sounds almost like a little child in a shop who
hasn’t got his chocolate, having a tantrum and screaming when you say no.
c: No, it’s not like that . . . I hear someone with a lot of anxiety and problems and who
simply needs help.
a: Yes, that’s what I hear too . . . but it’s me who has to do it, even if I don’t want that
responsibility.
m: But if you just leave, what would happen?
a: I sometimes say that I can’t relate to this, but I could not this morning. He came
into my room, there was no space to pass by, and I was so sleepy.
m: But what happens when you go?
a: He follows me.
m: Follows you?
a: Yes, and he makes use of it in a way . . . no . . . I don’t know . . . I have talked too
long here.
t1: OK, should we . . . ? (A-3)
t2: I am curious about you, K, you too have a difficult relationship. What are your
thoughts when listening to A? (A-4, A-11)

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k: Well, yes . . . I have a relationship with someone with mental problems, she is
immensely troubled, but I’m the one that breaks the door with my own head, see?
So I don’t know.
t2: So you recognize yourself in . . . (A-4, A-11)
k: Yes, but not like him. The one I live with gets stuck and maintains that only her
views represent the truth and she is very difficult to . . . and after heavy psychic
pressure, I just explode . . . a tremendous rage.
t1: Yes, that was the theme you announced, and it’s on the agenda, but is there any
preliminary conclusion here, A, on the issues you have talked about, or is it OK?
Have this been useful for you? (A-3)
å: Can I say something?
t1: Sure.
å: I’m becoming rather worried, because I recognize myself, and I believe you have
a high estimate of him, but I pose the question of what this is doing to you, and
him too. Will it destroy you instead of helping you?
a: I think I understand what you are saying, but it isn’t . . . him.
å: Yes, he is surely very kind and everything, but I have been seriously disturbed and
in a relationship, and no matter what they felt for me, by the end they were all
exhausted by this project of helping me.
a: I understand what you mean, but I believe it’s a bit different, because I have not
imposed my stuff on him.
å: But you take responsibility for him when you have enough to do with caring for
yourself.
c: I believe it’s important to try to separate a bit emotionally, so you don’t become a
carrier of his feelings.
t1: Seems like it is difficult to come to a closure. (A-3, A-5)
c: Yes, it does, because it is not . . .
t1: Perhaps it’s because there are . . .
a: There are many layers here.
t1: Yes, there are many layers. (A-14)
a: And it is such that . . .
å: But we, or I, engage in it just because I have been there.
m: I believe everybody here has experienced the same, and it is very difficult to provide simple answers to what should be done. But I believe he must grasp that you
can’t take all of the responsibility, he has to take some of it himself, for his own
development and get some help, because it will be too hard for you alone. He
needs support from other people as well.
a: I believe it will come, but anyhow, the conclusion I believe is that I have to work
more on my own emotions, something . . . but I’m actually finished.
t2: There seems to be lots of care here, from the others. Yes, many people care for you
and you care for yourself too by bringing it in here, and our starting point was
how you should relate to anger here in the group, so part of the job can be done
here, by working with . . . (A-5, A-17)

The transcript

a: Yes, but it’s a bit unclear. Let’s say it happens here, what should I do then in the
group, should I say . . .
t2: Yes.
a: Should I say: Stop, I feel it’s like . . .
		 [Laughter in the group]
t2: Yes.
a: Well . . . Hmm [laughs, and moves in the chair].
t2: Yes, I was thinking about you the last session, A. I wondered if I should have
stopped, and said “Is something happening now which is difficult?” but if you
had done it yourself I believe it would have been good too. (A-19)
a: I believe I also have a need for being seen, that someone see me.
t2: So it would have been OK for you if I had stopped then? (A-11, A-19)
a: Yes, I believe so.
m: Possibly a wrong theme, but I have real difficulties with recognizing how other
people feel. I’m blind at such things. But concerning your guy, I believe boundaries are important, that you manage to set limits when you feel that it’s enough.
t1: There seem to be some problems with boundaries here too, don’t there? It seems
difficult to come to a closure. (A-3, A-5, A-7)
		 [Group laughter]
t1: And to get ahead with the other themes that are announced, it keeps going and
going . . . (A-3)
a: Thanks for the conversation.
		 [Group laughter]
t2: Who is next? (A-3)
		 [Members look at each other]
t1: You, K, haven’t you already started? (A-3)
a: [To K] I would like to hear more.
t1: You were talking about your relationship, and . . . is it a pattern that you started to
describe? (A-11)
k: A pattern . . . yes . . . it is.
t1: And this makes you increasingly . . . irritated? (A-11, A-17)
a: Yes . . . she blurs things . . . and it becomes so narrow . . . it’s almost too difficult to
describe how she is . . . I have told you previously that she has tied me up with
friends and the like, she is very dominating and controlling, if I have not cleaned
the floor at the right time, she loses her temper, and . . .
t2: Do you have any example, which we can explore and possibly learn from?
(A-3)
k: No . . . don’t know . . . it’s like that the whole time, every day . . . Any examples? I
don’t know if I can manage that, but she is very sensitive to criticism . . . If I don’t
answer the mobile immediately she believes I am ignoring her.
		 [K’s mobile phone starts to ring]
t1: Is it her calling now? (A-5)
k: Yes, and if I don’t answer, then . . .

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c: She knows that you are here.
k: Yes, perhaps she has forgotten it, I don’t know.
t1: So what is happening right now is actually a typical example, that she is trying to
reach you on your mobile? (A-5, A-11)
k: And she gets furious.
c: When she can’t get in touch with you?
k: I’ll give you an example, when I flipped out. I went to Greece, I should have been
there for 3 weeks, but she allowed me to stay for only 1 week. Well, having been
there for 1 week, the night before the flight back home . . . I sent her a message
saying blah blah blah.
t1: You sent a message?
k: A mobile text message, about what I’d done that day, and then I wrote “Just to let
you know, I think I’m catching an upper respiratory infection.” I had got some
fever and felt it coming. Well, she became furious because she thought it was
some excuse for not being intimate when coming home, for not touching her. I
called her and tried to explain, but she was simply plain awful, it’s hard to explain
how, but she didn’t believe me, and that made me break down.
t2: So you were in Greece and sent her a text message.
k: Yes.
t2: Telling her that you were ill.
k: Yes, that I was ill and that I would travel back home that night, and she said: No,
no, it’s better for you to stay in Greece.
c: You should have done!
k: Yes, it’s very difficult, but I didn’t want any trouble, so it ended with me giving in.
I’m flattening out. Otherwise I flip out. Last time she did hit me. However, then I
hit her back.
t1: When you met after Greece?
k: No, a couple of days ago
t1: A couple of days ago?
k: We quarrel a lot.
t1: You quarrel a lot, and now you have started hitting each other? (A-11, A-17)
k: Yes, and when she punched me, I flipped.
t1: How did she punch you?
k: She . . . she . . . hit me hard in the chest, and then I hit her arm. I am an aggressive
person too, but I really try to hold it back, but she got so close and I could hardly
recognize her, completely weird, her eyes get so dark, she doesn’t see that what
she does is not OK, not OK at all, and then I can become really self-destructive
and bang my head against the wall.
t1: OK . . . [Looks around the group] What . . .
c: Oh . . .
t1: You say Oh, what do the rest of you think about what we have heard so far?
(A-4)
m: I do recognize, I’m afraid, myself a little, in her role, when I was feeling incredibly
low, so I feel that she can’t possibly be in a good way.

The transcript

k: Yes, she’s quite unwell I would think.
a: Does she get any help?
k: She’s been to a mental health center and a referral has been sent somewhere. Yes,
she needs treatment because I’m not able to carry her on my own. I’m carrying
both myself and her, and . . . She doesn’t manage to comfort me in any way, isn’t
able to say sorry . . . She seems to have been like this in previous relationships too;
if she feel somewhat threatened or things like that she becomes horrible to that
person, she does her best to break him or her down.
c: She has no reflection ability?
k: Well, she gets glimpses once a month. She breaks down and understands what
she is doing and shows remorse. I have said to her that my wish is . . . I am meeting her wishes all the time, but that I have a wish to go to couples counseling,
which is family therapy free of charge, because we need a third party to see us
both, as she always sees me as the bad one, you know, and I am in need of someone to observe the two of us and be able to talk through and finish a normal
conversation without it turning into hell.
t1: What I am wondering, I don’t know if the rest of you do too, is that she is saying
and doing things that are hard to live with . . . (A-4, A-11)
k: Hard demands.
t1: But you are living together, the two of you have chosen this, so there has to be
some positive sides. (A-11)
k: Yes, I love her, that’s why I am so . . .
t1: What is it that you love? (A-11)
k: She has got it all, apart from what happens in arguments, though, then everything
turns different.
t1: Mm.
k: She is a wonderful person too, and I understand her, why she is so . . . why she
feels the way she does . . . I understand very well why she reacts . . . no, not why
she reacts, that is wrong, but how she handles things, and I think and hope that it
can work out and be OK, that it can be resolved if she gets help. It got like this after
we moved in together 2 months ago.
t1: So then it got worse? (A-11)
k: Got much, much, much worse.
t1: When you moved in together?
k: Yes.
t1: Why do you think that is so? (A-11)
k: She probably thought that now we are living together, that it is a lot more responsibility, which it also is, to an extent, but . . . if she says one day, what are we going
to do today? Are you going to see a friend? Then it is OK, but if I make that suggestion, it all goes wrong.
t2: Is there something we, the group, can do to help you relate to her? (A-4)
k: No, for her there is nothing to do, but I’d like some help for my anger, because I
have had this anger since childhood. Then I used to hold my breath if the juice I
got was the wrong color.

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		 [Group laughter]
k: Yes, already as a baby I used to bang my head in the cot.
t2: So you were born with a strong temper? (A-17)
k: Yes, my brothers too . . . But the anger only comes in close relationships, not
otherwise.
t2: But what you describe is that you held your anger back, until you exploded,
or . . . (A-17)
k: Yes.
t2: So it is not the anger in itself that is the problem, but that you hold it back and
that . . . (A-11, A-17)
k: Have had it under control I guess, but it has been too much between me and X.
c: She does trigger you.
k: Yes.
c: She triggers you until you explode.
k: She is challenging me, to put it that way.
å: Such things get very difficult, if you get pushed and pushed and pushed . . . I
understand that you in the end . . . [waves arms]. It is the same with me, that if I
get pushed until a point . . . I understand it well.
c: I used to have it like that with my ex, but then I could give him a warning and
say . . . that now you are triggering me so much that I am on the edge of exploding, I could give him three warnings, but if he kept on going then . . . I would
explode.
k: Mm.
t2: You recognize . . . (A-4)
c: Yes, yes . . . when you feel that now it is starting to come, now . . .
k: Yes, I do feel that, and am trying to give some warnings.
c: Then you can choose to tell her, that you . . . now I feel my anger coming to get me,
kind of, do you remember last time how it turned out . . . I mean, starting to use
words . . . that maybe that could dampen it down, a bit.
k: Mm, yes.
c: Sometimes . . . I . . . not always, but . . .
k: I am the one who is trying to find solutions when we are arguing. Yes, when we
begin to get a little wound up, we can go our different ways and think it over, but
we keep winding each other up all the time . . . or we could say sorry, in a way.
m: I really identify with that, both in what you say [to C] and in X, and I don’t think
it will get better unless she gets some help.
k: Yes . . . no . . . because, even though I say that now we should part and think
through things on our own, she doesn’t manage to.
m: It is too . . . she . . . takes you to your limits and it’s . . . I remember that the only
thing I wanted in a situation like that was to be comforted, embraced, and hear “I
love you so much” and that he shouldn’t have a life at all, kind of, for himself, and
every time he was going to do anything, I turned . . . completely crazy.
k: Yes, she needs help, and I need to have something to do. So I’m looking forward
to starting school and . . .

The transcript

t1:
k:
t1:
k:
t1:
a:
k:
a:
å:
t1:
å:
t1:
a:

m:
k:

c:
k:
t1:
k:
c:
k:
t1:
k:
t1:
k:
t1:
k:

t2:
c:
k:
å:

Yes, to get out from home a bit.
Yes, I’ll probably feel a little freer then, not so locked up.
When do you start?
Next week.
Such that . . .
Is it completely filled up?
Yes, full.
People drop out in the beginning, so it might be . . .
[Laughing]
[To Å] Are you thinking about yourself? (A-11)
Yes, but I’ve found two other exams [laughs], each time when school stuff comes
up I think, yes, think I have to improve [laughs], yes, should . . .
Yes, but to round off . . . yes? [A wishes to say something]. . . Sorry. (A-3)
Yes, I have started to force myself to do other things, to get a distance from arguments like that. To spend time on other things; get out and away from it, then it is
so much nicer to meet again.
Doesn’t she have any friends?
Yes, one best friend, but . . . she used to have my friends, but she managed to ruin
that because she doesn’t like . . . doesn’t like people all that much, so now she
doesn’t like any of my friends, so they don’t want to be her friends, so she doesn’t
really have any friends . . . no. There are some people that she knows, but she isn’t
with them, so it’s only me.
So she is at home sleeping during the day?
No, she is working, is there until quarter to five and we go to bed at ten.
What kind of work does she do?
Works at a book warehouse.
So that is functioning, so she is working . . . and doing all right in her job?
Yes, she is very dutiful and . . . has a real pride in her work.
Is she Danish?
Yes, she is Danish.
Maybe we should hear a bit more about . . . How old is she?
Twenty-one. Moved to Norway in February.
So she has got her network in Denmark, then?
Moved here with a Danish friend and stayed with her until we moved in together,
but it changed when we all started hanging out together and her friend started
having a beer after work, she didn’t like that.
It is obvious that you have a tough time at home these days. It’s good that you are
telling us about it so we can hear more about it. (A-6, A-17)
What happens when you leave the group, do you call and tell her that you’ve been
here, does she understand that, or what?
Yes, yes, of course.
I feel really mean because I am so split between two opinions, because I understand, if you love each other and things can be really good . . . but I have, from
my experience, I have a very strong opinion, and it weighs on my conscience

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k:
å:
m:
k:
m:
k:
m:
k:

t1:
å:

c:

t2:

å:

c:
å:
t2:
å:
a:
å:
t2:

because I have this strong opinion . . . but I have this theory that two mentally ill
people who are struggling a bit with, well . . . if you are beginning to recover and
can talk about ways, have received therapy, maybe together, I think perhaps
that . . . but I don’t believe at all that two people who are struggling that much
together . . .
Most people have, you too [looks at A], wondered whether it is a good idea to go
on with the relationship, and . . .
In a way, I am trying to follow a rule for myself that no matter if I fall for someone
with mental problems, I will pull back . . .
It gets so intense by living together, one doesn’t get the space in a way, that escape
route which you need in order to withdraw a little.
I am independent now and have been independent before . . .
How old are you?
Twenty-two . . . I was perhaps a little bit like my girlfriend previously, with my
former partner, from 18 to 20. I was just sitting at home, waiting for her.
Has she had any time by herself?
Yes, in Denmark, actually. But relationships make her ill! She is independent,
strong, social, and makes friends too, a completely different person when she is
single, I knew her as a totally different person . . .
Closeness and living together is difficult, very difficult. (A-17)
I am getting really engaged in this, I relate to both so incredibly much, like when
I was together with Z, difficult, but I had some time off every night, was on Skype,
had some distance so I could work with myself, yes it’s like that in my life, when
there are two struggling, notice that I get so engaged . . .
I used to be a bit like that too, when I was single and on a break from A, I used to
be so independent, extrovert, in control, but after a few weeks of living together I
handed all responsibility over to him, then he could control it all, and I got selfeffacing and devoid of initiative.
I’m thinking that we should start rounding off, is that ok for you? When you,
Å, get so engaged, it seems like you’re identifying strongly with what has
being said? (A-3, A-11)
Yes, I either shut it all out, or . . . it can become quite perilous, I noticed lately, I
want to help everyone, if people are just talking about something, are moving, for
instance, I don’t even have to know the person, I am going to help out and help
out. I am a therapist for many . . .
But first you have to help yourself.
It’s so strange, I know what I should do. I can talk about it, but am not doing it, but
others who might need help with just about anything, I am on it.
You had a theme related to this. (A-3)
The only way I can help is to help others.
That’s how I feel too, I call it the Mother Theresa syndrome; my identity used to
be in being self-effacing and only helping others.
Yes, I notice that.
Do you notice when you are entering the role? (A-11)

The transcript

å: Well, in a way it has become better too, while at the same time it hasn’t, there is so
much going on at once, I got that understanding at the ward. I was hospitalized
because of suicidal thoughts.
t2: Yes, there are several things, you were hospitalized, and why? And the other thing
is that you push things away and later have a bad conscience about it, and what
happens here is that you are engaging strongly with what is being said. So what do
you wish to change? (A-11, A-17)
å: The two things bothering me the most are that I cannot give myself the space to
be. In addition, I get angry with myself, can’t accept it, alright, I don’t show emotions to others, but I go home with those emotions, and that people . . . but I have
nothing to be ashamed of, I’m not a bad person . . .
t2: Could we now go back to the previous group session, you told us that you then
were left with a feeling of being a bad person and that we hated you, was that it?
(A-17, A-18, A-19)
å: Yes, well . . . usually I hit rock bottom, it weighs me down very much that . . .
because I meant that I didn’t want the status of a hero you know, and when I felt
that someone thought so, I felt they perceived me as a very bad person, but to
make it completely clear, this is the situation, but anyway I am clearly hitting bottom and think I am the worst person in the world.
t2: Do the rest of you follow? My understanding is that you received comments on
having fantasies about being a hero, or . . . (A-4, A-11)
å: Yes, but that’s not how I feel, it is that I engage so much in others and I feel that my
life should be that of being there for everyone else, being strong for others, it’s not
that I crave recognition. Should I receive recognition, it should be for performing
well, or being slender and pretty, but . . .
t2: Should we stop here, you say that your life should be a kind of “being there for
others.” What do the rest of you think? (A-4, A-18)
a: I don’t think . . . I said different things, but I don’t think that you [Å] are looking
for recognition in that way.
å: No, that’s not it.
c: You were talking about how you had fantasies about going to Utøya [referring to
the July 22 terrorist attack] and that you could die in the place of someone else
who wished to live.
å: Yes, but that is about a lot of things, that that person’s life is more important, not
that . . . I’m thinking a lot about changing a situation where someone is trying to
kill me and that if I get away from it, I will take that as a sign that I should live, and
I have a fantasy in my head that I am not afraid of meeting it because then I will
have a confirmation of whether I should live or not . . .
t1: I commented on this last session by saying something about whether your ideas
were rather close to reality, whether it was nearly like you had actually been there,
almost doing it, instead of kinds of fantasies which are coming and going, like
thoughts do, that’s what I tried to say something about, and you reacted, A . . .
(A-16, A-19)
a: Yes, but I reacted because I was maybe a little jealous of Å, he he . . .

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		 [Group laughter]
t2: Yes, I noticed that it was difficult for you, what happened, and then I brought that
up with T1 later, and he hadn’t noticed, so I can understand that, tell us more.
(A-9, A-17, A-19)
a: Oh, I am ashamed. Å . . . I get jealous, maybe because I am struggling with the
same thing, and then I feel that T1 gives a lot of attention to Å because she feels
like this, but you don’t see that I am sitting there feeling much of the same.
t1: Oh! It is very good that you are saying this, because we discussed this in the post-­
session meeting and you, T2, told me that maybe A was jealous, then I said, I
remember, that yes, that is theoretically possible, but that on my part I hadn’t
noticed that she did or said anything to imply that she actually was jealous, but
you had a good hunch there. (A-5, A-9, A-14, A-17, A-19)
t2: Yes, I can understand that there might have been some uncertainty around what
Å’s problem was, what she wished to work on, so I thought it wasn’t necessarily
that bad, but then the main issue seemed to be that you felt it the same way, yes as
you say that you were a bit jealous about the attention, so what you are saying
now . . . (A-17, A-19)
a: It’s so embarrassing . . . It’s embarrassing to be here now . . .
c: That is an OK thing, surely. Those feelings are obviously strong, here in the
group.
a: Yes, but why?. . . I think it is embarrassing.
t1: Yes, I can understand that, but there is something about being able to own one’s
emotions. Emotions are emotions. (A-17)
m: I think it is very good you opened up, it is very brave.
a: Yes, he he.
t1: Did something happen here now too, when we were talking about Å? (A-5)
a: Yes, it came as a little wave, but I see myself so much in Å. I am often used to having your role, Å, used to have it, the one being the most confused and saying a lot
of the things you are saying, becoming one of those who people wish to take care
of. I have always had that role . . .
Å: It’s strange, because outside I am like . . . well, a bit like you, that I hope someone
will see it, but no one is seeing it because I am not saying anything . . .
a: Yes, but I used to be like that, especially around adults, or therapists or in care
settings, then I would be the one being taken care of, and I feel that you become
that one in the group here, but that outside you are the one trying to take care of
others . . . yes I used to be like that.
t2: Do you have a sister?
a: An older sister.
t2: Do you feel like, do you have the impression that you have become an older sister
to Å? (A-11)
a: The moment Å entered here, I felt I should take care of Å.
		 [Group laughter]
å: I get a bad conscience because a lot of what I say is hard for you to hear, I tell
myself that I should shut up.

The transcript

a: Well, because I feel I have been there before, that’s why I know, or don’t know but
feel, feel that I know what you need, so I can look after you, it is totally silly, I don’t
know where it comes from.
t2: Could it be that there is room for both, care for both older sister and younger
sister, how is that here? (A-6)
		 [Group laughter]
t1: You laugh. (A-17)
c: I think it is sweet, but my impression is that you actually do get as much care as Å
from T1, but that is what I see.
a: Yes, I too think that my siblings have the same amount of care and that I am seen
as much as them, by dad, for instance, so I don’t know where that is coming
from . . . but now it is turning towards me again . . .
t1: But what is happening now, is it especially Å? (A-5)
a: Yes.
t1: That you react to? How about the others? (A-5)
		 [Group laughter]
a: Are you thinking about the others here?
		 [Group laughter]
t1: Does it mean that I am less concerned with the rest? (A-12, A-19)
a: No, don’t know, it’s the way you do it maybe, I think you are especially interested
in Å, but I am sure you are not, but I feel it like that and don’t know why, think I
want you to be like that, but also be there for me.
t1: Yes I am interested in Å. . . (A-19)
å: You were irritated with me, oh, he he . . .
t1: Was I irritated with you? (A-17, A-19)
å: No, but . . . “You should calm down now”. . . [imitating]
t1: But I don’t know if I am more interested in Å than in the rest of you. Maybe in a
different way. (A-19)
m: I don’t notice any difference at all. I think you are the same to all.
c: You might be more interested in Å, but . . . no, I don’t think so . . . Well, maybe.
t2: It’s interesting that there are different opinions around this and different experiences of it. Do you all get a feeling of an extra care for Å, as a younger sister,
or . . . ? (A-11, A-17)
m: No, I have trouble getting to understand you [to Å].
å: I feel that T1 becomes like . . .
k: Yes, maybe he is trying to get something off the ground in you that the rest of us
have to try to understand, he is a therapist after all.
å: Yes I am pretty hard to understand, I am so different.
m: Do the rest of you follow? [To T1:] I could do with some extra explanation.
t2: Do you [Å] believe that T1 has difficulties in understanding you? (A-19)
å: He asks me a lot, but it can be because I am often quite confused.
t2: Do you recognize yourself in that, T1? (A-9, A-19)
t1: Yes . . . or rather that you can be a bit confusing. It is often . . . like, have I understood you now, or what? Was it like this or was it like that, because you are rather

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å:
t1:
å:
t1:

c:
t1:

t1:
c:
m:
t1:
c:
t1:
t2:
m:
c:

m:
c:
c:

t1:
c:
t1:
c:
t1:

contradictory. Before long, you can be like this, and then you can be like that.
Then you have these emotions and later you have those emotions, and you go so
in detail into things. (A-17, A-19)
Yes, things can go very fast.
And then it can be hard to follow the twists and turns. (A-19)
Things are going so quickly, in my head.
But it is going fast here as well, I see that we don’t have many minutes left, should
we simply move on a little here, you had something too [directed at C]? (A-2,
A-3)
It is nothing dramatic, but . . .
Just to say, I think it was quite useful, this last sequence, about the feelings
between us in this room that you brought up. It has something to do with being
able to be aware of one’s feelings, take them seriously, own them, and thus they
might become less catastrophic. (A-7, A-14, A-17, A-19)
several: Mm, mm.
But it is your turn [to C]. (A-3)
I have been in a relationship for a while and now we have moved in together.
[Applauds]
Well now, I have to admit . . . have we been updated? (A-19)
It was the summer vacation, but when I said about getting a partner, you were not
here, it was this other therapist [stepping in for T1].
Aha.
Possibly I didn’t catch that either.
No, I wasn’t here either.
I actually met him last summer, but then I wasn’t ready to have a relationship. I
was emotionally low, didn’t know who I was, didn’t have a sense of self, didn’t have
values, didn’t have anything. When the relationship got intense I chose to break it
off and focus on therapy and focus on myself and not be in any intimate relation.
He was from The Netherlands, right?
Yes.
However, we met again in January and then I was much stronger, had filled in my
own void and I was safe and stable, and then it was so much easier to go into a
relationship, because I know what I stand for, I know my limits. Then it was so
much easier to be with a person who loves you a lot. That love I am getting from
him now is kind of a bonus because I don’t need a man to fill the emptiness from
my belly up. I fill it myself and therefore it is going very well. But of course . . .
eh . . . and now we have moved in together and I was very afraid, because I am too
fond of my escape routes if things get tough emotionally.
Did he move in with you?
Yes.
Did he live in Nadderud, did you say?
No, he is from The Netherlands
Oh, The Netherlands . . . yes . . .

The transcript

t1:
c:
t1:
c:
t1:
c:

t1:
c:
t1:
c:
t1:
c:

t1:
c:

t1:
c:
t1:
c:

m:
c:

group laughing: Nadderud—Netherlands!
So he has moved in with you. From when?
Paying his rent from a few months ago.
OK . . . What does he do?
He is working with buses and . . . fixing buses, working day and night.
OK.
What is so nice is that when I now get into situations that are hard to handle emotionally, I haven’t had this feeling of escape, that I ought to kick him out, or that I
won’t bother with this mess anymore because I can’t handle it. I have worked a lot
with it, but yesterday, I went [gesticulating] from zero to ten, felt it was rather
good too, to be in that old role. That role is one I haven’t been in for a while, being
a real bastard, and childish and whiny and . . .
What happened? (A-11)
He is standing there, you know, solid as a mountain.
Yes, but what happened? (A-11)
Nothing, really.
Yes, obviously, but tell us what happened? (A-12)
Yes, well, I am quite premenstrual, my mood can swing from feeling well to
becoming incredibly irritated, and then all the time he’s asking what it is, what is
it . . . No, it is nothing! Right? And when it happens many times . . . what can I do
for you, what is it . . . then I have said beforehand that when I have a day like this,
it is ok to just leave me alone, because the more you ask me what it is, the worse
the situation gets. And he did that yesterday, he took it personally. He felt it was
something he had done, or that I didn’t love him anymore or didn’t want to be
with him anymore. And then he gets sensitive, when I have maybe put up the
somewhat strict mask, or, and then I burst.
And when you burst, how . . . (A-11)
Got angry [raises arms], bloody hell can you stop nagging, nagging, nagging . . .
and . . . I’m so sick of this, so sick of this . . . and then lots came out. But I didn’t
say that he should move out and I didn’t say that it was over, so that is an
improvement.
Yes, that is good news. (A-14)
Yes, that is good news for me, because that has been a pattern for many years.
Did you manage to fix it? (A-11)
Yes, yes [laughs]. . . This happened on our way to IKEA, we decide to . . . I am
about to turn around, fuck it, I won’t bother to go to IKEA, I won’t bother to be
out among people, I won’t bothered, won’t bother . . . But he stands there: “What
can I do? Sweetheart, can’t we just sit down at a café and have a cup of coffee?”
And then I begin to calm down and lower my shoulders. Oh no . . . and then we
talk about it, that he mustn’t take it personally . . .
Not to be rude or anything, but does he know what premenstrual means, with the
hormones and all that?
Yes, yes, he is a well-informed man.

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m: Not everyone knows.
t1: Now we have heard, and there are not so many minutes left, and we have to hear
the reactions here now, what do the rest of you think and feel? (A-4)
a: Yes I very often feel like you, but I’m impressed, that you . . . let’s have a coffee . . .
let’s resolve . . . then I think, don’t know, but then you use [points to head].
c: That is what I have learned! That exact minute up there, it was so familiar, the
emotions were so familiar, it is a pattern I have had for many years, it was almost
good to be there again, it had been a long time since I was there, but still it is not
the way I want it.
a: No, no.
c: We got to talk about it, went to IKEA and had some food, and had a nice time
afterwards.
m: I have to say that I recognize myself a hundred percent, I think I am close to
where you are, the same place, really recognize myself, having someone at your
side or with you who is so stable and at the same time having that safe feeling
inside yourself, that is new to me and very enjoyable.
t1: Are you thinking that the other person is receiving it in a way, without hurling it
back, is that what you are thinking about? (A-4)
m: Yes, stable.
c: And not starting to plough on with the same pattern, or throw the same anger
back, or [looks at K] getting this clash, anger against anger.
m: Then it might be easier, perhaps, to control oneself.
a: When I don’t manage what you did, it is a bit about pride, for some reason, don’t
know . . .
c: Earlier, yes earlier, that is what it was. But being able to back down . . . swallow
your feelings . . . and say sorry, or that I am saying sorry on my own behalf
too . . .
m: And simply respect for the other, because I notice that I have never had respect
for other people before, before the one I am with now.
c: But I have to laugh, when I am standing in the middle of hell, he says: “You are
incredibly beautiful, but now you are a difficult woman.”
		 [Group laughter]
t1: He says so?
c: Yes
		 [Group laughter]
c: “You are a beautiful woman, C, but now you are rather difficult.” It kind of takes
the edge off the mood [snaps fingers], it makes me come down again.
t1: Well, that is quite right, a good characterization!
		 [Group laughter]
c: I managed to come out of it, emotionally, very, very, heh, so I am proud of myself
for that.
t2: Yes, how wonderful. You have been in the group for about a year now, so you have
worked a lot with . . . (A-14)

Notes on the ratings

c: Oh yes I have. Earlier I would have broken up. With my ex . . . throw him out,
or myself out, because those were the escape routes I used to have. I have to
say that this is the first time that I am in a healthy, deep, natural and good relationship, really, I feel that I can be myself a hundred percent, for better or
worse.
m: I am just sitting here nodding, I recognize it so well.
c: Even though there are challenges for me emotionally, it is the first time that I have
lived with someone, actually, at my age of 39.
t2: It is wonderful and great that you still bring in episodes where you still wish to
work with things. There is space for that too, not just the more serious things.
(A-14)
t2: How has this time in the group been? We are in our last minute. I think it has been
a good meeting, but what do you think? (A-2, A-5, A-14)
m: I was a little late, but I had something to say too. I have been thinking about it
during the group, I have been completely at rock bottom.
t1: How bad (A-6)
m: It has gotten better. I could easily take your whole story [to C] and call it mine.
I have moved and I’m incredibly stressed, and after last time I was here I have
gone straight down to rock bottom and been to bed for a week and just staring
out of the window and cried and haven’t showered and only eaten junk food
and chain-smoked and had my birthday last week and just cried and thought
the world hated me and planned to kill me, and was about to go down and buy
some booze and take a lot of pills and felt that my partner forgot about my
birthday, and, la, la, la . . . and then I finally got everything in place in the
house and money into the account again and now it is beginning to calm
down, but it has been bloody horrible. And the conclusion, which is so dreary,
is that my partner handled it very badly, he just let me lie there in bed and be
in a bad place, he didn’t relate to it, he hasn’t supported me in it the way that I
had thought, I have felt completely alone and we have nearly broken up
and . . .
t1: Mm. It is a pity, but we won’t be able to comment fully. (A-6)
m: I know that, but to have said it now makes it a lot better.
t1: But you have a session with your individual therapist on Thursday, and we will
hear more about this next time. (A-6)
m: But the crisis is over, I just had to get it out.
c: It’s good that you are here.
t1: OK. Thanks for the session. (A-1)

Notes on the ratings
In this session, the therapists performed approximately 180 interventions. Of
these, 70 interventions (39%) could not be rated according to MBT-G-AQS.
Some of these interventions were too short, a few were incomprehensible due to

197

Transcript of a mentalization-based group therapy session

the poor sound quality of the recording, and some were outside the realm of
MBT (e.g., when T1 asks about facts which do not concern mental states, such
as “What’s her job?” and “When do you start school?”)
The 110 interventions that complied with the manual received from one to
five ratings each. In total, these 110 interventions received 186 ratings. An
example of a single rating is “OK, what did they say?” (A-11, exploration). An
example of a complex rating is “Oh! It is very good that you are saying this,
because we discussed this in the post-session meeting and you, T2, told me that
maybe A was jealous, then I said, I remember, that yes, that is theoretically possible, but that on my part I hadn’t noticed that she did or said anything to imply
that she actually was jealous, but you had a good hunch there.” This intervention received five ratings: A-5 (identifying and mentalizing events in the group),
A-14 (acknowledging good mentalization), A-17 (focus on emotions), A-19
(focus on patient–therapist relationship), and A-9 (cooperation between
co-therapists).
Figure 5.1 displays the adherence profile. The columns indicate the number
of interventions for each item. The most frequently used interventions are
“exploration, curiosity, and not-knowing stance” and “focus on emotions.”
Figure 5.2 displays the quality ratings. All items are rated equal to or higher
than 4 (“good enough”). There were no interventions on item 8 (“stimulating
discussions about group norms”) and nothing to be qualified.

50
40
30
20

Fig. 5.1 MBT-G adherence of transcripted session.

Patients-therapists relationship

Stop and rewind

Affect focus

Psychic equivalence

Validating good mentalization

Challenging

Not-knowing stance

Co-therapist cooperation

Group norms

Group events

Engaging members

Turntaking

0

Phases

10

Boundaries

198

Ratings of each item

7
6
5
4
3
2

Overall

Stop and rewind

Patients-therapists relationship

Affect focus

Psychic equivalence

Pretend mode

Validating good mentalization

Arousal regulation

Challenging

Not-knowing stance

Engagement warmth

Co-therapist cooperation

Group norms

Authority

Care

Group events

Engaging members

Turntaking

Phases

0

Boundaries

1

Fig. 5.2 MBT-G quality of transcripted session.

Ratings of each item
Item 1: Managing group boundaries
Before the video is turned on, the therapists make some comments about absent
group members and the video recording. T1 marks and greets when patient M
arrives. T1 terminates the group on time. There are no other boundary violations that need to be addressed.
Adherence rating: 4. Quality rating: 4.

Item 2: Regulating group phases
The therapists make several interventions in the opening phase and address all
group members. T1 comments on T2 who invites exploration of a theme and
this intervention helps to keep the discourse on an organizing level. The phase
is short and focused and the group “gets to work” rather quickly. Later on, the
therapists comment on time boundaries and provide space for all participants
that have signaled their own themes in the opening phase. The therapists also
comment on the termination, ask for opinions about the meeting, and build
some kind of bridge to the next meeting. The session is very well organized
without being rigid. On the negative side, the interventions that should “build
bridges” to the previous meeting were sparse, particularly since the content of
the previous meeting was so dramatic.
Adherence rating: 11. Quality rating: 6.

199

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Transcript of a mentalization-based group therapy session

Item 3: Initiating and fulfilling turntaking
The therapists take several initiatives and several interventions serve to clarify
the mentalizing stance on the themes that are presented. Interventions that
clarify the context are not rated, unless they clearly try to get the protagonist “on
track” and point toward a mental state.
Fulfilling turntaking does also concern the protagonist’s “ownership” of the
sequence. The other group members will naturally associate round the main
theme and talk about their own experiences. This provides the group with liveliness, diversity, and spontaneous emotions. However, if this goes too far, the
therapists should intervene in order to re-establish the protagonist. T1 intervened in this way when he said: “Yes . . . but, should we stick a bit longer with A’s
experiences?”
Fulfilling turntaking also involves terminating the sequence. The therapists
make several interventions that concern termination, including difficulties
with terminating. In this session, there are four well-delineated sequences and
many of the interventions comply with item 3. On the negative side, was the
sequence with patient K optimal? Was there any progress?
Adherence rating: 21. Quality rating: 6.

Item 4: Engaging group members in mentalizing
external events
This is a lively group with engaged patients and the engagement mainly concerns thoughts about mental states and feelings and relations between people,
outside and inside the group. We observe several comments on how to cope
with difficult issues. This will always occur in such groups and the take is understandable since many of the participants have large coping problems. However,
due to the therapists’ interventions, the group never declines into a counseling
group. The therapists have several item 4 interventions. For example, T2: “I
think you describe it very well. I too remember that episode. It seems that you
have been able to reflect upon it afterwards. You others here, do you feel you
understand what it’s all about? (A-4, A-14).”
Adherence rating: 14. Quality rating: 7.

Item 5: Identifying and mentalizing events in the group
The therapists identify several events in the group and explicitly invite the
members for collective reflection. One instance is when T1 says: “It created,
what shall I say . . . a sort of dramatic new direction here, when you said about
him banging his head. It seems like you are . . . crushed in a way . . . is that right?
(A-5, A-11, A-17)” This intervention reinforces the attention on A’s story and

Ratings of each item

the group oscillates between “there and then” and “here and now” (about the
strong impact of listening to the story).
Adherence rating: 12. Quality rating: 6.

Item 6: Caring for the group and each member
Caring is not rated for occurrence. For pedagogical reasons we have nevertheless noted A-6 on some interventions that indicate care. For example, when T1
greets patient M (“Hello”) when she arrives (late) in order to mark that she has
been noticed and that she is welcomed. Another example is when the therapists
comments when patient A talks about her boyfriend:
a: I’m afraid his head will burst or something, it’s so . . .
t2: Oh. (A-6)
t1: Surely that must be awful? (A-6, A-17)

The group as a whole and each member are well taken care of in this session.
Nobody is overruled or mistreated by someone else.
Rating of quality: 6.

Item 7: Managing authority
This item is not rated for occurrence, but here, as well as for item 6, we have
noted some interventions that comply with the manual. For example, T1:
“That’s a theme which is fine to explore here.” And T1: “There seem to be some
problems with boundaries here too, don’t there? It seems difficult to come to a
closure. (A-3, A-5, A-7)” The therapist refers implicitly through these interventions to the purpose of the group and to working methods, that is, that some
issues are better than others (anger is good!) and that sequences have to be terminated. It is done in ways that signal these norms, but does not proclaim them
in an authoritarian way. The therapists seem confident in their roles and the
interpersonal drama of the group can be played out in a controlled manner,
safeguarded by the frames created by the therapists.
Rating of quality: 7.

Item 8: Stimulating discussions about group norms
The norms in this group seem well established. No discussion occurs, and there
does not seem to be any urgent need for it either, about how to handle typical
group interaction problems. For example, “Is it allowed to be angry here?” or “Is
it okay to be frank and straightforward here?” The group members seem to
agree that emotions are the primary target of the group, but they find it hard to
practice (of course!).
Rating of occurrence: 0. Rating of quality: 0.

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Item 9: Cooperation between co-therapists
By and large, the co-therapists seem to work towards the same goals and
they adjust to each other. Six interventions do explicitly concern their cooperation. In the opening phase, T2 asks patient C: “What happened?” while
T1 says “Shall we take that later?” The implicit message from T1 is that T2
invites an exploration (which should come later). More important are the
comments where T1 and T2 refer to what they had discussed at the postsession meeting. T2 had wondered if patient A was sort of jealous, while T1
had no such thoughts. These interventions are important for several reasons.
Firstly because the therapists are open about their exchange at the post-­
session meeting, and secondly because the content matter concerns the core
of mentalizing theory, that is, that mental states are opaque and not always
easy to interpret and that even therapists can overlook or misinterpret mental states.
Rating of occurrence: 6. Rating of quality: 6.

Item 10: Engagement, interest, and warmth
As previously noted, this is an engaged and vital group. It oscillates between
serious explorations, strong emotions, humor, and laughter. The therapists contribute to this with their own engagement. They are active, empathic, open, and
authentic. When patient A says that she reacted at the end of last session because
T1 overlooked her, T1 answers: “Yes, but I think you are right that I overlooked
it. (A-14, A-19)” The therapists make several humorous comments that evoke
laughter. This does not distract the group or call for just jokes and fun. It seems
rather to have a liberating effect by indicating that it is also possible to play with
serious matters (“reality”).
Rating of quality: 7.

Item 11: Exploration, curiosity, and not-knowing stance
This item is the most frequently used. The therapists maintain an exploratory
and not-knowing stance through the entire meeting. It starts immediately,
when T2 asks: “Last time we spoke about the disaster of 22 July, and other things
as well. There have presumably been some thoughts and feelings in the aftermath?” Thereafter follows typical interventions, like: T1: “Mm, are you referring to what happened last session? (A-11)” And T1: “OK, so you . . . it was right
at the end of the group, and I did not recognize your feelings, is that what you
mean? (A-11, A-17, A-19)”
Rating of occurrence: 39. Rating of quality: 7.

Ratings of each item

Item 12: Challenging unwarranted beliefs
Unwarranted beliefs were uttered several times, and most frequently by patient
Å. However, most of these were challenged by fellow group patients, or they did
not have any dynamic significance, or they were subordinated to other major
themes. Two interventions were classified as item 12. For example (during the
discussion about if T1 favors patient Å): T1: “Does it mean that I am less concerned with the rest? (A-12, A-19)” The rater does not get the impression that
there are a lot of unwarranted beliefs that pass under the radar.
Rating of occurrence: 2. Rating of quality: 4.

Item 13: Regulating emotional arousal
The emotional temperature in this group is optimal for psychotherapeutic
work. As noted previously, there is vitality there and an oscillation between
eagerness, interest, care, sadness, anger, and laughter. The group is neither flat
nor boring, and not too emotional at the expense of RF. The therapists regulate
arousal not so much through specific interventions as through their general
therapeutic style.
Rating of quality: 6.

Item 14: Acknowledging good mentalization
There are several (15) interventions of this type. It starts with T2: “I think you
describe it very well. I too remember that episode. It seems that you have been
able to reflect upon it afterwards. You others here, do you feel you understand
what it’s all about? (A-4, A-14)” In order to receive the highest quality rating, the
therapists should have explored such phenomena more in detail.
Rating of occurrence: 15. Rating of quality: 6.

Item 15: Handling pretend mode
This item is not rated for occurrence. There were clearly some instances of pseudomentalization, for example, as part of the discussion about if it is wise that
people with mental health problems live together. Patients Å and M are the
major contributors to pretend mode. However, any lengthy discourse on emotions and relations will be credited with some degree of pseudomentalization. It
is part of everyday discourse. Here it is up to the rater to decide if any clinically
significant pretend mode sequences occurred where the patients were caught in
a kind of aloof dialogue where the therapists should have intervened. According to this rater, no such lengthy sequence occurred, which signifies that the
therapists handled the pseudomentalizing tendencies in an adequate manner.
Rating of quality: 4.

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Item 16: Handling psychic equivalence
The session is characterized by a notable willingness to explore and reflect.
Although psychic equivalence themes are often referred to (in fact that is what
preoccupies the group members the most), they are seldom enacted in the
group as rigid and reality-distorting claims. Psychic equivalence phenomena
are made a target from the very beginning through patient A who wants to discuss her experiences from the previous session, such as in the following clarifying sequence:
t1: Let’s clarify, you say that when C and Å talk to you in a certain manner, something happens with you, which expression are you using? It’s like . . . you used an
expression . . . (A-5, A-11)
a: I don’t know.
c: Against you in a way.
a: I felt attacked.
t1: You felt attacked, yes. (A-17)
a: And I know I am not . . . mentally. I am fully aware of what happens in the situation, but I cannot control my feelings, and therefore I often get very angry. When
this happens I can say “but don’t get so angry at me,” but actually I did not believe
that you were angry at me. In this way I can start quarrels.

During the course of the group, fellow patients do most of the work by challenging each other and presenting different perspectives. A discrete intervention is
the following from T1:
“I commented on this last session by saying something about whether your ideas were
rather close to reality, whether it was nearly like you had actually been there, almost
doing it, instead of kind of fantasies which are coming and going, like thoughts do,
that’s what I tried to say something about, and you reacted, A . . . (A-16, A-19)”

Rating of occurrence: 2. Rating of quality: 4.

Item 17: Focus on emotions
As commented on several times, the session is loaded with a variety of emotions,
in stories from there and then and in the current experiential flow of the group.
The therapists make many interventions that address most aspects of emotions:
consciousness of emotions, emotion tolerance, expression of emotions, ownership of emotions, intersubjective emotional transactions, and so on.
Rating of occurrence: 36. Rating of quality: 7.

Item 18: Stop and rewind
Two interventions are classified as belonging to item 18. Example: T2: “Could
we now go back to the previous group session, you told us that you then were

Overall rating

left with a feeling of being a bad person and that we hated you, was that it?
(A-17, A-18, A-19)”
Rating of occurrence: 2. Rating of quality: 4.

Item 19: Focus on the relationship between therapists
and patients
Quite a lot of interventions have this target. The group provided ample opportunities for this focus since patient A started with an event from the previous
session that involved one of the therapists. It starts when T1 says: “OK, so
you . . . it was right at the end of the group, and I did not recognize your feelings,
is that what you mean?” (A-11, A-17, A-19). Later there comes a lengthy
sequence when patient A reveals her jealousy and T1 invites for an exploration
of the theme in the group: “Does it mean that I am less concerned with the rest?
(A-12, A-19)” Through the therapists’ interventions, the relationship between
therapists and patients gains a clear and marked position as a favored theme for
the group and it is explored to a significant degree.
Rating of occurrence: 22. Rating of quality: 7.

Overall rating
Altogether, 110 (out of 180) interventions were rated for occurrence and these
110 interventions received 186 ratings. Exploration was rated most frequently
(39 times), followed by focus on emotions (36) and focus on the relationship
between therapists and patients (22). Compared to other group sessions (data
to be published), these are very high occurrences. It is also significant that the
therapists cover almost all items (except for item 8). This is clearly a kind of
group where the raters have no problems with recognizing the therapeutic style
(as MBT) and what the therapists’ intentions are.
Overall rating of occurrence: 7.
As for quality, the mean score for all items is 5.8. This is not the way we decide
on overall rating, but it hints at the level we are talking about. The most important question is the following: Do the therapists practice a mentalizing stance
throughout the session? Yes, it covers most of their verbal and behavioral
actions. All interventions are definitely not of Nobel prize quality (and should
not be either). However, there are no long sequences where the therapists clearly
deviate from what is recommended in the manual. As previously mentioned,
the quality is reduced somewhat by a less than optimal closure of the sequence
with patient K. However, this is a minor drawback. The overall impression is of
a very good performance: “The therapists clearly demonstrated skill and expertise in handling the item content.”
Overall rating of quality: 6.

205

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Appendix 1

Rating scale for mentalizationbased group therapy

Table A1.1 Rating scale for mentalization-based group therapy
Rater: ________ Rating date: ________ Therapists: ________
Group: _______ Session date: _______
Overall rating of MBT occurrence: _______ MBT quality: __________
Item name

Occurrence

1. Managing group boundaries
2. Regulating group phases
3. Initiating and fulfilling turntaking
4. Engaging group members in mentalizing external
events
5. Identifying and mentalizing events in the group
6. Caring for the group and each member

No rating

7. Managing authority

No rating

8. Stimulating discussions about group norms
9. Cooperation between co-therapists
10. Engagement, interest, and warmth

No rating

11. Exploration, curiosity, and not-knowing stance
12. Challenging unwarranted beliefs
13. Regulating emotional arousal

No rating

14. Acknowledging good mentalization
15. Handling pretend mode
16. Handling psychic equivalence
17. Focus on emotions
18. Stop and rewind
19. Focus on the relationship between therapists
and patients

No rating

Quality

Appendix 2

Rating scale for mentalizationbased group therapy quality

Table A2.1 is used for rating therapists’ interventions during group therapy. The
table describes the quality level 4 (“good enough”). For more detailed descriptions, please refer to the manual.
Table A2.1 Rating scale for mentalization-based group therapy quality
Item name

Quality level 4 (“good enough”)

1. Managing group
boundaries

The group is functioning smoothly with respect to boundary
issues. The therapists identify boundary-relevant events and
comment and deal with them in ways which seem
appropriate and clarifying for the group as a whole

2. Regulating group phases

At least two phases are addressed in a way that engages
members to reflect upon the possibilities and choices they
have

3. Initiating and fulfilling
turntaking

The therapists themselves take the initiative and they also
follow up patients’ initiatives for turntaking. They
contribute to the unfolding of the story and identification
of relevant scenes, intervene in ways that facilitate a
comprehensive narrative, and keep a focus on emotions,
mental states, and interpersonal interactions

4. Engaging group members The therapists invite the other group members, implicitly or
in mentalizing external
explicitly, to clarify relevant events and engage members to
events
participate in a collective exploration of the mental states
involved therein
5. Identifying and
mentalizing events
in the group

The therapists identify some important events in the group
and engage group members in a collective exploration
which seems meaningful and clarifying

6. Caring for the group
and each member

At this level, the group process is on an even keel when it
comes to care. The therapists seem to have an awareness
regarding negative comments between group members
and are quick to intervene in such situations

7. Managing authority

The therapists seem calm and confident as MBT-G
therapists. In theory and practice they stand up for the
group’s basic values

(continued)

220

APPENDIX 2 RATING SCALE FOR MENTALIZATION-BASED GROUP THERAPY QUALITY

Table A2.1 (continued) Rating scale for mentalization-based group therapy quality
Item name

Quality level 4 (“good enough”)

8. S timulating discussions
about group norms

The therapists take the initiative to norm discussions,
engage in an interested way in spontaneous discussions,
and try to modify restrictive group solutions which are being
made, if these are not challenged by other group members

9. C
 ooperation between
co-therapists

There seems to be a confident relationship between the
therapists, their interventions are complementary, and they
communicate with each other with open, reflective comments

10. Engagement, interest,
and warmth

The therapists appear genuinely warm and interested in
each member and the group as a whole. The rater gets the
impression that the therapists care in a positive way. Several
interventions and their stance indicate this

11. Exploration, curiosity,
and not-knowing stance

The therapists pose appropriate questions designed to
promote exploration of the patients’ and other’s mental
states, motives, and emotions and communicate a genuine
interest in finding out more about them

12. Challenging
unwarranted beliefs

The therapists confront and challenge unwarranted
opinions about oneself or others in an appropriate manner

13. Regulating emotional
arousal

The therapists play an active role in terms of maintaining
emotional arousal at an optimal level (not too high so that
patients lose their ability to mentalize and not too low so
that the session becomes meaningless emotionally)

14. Acknowledging good
mentalization

The therapists identify and explore good mentalization and
this is accompanied by approving words or judicious praise

15. Handling pretend mode

The therapists identify pretend mode sequences and
intervene to improve mentalizing capacity

16. Handling psychic
equivalence

The therapists identify psychic equivalence functioning and
intervene to improve mentalizing capacity

17. Focus on emotions

The interventions focus primarily on emotions, more than
on behavior. The attention is particularly directed at
emotions as they are expressed in the here and now in the
group, and particularly in terms of the relationship between
patients and between patients and therapists

18. Stop and rewind

The therapists identify at least one incident in which
patients describe interpersonal events in a noncoherent and
affected way, try to slow down the pace, and find out about
the event step by step. In a similar way, the therapists halt
events in the group that tend to be destructive and take the
initiative to explore the sequence together with the patients

19. Focus on the
relationship between
therapists and patients

The therapists comment on and attempt to explore,
together with the patients, how the patients relate to the
therapist during the session and stimulate reflections on
alternative perspectives whenever appropriate. The
therapists speak about their own feelings and thoughts,
related to the patients, and through this they try to engage
all parties in mutual exploration

Index

Notes
The following abbreviations have been used:
BPD - borderline personality disorder
MBT-G - mentalization-based group therapy
A
AAIs (adult attachment interviews) 10
absenteeism from meetings 104
active listening 61–2
active therapists 129
ADHD (attention deficit hyperactivity
disorder) 40
adherence and quality rating scales see
mentalization-based group therapy
adherence and quality rating scale (MBTG-AQS)
adherence profile, transcript example 198,
198f
adult attachment interviews (AAIs) 10
affective mentalizing, cognitive mentalizing
vs. 13–14
Affect Regulation, Mentalization and the
Development of the Self (Fonagy et al) 4
amnesia, infantile 6
anger monitoring 146
anxiety disorders, group therapy 41
anxious attachment, BPD 11
attachment 4–7, 136
anxious 11
BPD 10
evolution of 27
needs, dismissal of 10
attachment hyperactivating strategies 10
attachment theory 123
attendance to meetings 47
attention deficit hyperactivity disorder
(ADHD) 40
authenticity of transference 170
authority management see MBT-G-AQS item
7: managing authority
autobiographical self (5 to 6 years of age) 6–7
automatic (implicit) mentalizing, explicit
(controlled) mentalizing vs. 10–12
B
balanced friendliness, therapists 136
Bateman, Anthony 7, vii
behavioural indicators, group membership
termination 73
behavioural studies, implicit/explicit
mentalizing 10

Bion, Wilfred 3
bipolar II disorder, group therapy 40
borderline personality disorder (BPD) 2–3
anxious attachment 11
attachment 10
borderline groups 2–3
deactivating/hyperactivating strategies 11
definition v
family conditions 11
group therapy see below
internal mentalizing 12
maltreatment 11
negative emotions 24
non-mentalizing 9
transference problems 171–2
borderline personality disorder, group
therapy 18–26, 37–41
clinical literature 19
efficacy of 19–20
problems 18
Bowlby, John 4, 29
BrainMind 33–4
C
CARE 27
dependency group 36
caring
for group see MBT-G-AQS item 6: caring for
the group and each member
importance of 47
challenging unwanted beliefs see MBT-G-AQS
item 12: challenging unwanted beliefs
cheating 29
clarification of events, MBT-G 48–9
closing comments, in turntaking 111
closure time, in turntaking 111
cognitive group therapy, MBT-G vs. 79–80
cognitive mentalizing, affective mentalizing
vs. 13–14
cognitive theory 7
Cognitive Therapy in Groups (Free) 80
combined psychotherapy 20
communication
networks 89
types of 87–8
complementary countertransference 170–1
component balance, mentalizing 9–10
concordant countertransference 171–2
concreteness of thought 156
conflicts, MBT-G sequence closing 68
conjoint psychotherapy 20–1

222

INDEX

continuous interactions 49
controlled mentalizing see explicit (controlled)
mentalizing
controlled premature termination 73
countertransference 75, 170–3
complementary 170–1
concordant 171–2
reactions 152–3
crisis plans 16–17
curiosity see MBT-G-AQS item 11:
exploration, curiosity and not-knowing
stance
D
dependency group 36
destructive group behaviour 124
devaluation of group by patient 76–7
developmental psychology 5–7
Diagnostic and Statistical Manual of Mental
Disorders (DSM-5) 2
dialectical behavioural therapy (DBT) 25
MBT-G vs. viii, 80–2
distorted communication 87–8
dynamic formulations 16–17
dynamic group psychotherapy 26
dynamic matrix 88
E
educational advantages, MBT-G 47–8
ego ideal 34
emotion(s)
arousal management see MBT-G-AQS item
13: regulating emotional arousal
detector mechanism 30
dysregulation 161
focus see MBT-G-AQS item 17: focus on
emotions
identification 162
reactions 64, 65–7
emotional abuse, PD 164
emotional bonds 27
empathy, system for 30
engagement see MBT-G-AQS item 10:
engagement, interest and warmth
events in MBT-G 56–8
clarification of 48–9, 58–60
external events 65, 120
see also MBT-G-AQS item 4: engaging
group members in mentalizing
external events
graveness in sequence closing 68
identification 64–7
see also MBT-G-AQS item 5: identifying
and mentalizing events in the group
mentalizing of 121
see also MBT-G-AQS item 5: identifying
and mentalizing events in the group
non-exploration of 125–7

relevance in sequence closing 68
within the session 120–1
evolution of thinking, group dynamics 26
Experiences in Groups (Bion) 34–5
explicit (controlled) mentalizing
acquisition 32
definition 10
implicit (automatic) mentalizing vs. 10–12
exploration see MBT-G-AQS item 11:
exploration, curiosity and not-knowing
stance
external events 65, 120
external mentalizing 12
F
facial expression reading 12
family conditions, BPD 11
FEAR 27
fight/flight group 36
fight/flight group 35–6, 146
RAGE 146
5-6 years of age (autobiographical self) 6–7
Fonagy, Peter 3–4, 7
foundation matrix 88
4 years of age
developmental psychology 6
explicit mentalization 32
free association 44
Free, Michael 80
friendliness, therapists 136–7
future events, MBT-G 57–8
G
Gabbard’s Treatment of Psychiatric Disorders
(Gabbard) 22
Gergly, György 4–5
good mentalization see MBT-G-AQS item 14:
acknowledging good mentalization
group(s)
boundary management see MBT-G-AQS
item 1: managing group boundaries
care for see MBT-G-AQS item 6: caring for
the group and each member
description of viii
dynamics see below
norm discussion see MBT-G-AQS item 8:
stimulating discussions about group
norms
phase regulation see MBT-G-AQS item 2:
regulating group phases
purpose in MBT-G 45–6
therapy see below
group analytic (GA) psychotherapy, MBT-G
vs. 82–3
group dynamics 26–37
contagious effect 34
evolution of thinking 26
group affiliation 26

INDEX

group cohesion 29
hierarchal structure 28
male aggression 28
primary emotion concerns 27
primary emotion systems 26
safety 28
social behaviour modes 27
Group Psychotherapy Intervention Rating
Scale (GPIRS) 92–3
Group Psychotherapy: The Psychoanalytical
Approach (Foulkes & Anthony) 87
group therapy
adverse effects 22–4
cohesion 29
destructive behaviour 124
devaluation by patient 76–7
dynamic psychotherapy 26
individual therapy vs. 103
inpatient 77–8
insecure attachment patterns 39
primitive defenses 38–9
rating scales 91–3
as stand-alone treatment 21
see also specific types of therapy
H
hierarchal structure, group dynamics 28
historical background of MBT-G 1–41
histrionic features 153
hospital treatment, MBT-G 15
hostility 130
Hrdy, Sarah 27–8
I
implicit (automatic) mentalizing
definition 10
explicit (controlled) mentalizing vs. 10–12
importance of caring 47
individual therapy, group therapy vs. 103
infantile amnesia 6
inpatient groups 77–8
insecure attachment patterns, group
therapy 39
institutions 78
intentionality, shared 31–2
intention detector mechanism 30
Interaction Process Analysis (Bales) 92
interactions, continuous 49
interest see MBT-G-AQS item 10: engagement,
interest and warmth
internal mentalizing 12
interpersonal group psychotherapy (IPT),
MBT-G vs. 83–4
interpersonal transactions 110
MBT-G 50
spontaneity 140
IPT (interpersonal group psychotherapy),
MBT-G vs. 83–4

K
Klein, Melanie 35
Kohut, Heinz, v
L
language, evolution of 32
Lineham, Marsha 25, 80–1
listening, active 61–2
loss of mentalizing 9
LUST 27
M
male aggression, group dynamics 28
maltreatment, BPD 11
management of authority see MBT-G-AQS
item 7: managing authority
managing emotional arousal see MBT-G-AQS
item 13: regulating emotional arousal
marked responses 162
Marziali, Elsa 84
member engagement in mentalizing, MBTG 62–4
mental health centers (MHCs) 78
mentalization
adjustment to level of 102
definition 3, 5
external events see MBT-G-AQS item 4:
engaging group members in mentalizing
external events
good see MBT-G-AQS item
14:acknowledging good mentalization
historical roots 3–4
measured as reflective functioning 14
mentalization-based group therapy (MBT-G)
attendance 47
continuous interactions 49
control of 43–4
course of treatment 72–4
development of 25
different contexts 77–9
educational advantages 47–8
events see events in MBTG
external–internal mentalizing switch 49
group phases 53–5
see also specific phases below
hospital treatment 15
interpersonal transactions 50
last session referencing 48
matrix 87–90
member engagement in mentalizing 62–4
mentalizing training ground 44–50
metacognition 50
opening phase 53
organization of group 48
outpatient treatment 15–16
phase termination 53, 55
previous meeting summation 53–4, 106,
115

223

224

INDEX

mentalization-based group therapy (continued )
principles of 43–90
prior interviews 46–7
purpose of group 45–6
rating scale see below
sequence closing 68–9
sequence of event clarification 49
slow-open groups 70–1
starting groups 69–72
starting session 48
structure 25–6, 44
subject matter 99
successful 99
termination of group 72–4
themes of 99
therapist role 45
transcript of 175–205
turntaking 48, 55–6
see also MBT-G-AQS item 3: initiating and
fulfilling turntaking
unparticipatory members 59–60
working (middle) phase 53, 54–5, 106
see also therapists
mentalization-based group therapy adherence
and quality rating scale (MBT-GAQS) 91–8, 217, 219–20
items 93–5, 99–174, 217
see also specific items below
rater training and reliability 98
rating of occurrence 95–6, 205
MBT-G-AQS item 1: managing group
boundaries 104–6
rating of occurrence 105
rating of quality 105–6
transcript example 199
MBT-G-AQS item 2: regulating group
phases 106–9
fair example 107
poor example 107–8
rating of occurrence 108
rating of quality 109
transcript example 199
MBT-G-AQS item 3: initiating and fulfilling
turntaking 109–15
example of good practice 111–12
example of poor practice 112–13
rating of occurrence 113–14
rating of quality 114–15
transcript example 200
MBT-G-AQS item 4: engaging group
members in mentalizing external
events 115–20
example of good practice 116–17
rating of occurrence 118
rating of quality 119–20
transcript example 200
MBT-G-AQS item 5: identifying and
mentalizing events in the group 120–3

rating of occurrence 122–3
rating of quality 123
transcript example 200–1
MBT-G-AQS item 6: caring for the group and
each member 123–8
example of good practice 124–5
example of poor practice 125–7
rating of occurrence 128
rating of quality 128
transcript example 201
MBT-G-AQS item 7: managing
authority 128–31
example of good practice 129
example of poor practice 129–30
rating of occurrence 131
rating of quality 131
transcript example 201
MBT-G-AQS item 8: stimulating discussions
about group norms 130–3
rating of occurrence 133
rating of quality 133
transcript example 201
MBT-G-AQS item 9: cooperation between
co-therapists 133–6
example of good practice 134–5
rating of occurrence 135
rating of quality 135–6
transcript example 201
MBT-G-AQS item 10: engagement, interest
and warmth 136–8
rating of quality 137–8
transcript example 201
MBT-G-AQS item 11: exploration, curiosity
and not-knowing stance 138–42
rating of occurrence 140–1
rating of quality 141–2
transcript example 202
MBT-G-AQS item 12: challenging unwanted
beliefs 142–4
rating of occurrence 143
rating of quality 143–4
transcript example 203
MBT-G-AQS item 13: regulating emotional
arousal 144–9
example of poor practice 148
rating of occurrence 148
rating of quality 148–9
transcript example 203
MBT-G-AQS item 14:acknowledging good
mentalization 149–51
rating of occurrence 150
rating of quality 150–1
transcript example 203
MBT-G-AQS item 15: handling pretend
mode 151–6
rating of occurrence 155
rating of quality 155–6
transcript example 203

INDEX

MBT-G-AQS item 16: handling psychic
equivalents 156–61
example of good practice 157–9
rating of occurrence 160–1
rating of quality 161
transcript example 204
MBT-G-AQS item 17: focus on emotions
161–6
rating of occurrence 162–5
rating of quality 165–6
transcript example 204
MBT-G-AQS item 18: stop and rewind 166–7
rate of quality 167
rating of occurrence 167
transcript example 204–5
MBT-G-AQS item 19: therapist–patient
relationship 167–74
rating of occurrence 173–4
rating of quality 174
transcript example 205
mentalization-oriented psychotherapy 14
mentalizing
affective vs. cognitive 13–14
component balance 9–10
controlled see explicit (controlled)
mentalizing
dimensions of 8–10
explicit see explicit (controlled) mentalizing
external 12
failure identification 60–2
implicit vs. explicit 10–12
internal 12
internal vs. external 12–13
loss of 9
member engagement in 62–4
regaining 9
rigidity 9
self 13
self vs. other 13
mentalizing training ground, MBT-G 44–50
mental state interpretations 102
metacognition
4 years of age 6
MBT-G 50
MHCs (mental health centers) 78
“minding the group,” therapists 50–3
mirror neurons 34
multiround economic exchange game 12–13
Munroe-Blum, Heather 84
N
narratives, group membership
termination 73–4
neuroaffective theory 35–6
neurobiological studies, implicit/explicit
mentalizing 10
neuroimaging studies, implicit/explicit
mentalizing 10

9 months of age, developmental psychology 5
normality issues 165
not-knowing stance 139
see also MBT-G-AQS item 11: exploration,
curiosity and not-knowing stance
O
Oneself as Another (Ricoeur) vi
opening phase, MBT-G 53
open questions 62
other mentalizing, self mentalizing vs. 13
outpatient treatment 78
MBT-G 15–16
P
pairing group 36
panic attacks 127–8
Panksepp, Jaak 35
paranoid personality disorder (PPD) 8
patient(s)
group devaluation 76–7
poor functioning 75–6
relationship with therapists see MBT-G-AQS
item 19: therapist–patient relationship
personality assessments 16–17
personality disorders (PDs) 7–8
emotional abuse 164
Pines, Malcolm v
PLAY 27
pairing group 36
poor functioning patients 75–6
post-session meetings, therapists 51–3, 133
prementalistic thinking 6
pre-session meetings, therapists 51–3, 133
pretend mode 151–2
speech of 152
see also MBT-G-AQS item 15: handling
pretend mode
primary emotions, group dynamics 26, 27
primate identification 28–9
primitive defenses, group therapy 38–9
prior interviews, MBT-G 46–7
private practice 77, 79
pseudomentalizing 39–40, 151
pseudotherapy sequences 153–4
psychic equivalence, concreteness of thought 156
psychic equivalents see MBT-G-AQS item 16:
handling psychic equivalents
psychodynamic (PD) group psychotherapy,
MBT-G vs. 82–3
psychoeducational groups 69–70
psychology, developmental see developmental
psychology
psychotherapy
combined 20
conjoint 20–1
dynamic group 26
mentalization-oriented 14

225

226

INDEX

Q
quality of object relations (QOR) 21–2
R
RAGE 27
fight/flight group 146
rater training and reliability, MBT-G-AQS 98
rating of occurrence, MBT-G-AQS 95–6
initiating and fulfilling turntaking 113–14
item 4: engaging group members in
mentalizing external events 118
item 5: identifying and mentalizing events in
the group 122–3
item 6: caring for the group and each
member 128
item 7: managing authority 131
item 8: stimulating discussions about group
norms 133
item 9: cooperation between cotherapists 135
item 11: exploration, curiosity and notknowing stance 140–1
item 12: challenging unwanted beliefs 143
item 13: regulating emotional arousal 148
item 14:acknowledging good
mentalization 150
item 15: handling pretend mode 155
item 16: handling psychic equivalents
160–1
item 17: focus on emotions 162–5
item 18: stop and rewind 167
item 19: therapist–patient relationship
173–4
managing group boundaries 105
regulating group phases 108
rating of overall occurrence and quality, MBTG-AQS 98
rating of quality, MBT-G-AQS 96–7, 105–6
128, 127–8
initiating and fulfilling turntaking 114–15
item 4: engaging group members in
mentalizing external events 119–20
item 5: identifying and mentalizing events in
the group 123
item 7: managing authority 131
item 8: stimulating discussions about group
norms 133
item 9: cooperation between cotherapists 135–6
item 11: exploration, curiosity and notknowing stance 141–2
item 13: regulating emotional arousal 148–9
item 14:acknowledging good
mentalization 150–2
item 15: handling pretend mode 155–6
item 17: focus on emotions 165–6
item 18: stop and rewind 167
item 19: therapist–patient relationship 174

regulating group phases 109
tem 10: engagement, interest and
warmth 137–8
tem 12: challenging unwanted beliefs
143–4
tem 16: handling psychic equivalents 160,
161
transcript example 198, 199f
reflective functioning (RF) 14, 101–2
Ricoeur, Paul vi
rigidity, mentalizing 9
S
safety, group dynamics 28
SEEKING 27, 138
self-awareness ability 30
self-destructive act control, group membership
termination 73
self-development 4–7
self mentalizing, other mentalizing vs. 13
self-report studies, attachment in BPD 10
self-righteous attitudes 157
separation distress 146
SEPARATION DISTRESS 27
dependency group 36
sequence of event clarification, MBT-G 49
SEX, pairing group 36
shared intentionality 31–2
Skills Training Manual for Treating Borderline
Personality Disorder (Linehan) 81
slow-open groups, MBT-G 70–1
social behaviour modes, group dynamics 27
speech, pretend mode 152
starting session, MBT-G 48
Stern, Adolf 3
Structured Clinical Interview for DSM-IV Axis
disorders (SCID-II) 2, 16–17
subject matter, MBT-G 99
system for empathy 30
T
termination phase
controlled premature 73
MBT-G 53, 55
therapists
active 129
activity monitoring 58
balanced friendliness 136
caring, importance of 47
co-operation between see MBT-G-AQS item
9: cooperation between co-therapists
errors 103
exploitation of 76
group organization 48
interventions 100
meeting coordination 74–7
“minding the group,” 50–3
post-session meetings 51–3, 133

INDEX

pre-session meetings 51–3, 133
relationship with patients see MBT-GAQS item 19: therapist–patient
relationship
roles 45
sophistication of 102
talking during meetings 134
turntaking control 110–11
thought, concreteness of 156
transactions, interpersonal see interpersonal
transactions
transference 168–70
alternative perspectives 170
authenticity of 170
validation of 169
turntaking
MBT-G 48, 55–6
therapists’ role 110–11

see also MBT-G-AQS item 3:initiating and
fulfilling turntaking
2 years of age 5–6
U
unparticipatory members, MBT-G 59–60
V
validation of transference 169
verbal language, evolution of 31
W
warmth see MBT-G-AQS item 10: engagement,
interest and warmth
working (middle) phase, MBT-G 53, 54–5, 106
Y
Yalom, Irvin 83

227



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saved, saved, saved, saved
History Instance ID             : xmp.iid:04801174072068119457E2734B67B56E, xmp.iid:05801174072068119457E2734B67B56E, xmp.iid:FF7F117407206811B351F91DA678FCD3, xmp.iid:0080117407206811B351F91DA678FCD3, xmp.iid:0484097376206811B351F91DA678FCD3, xmp.iid:0584097376206811B351F91DA678FCD3, xmp.iid:0684097376206811B351F91DA678FCD3, xmp.iid:0D84097376206811B351F91DA678FCD3, xmp.iid:BF09A9F686206811B351F91DA678FCD3, xmp.iid:C009A9F686206811B351F91DA678FCD3, xmp.iid:F87F11740720681192B0BF26A27E1F47, xmp.iid:0380117407206811BEDCF52FFCEE7E9C, xmp.iid:FF7F117407206811A613A5A17E0F552A, xmp.iid:FDCDD2D215206811A613A5A17E0F552A, xmp.iid:FF7F11740720681192B0AF6D540584EB, xmp.iid:864B1AD90A206811A8EDCCB15EE19A73, xmp.iid:845BC9B122206811A8EDCCB15EE19A73, xmp.iid:21E97D201A2068118DBB9F080947D1F2, xmp.iid:22E97D201A2068118DBB9F080947D1F2, xmp.iid:2520611E3C2068119109C1790DE0560E, xmp.iid:05801174072068118DBBCBB7037378AA, xmp.iid:B2C2EDF116206811871F99EFF0234FEE, xmp.iid:B238D264362068118A6D8F1F303DE7CE, xmp.iid:EE66D664362068118A6D8F1F303DE7CE, xmp.iid:E63326ED3A2068118A6D8F1F303DE7CE, xmp.iid:5DE3CA063D2068118A6D8F1F303DE7CE, xmp.iid:61E3CA063D2068118A6D8F1F303DE7CE, xmp.iid:3F9A8D1D3E2068118A6D8F1F303DE7CE, xmp.iid:429A8D1D3E2068118A6D8F1F303DE7CE, xmp.iid:BA8BDCB81B206811B2DA814C39A0F9D8, xmp.iid:24DAAA362D206811B2DA814C39A0F9D8, xmp.iid:25DAAA362D206811B2DA814C39A0F9D8, xmp.iid:26DAAA362D206811B2DA814C39A0F9D8, xmp.iid:27DAAA362D206811B2DA814C39A0F9D8, xmp.iid:28DAAA362D206811B2DA814C39A0F9D8, xmp.iid:29DAAA362D206811B2DA814C39A0F9D8, xmp.iid:2ADAAA362D206811B2DA814C39A0F9D8, xmp.iid:2BDAAA362D206811B2DA814C39A0F9D8, xmp.iid:2CDAAA362D206811B2DA814C39A0F9D8, xmp.iid:2DDAAA362D206811B2DA814C39A0F9D8, xmp.iid:2EDAAA362D206811B2DA814C39A0F9D8, xmp.iid:3E1830B32D206811B2DA814C39A0F9D8, xmp.iid:3F1830B32D206811B2DA814C39A0F9D8, xmp.iid:401830B32D206811B2DA814C39A0F9D8, xmp.iid:411830B32D206811B2DA814C39A0F9D8, xmp.iid:441830B32D206811B2DA814C39A0F9D8, xmp.iid:471830B32D206811B2DA814C39A0F9D8, xmp.iid:3D1702AF30206811B2DA814C39A0F9D8, xmp.iid:401702AF30206811B2DA814C39A0F9D8, xmp.iid:431702AF30206811B2DA814C39A0F9D8, xmp.iid:BF25F4EF34206811B2DA814C39A0F9D8, xmp.iid:C225F4EF34206811B2DA814C39A0F9D8, xmp.iid:C325F4EF34206811B2DA814C39A0F9D8, xmp.iid:ED64279135206811B2DA814C39A0F9D8, xmp.iid:F064279135206811B2DA814C39A0F9D8, xmp.iid:F364279135206811B2DA814C39A0F9D8, xmp.iid:F664279135206811B2DA814C39A0F9D8, xmp.iid:6A3E9CB839206811B2DA814C39A0F9D8, xmp.iid:6D3E9CB839206811B2DA814C39A0F9D8, xmp.iid:703E9CB839206811B2DA814C39A0F9D8, xmp.iid:A402CBC33B206811B2DA814C39A0F9D8, xmp.iid:A702CBC33B206811B2DA814C39A0F9D8, xmp.iid:A802CBC33B206811B2DA814C39A0F9D8, xmp.iid:AB02CBC33B206811B2DA814C39A0F9D8, xmp.iid:AE02CBC33B206811B2DA814C39A0F9D8, xmp.iid:B43F56053D206811B2DA814C39A0F9D8, xmp.iid:B73F56053D206811B2DA814C39A0F9D8, xmp.iid:B83F56053D206811B2DA814C39A0F9D8, xmp.iid:B93F56053D206811B2DA814C39A0F9D8, xmp.iid:BC3F56053D206811B2DA814C39A0F9D8, xmp.iid:17830EF43D206811B2DA814C39A0F9D8, xmp.iid:DEC7EA4D42206811B2DA814C39A0F9D8, xmp.iid:E2C7EA4D42206811B2DA814C39A0F9D8, xmp.iid:E5C7EA4D42206811B2DA814C39A0F9D8, xmp.iid:E8C7EA4D42206811B2DA814C39A0F9D8, xmp.iid:A8DF95F242206811B2DA814C39A0F9D8, xmp.iid:ABDF95F242206811B2DA814C39A0F9D8, xmp.iid:AEDF95F242206811B2DA814C39A0F9D8, xmp.iid:AFDF95F242206811B2DA814C39A0F9D8, xmp.iid:B2DF95F242206811B2DA814C39A0F9D8, xmp.iid:5CB3088443206811B2DA814C39A0F9D8, xmp.iid:5DB3088443206811B2DA814C39A0F9D8, xmp.iid:60B3088443206811B2DA814C39A0F9D8, xmp.iid:63B3088443206811B2DA814C39A0F9D8, xmp.iid:64B3088443206811B2DA814C39A0F9D8, xmp.iid:65B3088443206811B2DA814C39A0F9D8, xmp.iid:53E40E3344206811B2DA814C39A0F9D8, xmp.iid:56E40E3344206811B2DA814C39A0F9D8, xmp.iid:59E40E3344206811B2DA814C39A0F9D8, xmp.iid:5CE40E3344206811B2DA814C39A0F9D8, xmp.iid:DC687C1745206811B2DA814C39A0F9D8, xmp.iid:DD687C1745206811B2DA814C39A0F9D8, xmp.iid:DE687C1745206811B2DA814C39A0F9D8, xmp.iid:DF687C1745206811B2DA814C39A0F9D8, xmp.iid:E0687C1745206811B2DA814C39A0F9D8, xmp.iid:E1687C1745206811B2DA814C39A0F9D8, xmp.iid:E2687C1745206811B2DA814C39A0F9D8, xmp.iid:E3687C1745206811B2DA814C39A0F9D8, xmp.iid:E4687C1745206811B2DA814C39A0F9D8, xmp.iid:38A7C98C45206811B2DA814C39A0F9D8, xmp.iid:39A7C98C45206811B2DA814C39A0F9D8, xmp.iid:3AA7C98C45206811B2DA814C39A0F9D8, xmp.iid:3BA7C98C45206811B2DA814C39A0F9D8, xmp.iid:205AED6C46206811B2DA814C39A0F9D8, xmp.iid:235AED6C46206811B2DA814C39A0F9D8, xmp.iid:265AED6C46206811B2DA814C39A0F9D8, xmp.iid:769E228647206811B2DA814C39A0F9D8, xmp.iid:799E228647206811B2DA814C39A0F9D8, xmp.iid:7C9E228647206811B2DA814C39A0F9D8, xmp.iid:7D9E228647206811B2DA814C39A0F9D8, xmp.iid:770B00A248206811B2DA814C39A0F9D8, xmp.iid:7A0B00A248206811B2DA814C39A0F9D8, xmp.iid:7D0B00A248206811B2DA814C39A0F9D8, xmp.iid:800B00A248206811B2DA814C39A0F9D8, xmp.iid:058011740720681198DB92736594D92D, xmp.iid:088011740720681198DB92736594D92D, xmp.iid:1445B4D11420681198DB92736594D92D, xmp.iid:1745B4D11420681198DB92736594D92D, xmp.iid:1A45B4D11420681198DB92736594D92D, xmp.iid:1D45B4D11420681198DB92736594D92D, xmp.iid:713BF59B1620681198DB92736594D92D, xmp.iid:743BF59B1620681198DB92736594D92D, xmp.iid:773BF59B1620681198DB92736594D92D, xmp.iid:7A3BF59B1620681198DB92736594D92D, xmp.iid:C2DC937C1920681198DB92736594D92D, xmp.iid:C5DC937C1920681198DB92736594D92D, xmp.iid:C8DC937C1920681198DB92736594D92D, xmp.iid:C9DC937C1920681198DB92736594D92D, xmp.iid:CADC937C1920681198DB92736594D92D, xmp.iid:7467FE4E1B20681198DB92736594D92D, xmp.iid:7567FE4E1B20681198DB92736594D92D, xmp.iid:7667FE4E1B20681198DB92736594D92D, xmp.iid:7767FE4E1B20681198DB92736594D92D, xmp.iid:7867FE4E1B20681198DB92736594D92D, xmp.iid:7967FE4E1B20681198DB92736594D92D, xmp.iid:7A67FE4E1B20681198DB92736594D92D, xmp.iid:7B67FE4E1B20681198DB92736594D92D, xmp.iid:7C67FE4E1B20681198DB92736594D92D, xmp.iid:54DC1DC11B20681198DB92736594D92D, xmp.iid:55DC1DC11B20681198DB92736594D92D, xmp.iid:56DC1DC11B20681198DB92736594D92D, xmp.iid:57DC1DC11B20681198DB92736594D92D, xmp.iid:5ADC1DC11B20681198DB92736594D92D, xmp.iid:5BDC1DC11B20681198DB92736594D92D, xmp.iid:5CDC1DC11B20681198DB92736594D92D, xmp.iid:5DDC1DC11B20681198DB92736594D92D, xmp.iid:5EDC1DC11B20681198DB92736594D92D, xmp.iid:1276A3F71B20681198DB92736594D92D, xmp.iid:1576A3F71B20681198DB92736594D92D, xmp.iid:1676A3F71B20681198DB92736594D92D, xmp.iid:1776A3F71B20681198DB92736594D92D, xmp.iid:1876A3F71B20681198DB92736594D92D, xmp.iid:1B76A3F71B20681198DB92736594D92D, xmp.iid:1C76A3F71B20681198DB92736594D92D, xmp.iid:DC68114A1C20681198DB92736594D92D, xmp.iid:DD68114A1C20681198DB92736594D92D, xmp.iid:E068114A1C20681198DB92736594D92D, xmp.iid:E168114A1C20681198DB92736594D92D, xmp.iid:E468114A1C20681198DB92736594D92D, xmp.iid:4404369A1C20681198DB92736594D92D, xmp.iid:4504369A1C20681198DB92736594D92D, xmp.iid:4604369A1C20681198DB92736594D92D, xmp.iid:4704369A1C20681198DB92736594D92D, xmp.iid:4804369A1C20681198DB92736594D92D, xmp.iid:4904369A1C20681198DB92736594D92D, xmp.iid:4C04369A1C20681198DB92736594D92D, xmp.iid:54A50EEC1D20681198DB92736594D92D, xmp.iid:57A50EEC1D20681198DB92736594D92D, xmp.iid:5AA50EEC1D20681198DB92736594D92D, xmp.iid:5DA50EEC1D20681198DB92736594D92D, xmp.iid:0793CB3E1E20681198DB92736594D92D, xmp.iid:0893CB3E1E20681198DB92736594D92D, xmp.iid:0993CB3E1E20681198DB92736594D92D, xmp.iid:0C93CB3E1E20681198DB92736594D92D, xmp.iid:0F93CB3E1E20681198DB92736594D92D, xmp.iid:D3AAEF072020681198DB92736594D92D, xmp.iid:D6AAEF072020681198DB92736594D92D, xmp.iid:D9AAEF072020681198DB92736594D92D, xmp.iid:DCAAEF072020681198DB92736594D92D, xmp.iid:E401E8242120681198DB92736594D92D, xmp.iid:E701E8242120681198DB92736594D92D, xmp.iid:EA01E8242120681198DB92736594D92D, xmp.iid:AC86D32A2220681198DB92736594D92D, xmp.iid:AF86D32A2220681198DB92736594D92D, xmp.iid:B286D32A2220681198DB92736594D92D, xmp.iid:B586D32A2220681198DB92736594D92D, xmp.iid:1D6FBD9B2320681198DB92736594D92D, xmp.iid:206FBD9B2320681198DB92736594D92D, xmp.iid:236FBD9B2320681198DB92736594D92D, xmp.iid:246FBD9B2320681198DB92736594D92D, xmp.iid:601DEF712420681198DB92736594D92D, xmp.iid:611DEF712420681198DB92736594D92D, xmp.iid:641DEF712420681198DB92736594D92D, xmp.iid:671DEF712420681198DB92736594D92D, xmp.iid:6A1DEF712420681198DB92736594D92D, xmp.iid:1E4DAD932920681198DB92736594D92D, xmp.iid:214DAD932920681198DB92736594D92D, xmp.iid:244DAD932920681198DB92736594D92D, xmp.iid:274DAD932920681198DB92736594D92D, xmp.iid:284DAD932920681198DB92736594D92D, xmp.iid:9BFED58B2F20681198DB92736594D92D, xmp.iid:9EFED58B2F20681198DB92736594D92D, xmp.iid:8CE005293020681198DB92736594D92D, xmp.iid:8FE005293020681198DB92736594D92D, xmp.iid:92E005293020681198DB92736594D92D, xmp.iid:95E005293020681198DB92736594D92D, xmp.iid:7766F8103120681198DB92736594D92D, xmp.iid:7A66F8103120681198DB92736594D92D, xmp.iid:7E66F8103120681198DB92736594D92D, xmp.iid:32884D3C3220681198DB92736594D92D, xmp.iid:35884D3C3220681198DB92736594D92D, xmp.iid:38884D3C3220681198DB92736594D92D, xmp.iid:3B884D3C3220681198DB92736594D92D, xmp.iid:9BBF6FCF3220681198DB92736594D92D, xmp.iid:9EBF6FCF3220681198DB92736594D92D, xmp.iid:A4BF6FCF3220681198DB92736594D92D, xmp.iid:B2E26B713320681198DB92736594D92D, xmp.iid:B5E26B713320681198DB92736594D92D, xmp.iid:B8E26B713320681198DB92736594D92D, xmp.iid:FC41FBB33320681198DB92736594D92D, xmp.iid:0542FBB33320681198DB92736594D92D, xmp.iid:52291F523420681198DB92736594D92D, xmp.iid:84CA90773520681198DB92736594D92D, xmp.iid:87CA90773520681198DB92736594D92D, xmp.iid:8ACA90773520681198DB92736594D92D, xmp.iid:3281A3023620681198DB92736594D92D, xmp.iid:3581A3023620681198DB92736594D92D, xmp.iid:3881A3023620681198DB92736594D92D, xmp.iid:3B81A3023620681198DB92736594D92D, xmp.iid:468E25773620681198DB92736594D92D, xmp.iid:498E25773620681198DB92736594D92D, xmp.iid:4C8E25773620681198DB92736594D92D, xmp.iid:609DDC3D3820681198DB92736594D92D, xmp.iid:639DDC3D3820681198DB92736594D92D, xmp.iid:669DDC3D3820681198DB92736594D92D, xmp.iid:9E42AC8D3820681198DB92736594D92D, xmp.iid:A142AC8D3820681198DB92736594D92D, xmp.iid:A242AC8D3820681198DB92736594D92D, xmp.iid:A542AC8D3820681198DB92736594D92D, xmp.iid:A842AC8D3820681198DB92736594D92D, xmp.iid:7673FBE93A20681198DB92736594D92D, xmp.iid:7973FBE93A20681198DB92736594D92D, xmp.iid:7C73FBE93A20681198DB92736594D92D, xmp.iid:5C6939BE3B20681198DB92736594D92D, xmp.iid:5F6939BE3B20681198DB92736594D92D, xmp.iid:606939BE3B20681198DB92736594D92D, xmp.iid:636939BE3B20681198DB92736594D92D, xmp.iid:666939BE3B20681198DB92736594D92D, xmp.iid:DC3858DC3D20681198DB92736594D92D, xmp.iid:DF3858DC3D20681198DB92736594D92D, xmp.iid:E23858DC3D20681198DB92736594D92D, xmp.iid:DE7B2A643F20681198DB92736594D92D, xmp.iid:E17B2A643F20681198DB92736594D92D, xmp.iid:E47B2A643F20681198DB92736594D92D, xmp.iid:4AA897E33F20681198DB92736594D92D, xmp.iid:4BA897E33F20681198DB92736594D92D, xmp.iid:4EA897E33F20681198DB92736594D92D, xmp.iid:F97F1174072068118A6D88B431AFC7B1, xmp.iid:FE7F1174072068118A6D88B431AFC7B1, xmp.iid:FF7F1174072068118A6D88B431AFC7B1, xmp.iid:B9E912A80A2068118A6D88B431AFC7B1, xmp.iid:BCE912A80A2068118A6D88B431AFC7B1, xmp.iid:BFE912A80A2068118A6D88B431AFC7B1, xmp.iid:C2E912A80A2068118A6D88B431AFC7B1, xmp.iid:E24D6A4A0C2068118A6D88B431AFC7B1, xmp.iid:E54D6A4A0C2068118A6D88B431AFC7B1, xmp.iid:E84D6A4A0C2068118A6D88B431AFC7B1, xmp.iid:E94D6A4A0C2068118A6D88B431AFC7B1, xmp.iid:EA4D6A4A0C2068118A6D88B431AFC7B1, xmp.iid:DE27FD560D2068118A6D88B431AFC7B1, xmp.iid:E127FD560D2068118A6D88B431AFC7B1, xmp.iid:E427FD560D2068118A6D88B431AFC7B1, xmp.iid:E727FD560D2068118A6D88B431AFC7B1, xmp.iid:53C100A50D2068118A6D88B431AFC7B1, xmp.iid:56C100A50D2068118A6D88B431AFC7B1, xmp.iid:59C100A50D2068118A6D88B431AFC7B1, xmp.iid:5CC100A50D2068118A6D88B431AFC7B1, xmp.iid:02C4C0560E2068118A6D88B431AFC7B1, xmp.iid:05C4C0560E2068118A6D88B431AFC7B1, xmp.iid:08C4C0560E2068118A6D88B431AFC7B1, xmp.iid:8EE2D8E60E2068118A6D88B431AFC7B1, xmp.iid:91E2D8E60E2068118A6D88B431AFC7B1, xmp.iid:94E2D8E60E2068118A6D88B431AFC7B1, xmp.iid:97E2D8E60E2068118A6D88B431AFC7B1, xmp.iid:7718F7540F2068118A6D88B431AFC7B1, xmp.iid:7A18F7540F2068118A6D88B431AFC7B1, xmp.iid:7D18F7540F2068118A6D88B431AFC7B1, xmp.iid:8018F7540F2068118A6D88B431AFC7B1, xmp.iid:1CBCF224102068118A6D88B431AFC7B1, xmp.iid:1FBCF224102068118A6D88B431AFC7B1, xmp.iid:22BCF224102068118A6D88B431AFC7B1, xmp.iid:E8AAE457102068118A6D88B431AFC7B1, xmp.iid:EBAAE457102068118A6D88B431AFC7B1, xmp.iid:EEAAE457102068118A6D88B431AFC7B1, xmp.iid:F1AAE457102068118A6D88B431AFC7B1, xmp.iid:87304213152068118A6D88B431AFC7B1, xmp.iid:8A304213152068118A6D88B431AFC7B1, xmp.iid:8D304213152068118A6D88B431AFC7B1, xmp.iid:8E304213152068118A6D88B431AFC7B1, 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xmp.iid:7732A0BF3520681188C6A8DDA0212EF1, xmp.iid:7832A0BF3520681188C6A8DDA0212EF1, xmp.iid:7932A0BF3520681188C6A8DDA0212EF1, xmp.iid:7A32A0BF3520681188C6A8DDA0212EF1, xmp.iid:7B32A0BF3520681188C6A8DDA0212EF1, xmp.iid:7C32A0BF3520681188C6A8DDA0212EF1, xmp.iid:16ED563A3720681188C6A8DDA0212EF1, xmp.iid:17ED563A3720681188C6A8DDA0212EF1, xmp.iid:18ED563A3720681188C6A8DDA0212EF1, xmp.iid:19ED563A3720681188C6A8DDA0212EF1, xmp.iid:1AED563A3720681188C6A8DDA0212EF1, xmp.iid:1CED563A3720681188C6A8DDA0212EF1, xmp.iid:20ED563A3720681188C6A8DDA0212EF1, xmp.iid:AAC293A03920681188C6A8DDA0212EF1, xmp.iid:ABC293A03920681188C6A8DDA0212EF1, xmp.iid:ACC293A03920681188C6A8DDA0212EF1, xmp.iid:ADC293A03920681188C6A8DDA0212EF1, xmp.iid:AFC293A03920681188C6A8DDA0212EF1, xmp.iid:B0C293A03920681188C6A8DDA0212EF1, xmp.iid:B1C293A03920681188C6A8DDA0212EF1, xmp.iid:B2C293A03920681188C6A8DDA0212EF1, xmp.iid:B3C293A03920681188C6A8DDA0212EF1, xmp.iid:B4C293A03920681188C6A8DDA0212EF1, xmp.iid:FCFE1C333A20681188C6A8DDA0212EF1, xmp.iid:FDFE1C333A20681188C6A8DDA0212EF1, xmp.iid:FEFE1C333A20681188C6A8DDA0212EF1, xmp.iid:FFFE1C333A20681188C6A8DDA0212EF1, xmp.iid:00FF1C333A20681188C6A8DDA0212EF1, xmp.iid:01FF1C333A20681188C6A8DDA0212EF1, xmp.iid:02FF1C333A20681188C6A8DDA0212EF1, xmp.iid:04FF1C333A20681188C6A8DDA0212EF1, xmp.iid:05FF1C333A20681188C6A8DDA0212EF1, xmp.iid:06FF1C333A20681188C6A8DDA0212EF1, xmp.iid:981DF4D23A20681188C6A8DDA0212EF1, xmp.iid:991DF4D23A20681188C6A8DDA0212EF1, xmp.iid:9A1DF4D23A20681188C6A8DDA0212EF1, xmp.iid:9B1DF4D23A20681188C6A8DDA0212EF1, xmp.iid:9C1DF4D23A20681188C6A8DDA0212EF1, xmp.iid:9D1DF4D23A20681188C6A8DDA0212EF1, xmp.iid:9E1DF4D23A20681188C6A8DDA0212EF1, xmp.iid:9F1DF4D23A20681188C6A8DDA0212EF1, xmp.iid:A01DF4D23A20681188C6A8DDA0212EF1, xmp.iid:A11DF4D23A20681188C6A8DDA0212EF1, xmp.iid:A21DF4D23A20681188C6A8DDA0212EF1, xmp.iid:4230C5AD3B20681188C6A8DDA0212EF1, xmp.iid:4330C5AD3B20681188C6A8DDA0212EF1, xmp.iid:4430C5AD3B20681188C6A8DDA0212EF1, xmp.iid:4530C5AD3B20681188C6A8DDA0212EF1, xmp.iid:4630C5AD3B20681188C6A8DDA0212EF1, xmp.iid:4730C5AD3B20681188C6A8DDA0212EF1, xmp.iid:4830C5AD3B20681188C6A8DDA0212EF1, xmp.iid:4930C5AD3B20681188C6A8DDA0212EF1, xmp.iid:4B30C5AD3B20681188C6A8DDA0212EF1, xmp.iid:4C30C5AD3B20681188C6A8DDA0212EF1, xmp.iid:2204E75D3D20681188C6A8DDA0212EF1, xmp.iid:2304E75D3D20681188C6A8DDA0212EF1, xmp.iid:2404E75D3D20681188C6A8DDA0212EF1, xmp.iid:2504E75D3D20681188C6A8DDA0212EF1, xmp.iid:2604E75D3D20681188C6A8DDA0212EF1, xmp.iid:2704E75D3D20681188C6A8DDA0212EF1, xmp.iid:2804E75D3D20681188C6A8DDA0212EF1, xmp.iid:2A04E75D3D20681188C6A8DDA0212EF1, xmp.iid:2B04E75D3D20681188C6A8DDA0212EF1, xmp.iid:2C04E75D3D20681188C6A8DDA0212EF1, xmp.iid:3CAF79A43F20681188C6A8DDA0212EF1, xmp.iid:3DAF79A43F20681188C6A8DDA0212EF1, xmp.iid:3EAF79A43F20681188C6A8DDA0212EF1, xmp.iid:3FAF79A43F20681188C6A8DDA0212EF1, xmp.iid:40AF79A43F20681188C6A8DDA0212EF1, xmp.iid:41AF79A43F20681188C6A8DDA0212EF1, xmp.iid:42AF79A43F20681188C6A8DDA0212EF1, xmp.iid:43AF79A43F20681188C6A8DDA0212EF1, xmp.iid:44AF79A43F20681188C6A8DDA0212EF1, xmp.iid:45AF79A43F20681188C6A8DDA0212EF1, xmp.iid:46AF79A43F20681188C6A8DDA0212EF1, xmp.iid:C49EAEB04020681188C6A8DDA0212EF1, xmp.iid:C59EAEB04020681188C6A8DDA0212EF1, xmp.iid:C69EAEB04020681188C6A8DDA0212EF1, xmp.iid:C89EAEB04020681188C6A8DDA0212EF1, xmp.iid:C99EAEB04020681188C6A8DDA0212EF1, xmp.iid:CA9EAEB04020681188C6A8DDA0212EF1, xmp.iid:CB9EAEB04020681188C6A8DDA0212EF1, xmp.iid:CC9EAEB04020681188C6A8DDA0212EF1, xmp.iid:CE9EAEB04020681188C6A8DDA0212EF1, xmp.iid:B2B4BEF04120681188C6A8DDA0212EF1, xmp.iid:B3B4BEF04120681188C6A8DDA0212EF1, xmp.iid:B4B4BEF04120681188C6A8DDA0212EF1, xmp.iid:B5B4BEF04120681188C6A8DDA0212EF1, xmp.iid:B6B4BEF04120681188C6A8DDA0212EF1, xmp.iid:B7B4BEF04120681188C6A8DDA0212EF1, xmp.iid:B8B4BEF04120681188C6A8DDA0212EF1, xmp.iid:B9B4BEF04120681188C6A8DDA0212EF1, xmp.iid:BAB4BEF04120681188C6A8DDA0212EF1, xmp.iid:BBB4BEF04120681188C6A8DDA0212EF1, xmp.iid:BCB4BEF04120681188C6A8DDA0212EF1, xmp.iid:D8CCCD934220681188C6A8DDA0212EF1, xmp.iid:D9CCCD934220681188C6A8DDA0212EF1, xmp.iid:DACCCD934220681188C6A8DDA0212EF1, xmp.iid:DBCCCD934220681188C6A8DDA0212EF1, xmp.iid:DCCCCD934220681188C6A8DDA0212EF1, xmp.iid:DDCCCD934220681188C6A8DDA0212EF1, xmp.iid:DECCCD934220681188C6A8DDA0212EF1, xmp.iid:5948904A4920681188C6A8DDA0212EF1, xmp.iid:5A48904A4920681188C6A8DDA0212EF1, xmp.iid:34FFF9EA4920681188C6A8DDA0212EF1, xmp.iid:F77F1174072068118A6DCBF0DC78FD47, xmp.iid:69C401410E2068118A6DCBF0DC78FD47, xmp.iid:6AC401410E2068118A6DCBF0DC78FD47, xmp.iid:6BC401410E2068118A6DCBF0DC78FD47, xmp.iid:6CC401410E2068118A6DCBF0DC78FD47, xmp.iid:6DC401410E2068118A6DCBF0DC78FD47, xmp.iid:6EC401410E2068118A6DCBF0DC78FD47, xmp.iid:70C401410E2068118A6DCBF0DC78FD47, xmp.iid:242CBA19162068118A6DCBF0DC78FD47, xmp.iid:252CBA19162068118A6DCBF0DC78FD47, xmp.iid:272CBA19162068118A6DCBF0DC78FD47, xmp.iid:282CBA19162068118A6DCBF0DC78FD47, xmp.iid:292CBA19162068118A6DCBF0DC78FD47, xmp.iid:2A2CBA19162068118A6DCBF0DC78FD47, xmp.iid:2B2CBA19162068118A6DCBF0DC78FD47, xmp.iid:2C2CBA19162068118A6DCBF0DC78FD47, xmp.iid:2D2CBA19162068118A6DCBF0DC78FD47, xmp.iid:2E2CBA19162068118A6DCBF0DC78FD47, xmp.iid:8245722A172068118A6DCBF0DC78FD47, xmp.iid:8345722A172068118A6DCBF0DC78FD47, xmp.iid:8445722A172068118A6DCBF0DC78FD47, xmp.iid:8545722A172068118A6DCBF0DC78FD47, xmp.iid:8645722A172068118A6DCBF0DC78FD47, xmp.iid:C991261A192068118A6DCBF0DC78FD47, xmp.iid:CA91261A192068118A6DCBF0DC78FD47, xmp.iid:CB91261A192068118A6DCBF0DC78FD47, xmp.iid:CC91261A192068118A6DCBF0DC78FD47, xmp.iid:A0531CF2192068118A6DCBF0DC78FD47, xmp.iid:645D7942262068118A6DCBF0DC78FD47, xmp.iid:6D5D7942262068118A6DCBF0DC78FD47, xmp.iid:6E5D7942262068118A6DCBF0DC78FD47, xmp.iid:1262B6292C2068118A6DCBF0DC78FD47, xmp.iid:1362B6292C2068118A6DCBF0DC78FD47, xmp.iid:1462B6292C2068118A6DCBF0DC78FD47, xmp.iid:1562B6292C2068118A6DCBF0DC78FD47, xmp.iid:1662B6292C2068118A6DCBF0DC78FD47, xmp.iid:1762B6292C2068118A6DCBF0DC78FD47, xmp.iid:1962B6292C2068118A6DCBF0DC78FD47, xmp.iid:1A62B6292C2068118A6DCBF0DC78FD47, xmp.iid:1C62B6292C2068118A6DCBF0DC78FD47, xmp.iid:46BBD7712D2068118A6DCBF0DC78FD47, xmp.iid:47BBD7712D2068118A6DCBF0DC78FD47, xmp.iid:48BBD7712D2068118A6DCBF0DC78FD47, xmp.iid:49BBD7712D2068118A6DCBF0DC78FD47, xmp.iid:4ABBD7712D2068118A6DCBF0DC78FD47, xmp.iid:4BBBD7712D2068118A6DCBF0DC78FD47, xmp.iid:F77F1174072068118A6D880AF10AA69F, xmp.iid:F87F1174072068118A6D880AF10AA69F, xmp.iid:F97F1174072068118A6D880AF10AA69F, xmp.iid:FB7F1174072068118A6D880AF10AA69F, xmp.iid:FC7F1174072068118A6D880AF10AA69F, xmp.iid:FD7F1174072068118A6D880AF10AA69F, xmp.iid:FE7F1174072068118A6D880AF10AA69F, xmp.iid:FF7F1174072068118A6D880AF10AA69F, xmp.iid:00801174072068118A6D880AF10AA69F, xmp.iid:8AFDABD5082068118A6D880AF10AA69F, xmp.iid:8BFDABD5082068118A6D880AF10AA69F, xmp.iid:8CFDABD5082068118A6D880AF10AA69F, xmp.iid:8DFDABD5082068118A6D880AF10AA69F, xmp.iid:8EFDABD5082068118A6D880AF10AA69F, xmp.iid:8FFDABD5082068118A6D880AF10AA69F, xmp.iid:90FDABD5082068118A6D880AF10AA69F, xmp.iid:91FDABD5082068118A6D880AF10AA69F, xmp.iid:92FDABD5082068118A6D880AF10AA69F, xmp.iid:94FDABD5082068118A6D880AF10AA69F, xmp.iid:DAF6F1A30A2068118A6D880AF10AA69F, xmp.iid:DBF6F1A30A2068118A6D880AF10AA69F
History When                    : 2010:03:01 14:19:50Z, 2010:03:01 14:19:50Z, 2010:03:16 12:16:25Z, 2010:03:16 12:19:06Z, 2010:03:16 12:19:06Z, 2010:03:16 12:20:43Z, 2010:03:16 12:25:05Z, 2010:03:16 14:03:34Z, 2010:03:16 14:18:45Z, 2010:03:16 14:20:10Z, 2010:03:17 09:05:51Z, 2010:03:17 09:26:57Z, 2010:03:18 09:34:07Z, 2010:03:18 10:43:12Z, 2010:03:18 12:23:26Z, 2010:03:18 14:28:15Z, 2010:03:18 20:10:26Z, 2010:03:19 14:38:37Z, 2010:03:19 14:39:32Z, 2010:03:20 15:46:06Z, 2010:03:20 19:51:33Z, 2010:03:22 11:37:09Z, 2012:02:16 15:01:13+05:30, 2012:02:16 15:01:13+05:30, 2012:02:16 15:46:30+05:30, 2012:02:16 15:48:42+05:30, 2012:02:16 15:52:17+05:30, 2012:02:16 15:57:15+05:30, 2012:02:16 15:57:46+05:30, 2012:02:27 13:59:46+05:30, 2012:02:27 14:00:27+05:30, 2012:02:27 14:01:02+05:30, 2012:02:27 14:01:26+05:30, 2012:02:27 14:01:38+05:30, 2012:02:27 14:01:49+05:30, 2012:02:27 14:02:04+05:30, 2012:02:27 14:02:22+05:30, 2012:02:27 14:02:33+05:30, 2012:02:27 14:02:43+05:30, 2012:02:27 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History Software Agent          : Adobe InDesign 6.0, Adobe InDesign 6.0, Adobe InDesign 6.0, Adobe InDesign 6.0, Adobe InDesign 6.0, Adobe InDesign 6.0, Adobe InDesign 6.0, Adobe InDesign 6.0, Adobe InDesign 6.0, Adobe InDesign 6.0, Adobe InDesign 6.0, Adobe InDesign 6.0, Adobe InDesign 6.0, Adobe InDesign 6.0, Adobe InDesign 6.0, Adobe InDesign 6.0, Adobe InDesign 6.0, Adobe InDesign 6.0, Adobe InDesign 6.0, Adobe InDesign 6.0, Adobe InDesign 6.0, Adobe InDesign 6.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe InDesign 7.0, Adobe 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Create Date                     : 2015:08:17 17:07:58+05:30
Modify Date                     : 2015:08:19 18:49:25+05:30
Metadata Date                   : 2015:08:19 18:49:25+05:30
Creator Tool                    : Adobe InDesign CS5 (7.0)
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Creator                         : Adobe InDesign CS5 (7.0)
Title                           : Mentalization-Based Group Therapy (MBT-G): A Theoretical, Clinical, and Research Manual
EBX PUBLISHER                   : Oxford University Press USA
Author                          : Sigmund Karterud

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