Are there distinctions here? Are this generally in the same bucket?

Yeah.

Peter Fonagy was really the person, um, most responsible for kind of bringing the concept of mentalization, like, in, like, a, a prominent part in kind of mental health thinking.

Um, he wrote a really kind of seminal paper in the late 1980s talking about this issue of theory of mind, which, um, you know, comes out of, like, research and thinking on autism.

And then what Peter did was really kind of apply that to understand the challenges that people experience with borderline personality disorder.

And so he wrote a paper about, like, how does mentalizing relate to borderline, and how could there maybe be, like, challenges with sort of reflecting on mental states, specifically in borderline personality disorder? And that's what led, he ended up partnering with Anthony Bateman.

Um, they're both kind of psychoanalysts from London, and they were both a little kind of discouraged about the ability at the time, psychoanalysis was the treatment of the day, but they were inspired by the work of DBT, which was showing that BPD, borderline personality disorder, was very treatable.

Mm-hmm.

Now what about narcissism when we s- when we talked about does it matter and how does it matter?

So basically from a narcissism standpoint, it matters in a couple kind of pieces.

One, there are no evidence-based therapies for, specifically for narcissistic personality disorder.

So there just hasn't been enough research on that.

A couple forms of therapy show benefit for people with both borderline and narcissistic traits, and that's MBT, the type of therapy that I do, and also TFP.

So that's just an important thing to consider is there's not as much research on how to treat narcissism, which I think is really, really important that we're having conversations about it, d- teaching the public about it, just so we can kind of bring more attention to this understudied concept that sort of really, like, people are really suffering from, and, you know, they, they do need, you know, they deserve evidence-based and, or sort of treatment that we know will work.

But the other reason why it matters is exactly what you said, which you said, I love that kind of way of putting it, the, the issue of borderline is that there's not enough self.

Can you say a little bit about the hope of change?

Do you see what I'm talking about?

... you're making the point, you're making the point that if we target the certainty and essentially what we call process mentalizing, that patients will then be able to kind of reflect on where this is coming from in a more flexible, nuanced way, which that is definitely MBT's argument.

Like, essentially stimulate a process of reflection, and then patients are gonna be in a spot where they can see things from a variety of perspectives.

I would still propose, though, we need to give patients more resources to kinda understand where all these things are coming from.

And so part of it is that essentially if, if people are trying to...

Oh, let's say they know...

Okay, so in this case, they feel clear that what's a mental state that they think is going on in their partner.

Yeah.

Yeah, that'd be great.

Yeah.

OK, cool.

So, well, this is a patient who essentially.

presented to treatment maybe in their like early or in her early, early thirties and really struggled with like a lot of self-injury, you know, like a lot of like burning, um, some cutting, a lot of kind of, um, suicidality, um, like, you know, would do like sort of quite, um, And, you know, impulsive actions of just sort of like stepping out in the street, kind of like hoping that that they were just, you know, get hit by a car or they should get hit by a car.

And and also really sort of engaging in like kind of risky, promiscuous sex with sort of strangers.

And so a lot of like tremendous self-loathing, really, you know, just really, really hating herself.

Yeah.

Maybe we can start there in, in terms of talking about this.

This is kind of like implicit in what we're talking about, but just to kinda mention, mentalization-based treatment, it's an evidence-based therapy for borderline personality disorder, as we've been kinda discussing.

But it's not just a way to understand borderline personality disorder, it's also, um, you know, really just there have been tons of randomized controlled trials showing that it really helps with some of, some of the core symptoms of borderline personality disorder.

So decreased self-injury, decreased depression, decreased hospitalizations, all that stuff.

And, um, so part of the, the version of MBT that's been like researched involves at the early stages developing what we call like a, an MBT formulation.

Sort of it's an early part of the treatment, which is really we're trying to kinda like itemize with, with patients their, um, their core problems in mentalizing.

I really wrote the book so that people could develop their own MBT formulation.

But then it makes me wonder, well, then what are you doing? [laughs] Like, how, how is this process happening with somebody?