we developed mentalization based
therapies specifically for antisocial
personality disorder
simply because it was useful in
borderline personality disorder but in
effect we have a lot of people who
comorbid for both disorders and in our
clinical services actually there was a
problem with that overlap so people who
were more antisocial or actually quite
distinct from those who are more
borderline personality disorders so we
decided to separate them having done
that we of course had to have some view
about what the mind states of people
with antisocial personality disorder
were like as people actually have a
disregard for others they actually have
a disregard for their own safety very
often they're not very interested in
other people's views and perspectives or
mental states we know that they misuse
sort of emotions of other people
generally they may trigger emotions and
then use them or exploit them and so on
all this is described in the literature
and we think that those sorts of
attitudes those sorts of behaviors and
those sorts of relational problems that
they have are fundamentally based on our
problems and mentalizing so in fact we
used that to generate a treatment
program for targeting areas of
mentalizing problems for people with
antisocial personality disorder
I mean we start the groups with
agreements between us all which we call
a code of conduct you know how we're
going to relate here what's our values
as individuals in this group and what
are our values so we're going to try to
follow in the group and we have a series
of examples with them about what how we
might behave how we might not be a how
we expect each other to be a and we
specify those all right so we can always
come back to that it starts going wrong
that actually we simply don't do this
here and so on and they're quite good
respecting their own codes of conduct if
they've generated them
well that's a
question because when you first see them
they have no interest in thinking
differently whatsoever so the first task
is always to actually try to engender a
process whereby you're solely taking
their mind States into account you're
simply exploring their views their
values their perspective on what's
happened to them what is happening to
them their perspective on their current
relationship however they perceive it
and to take that absolutely seriously
face value and explore you know a lot of
detail and depth until they have a sense
that you see things from their
perspective you can't do anything else
at all once you've done that you then
subtly or gently move away to actually
push them to consider others mental
states in various ways or well in fact
others emotional states very often
because they're not very good at seeing
other people's emotions or at least
responding to them in a feedback system
so for example if they see someone else
is a little scared they don't care when
actually people without antisocial
personality disorder they see someone
they're making anxious or scared they
tend to get a feedback system which
alters their behavior so we spend a lot
of time getting them to consider these
sort of feedback loops particularly
about others emotional states and we do
that now primarily in groups and the
reason for that is of course is that
peer pressure and that your social
personality disorder gangs for example
actually can function incredibly well
they're very good at gangs they organize
them they have a proper hierarchy they
understand each other's roles they know
how someone's going to respond and so on
so we simply set up a gang in a sense
upset is called a therapeutic group and
then we get them to start considering
each other about what they're doing what
they're like how they see each other and
so on
the low-hanging fruit you see early on
is actually their recognition of other
people's emotional states of when they
start in the group they have no interest
in looking at others particularly trying
to read what their mental state might be
from how they're presenting or how
they're expressing something and we
focus a lot on that early and actually
they begin to realize it's incredibly
informative that if you bother to look
at people if you bother to things say
what's behind that smile do you laughing
at in a genuine curiosity they actually
begin to work out that this is quite
useful actually and they then of course
try and misuse it later you never know
but but nevertheless it's it they're
very quick at picking up actually you
can ask people things you can check
things out you can understand what
people's emotions are a little bit
rather than just seeing them as a threat
or something like that
the vast majority of people with
antisocial personality disorder spend an
inordinate amount of energy trying to
deactivate their attachment systems if
possible because attachment creates a
lot of trouble so once their attachment
systems are activated they're in trouble
of all sorts of things dependency of
need desire you sort of mean you of
other people and that of course is very
problematic for them because they're
very self organized they don't like to
need someone else if you like they're
autonomous in that sense so mostly they
tried to deactivate them
the problem with antisocial personality
disorder individuals they can't they
don't know very well because they tend
to be disorganized so bursts out all the
time in different ways so in fact what
we do with this is get them first to
begin to actually scrutinize and think
about the relationship processes just
what are they like how do they go what
happens we get them to do that
and we give them information about
attachment and attachment processes and
then we get them to actually map them
and so on and we actually give them what
we call a relational passport is simply
a little thing about their own
attachment processes really and they
discuss that in the group and of course
in the group they actually are mostly
activated so they're dismissive
processes are activated their attempts
to deactivate are activated if you short
of me and so on and we alight on those
in the group that's one on the other
focus of the group is looking at those
as they do them with us and within with
each other
the SafeZone they step into is to a
large extent they become less reactive
to others so they're less sensitive a
little less a submit him they're less
unlikely to make assumptions about other
people's malign mental states they don't
assume somebody's against them too
quickly and things like that so they're
much less reactive
once they're less reactive they're able
to maintain the stability of their own
mental state so they they don't feel so
threatened by other people and they
actually get better at reading other
people so they they differentiate not
everybody's and an enemy
some people actually are friends or
they've got benign motives and so on and
they feel better about that generally
speaking
people worry about
honest with reactivity for the therapist
and sense of feeling controlled or
coerced or tricked or lied to these
sorts of phenomena which are sincerely
an issue but actually the ones that
cause quite a bit of trouble in terms of
therapeutic work one is that a reaction
where the counter responsiveness is
actually to start minimizing events we
simply listen to these things and
gradually you begin to get the sort of
sense well early on I stabbed him once
and he said oh yes okay then you know
you sort of get drawn into this idea
that certain events actually you could
they minimize they say well it's only
they say honey
beat him up oh yeah yeah yeah and you
start generating this sort of response
where things become minimized all right
now that can actually happen in things
like your reactions to other things in
borderline personality disorder of
course but it's quite common in
antisocial personality sort of they
minimize what they do as if they're
perfectly okay the second one is
actually they which links is that they
use a lot of humor and to be honest
they're the best comedians you've ever
met they draw you into this comedic sort
of situation where you lose sight of the
fact you're delivering therapy and you
have these sort of great jokes being
made about things often which I've a
slide makar element in them and things
like that and and it's very easily
create a certain humorous sort of
interaction which actually avoids the
seriousness of things and it's easy to
lose that and you have to watch out if
you counter responsiveness down those
two
certainly
you