The mentalization based treatment (MBT) model may be a valuable theoretical perspective for music therapists to consider using with clients in need of mental health care, particularly those with borderline personality disorder. This article explores some of the basic principles of MBT and its application to music therapy. We have included a case study and reflections for further consideration. It is our hope that music therapists will begin to incorporate this model within their treatment and care of clients with psychiatric disorders.
A woman was playing an improvisation together with me (NH), her music therapist. It was our first session. She was in her 40s. She was slim, well-dressed with makeup and hair in order, and not very tall. She seemed calm and appeared to be nothing out of the ordinary. In the first session, she quickly told me about a traumatic loss of her fiancé who died in an accident 20 years ago. She presented this loss with no emotion and still gave me the impression that she had not yet processed this traumatic event. After talking some more, we engaged in playing an improvisation together on two separate pianos facing one another. She played one note at a time, simply playing like there was only the next note. I accompanied her note while playing a stable grounding rhythm, a few notes, and sometimes some simple chords. There was little progression in the music. Then, the music began to form, a simple melody coming from her, and a simple harmonic ground coming from the therapist, added to a stable pulse. The music had an emotional quality, quiet, maybe sad, or even peaceful. She stopped and said it was peaceful. She associated being at peace with being dead, and suddenly the process of therapy took a new turn. The intimacy level changed. What were only tones on a piano became a wish to die. The intensity of the emotions in this newly formed relationship with the therapist was almost overwhelming, and for the following weeks and months engaging in music became difficult and threatening for her. What happened? How can we understand this process?
In this paper, we will present the mentalization based treatment (MBT) model as a
theoretical model that can help define the process of music therapy. The model
originates from verbal therapy (
Music therapists often use the theoretical framework related to the treatment context in which they work. Every clinical setting has its preferred focus points and treatment agenda reflected in some sort of theoretical model. When we as music therapists work in such a setting, we have to be able to communicate the process and outcome of therapy with our clients to the interdisciplinary team. We need some kind of mutual theory and understanding as a bridge between music therapy and other forms of treatment. In this article, we present the view that since we cannot be non-theoretical we have to be explicit about the theory we use. It is therefore important to be clear about our theoretical framework when we describe our clinical practice.
In this case report, we want to elaborate on how MBT can be relevant for discussing,
understanding, and communicating about music therapy specifically with people with
personality disorders. Clients with personality disorders and especially clients with
borderline personality disorder (BPD) have unstable relationships, intense and unstable
emotional states, and self-destructive behaviour. They experience emptiness or are
overwhelmed by emotions that they do not understand (they cannot mentalize), and as a
survival strategy they project their feelings, and use splitting and denial to keep
their internal balance. They are often in distress, and their state of mind or their
emotional state can change in an instant. This is why their relationships are so
unstable. For more information see Bateman and Fonagy (
There are two main reasons for choosing MBT with clients with personality disorders.
First, MBT is a treatment concept that is used worldwide in the treatment of people with
personality disorders, particularly BPD (
The term mentalization was first mentioned by researchers from the Ecole
Psychosomatique de Paris who also worked with theory of mind (
Mentalizing is defined as a form of “imaginative mental activity about others or
oneself, namely, perceiving and interpreting human behaviour in terms of intentional
mental states (e.g. needs, desires, feelings, beliefs, goals, purposes, and reasons)”
(
One central and important element of MBT is the integration of attachment theory
(
The MBT model was designed as an intervention model to treat clients who have problems with interpersonal relationships and their sense of self, because their ability to mentalize broke down easily. This meant that these individuals were especially vulnerable in interpersonal relationships. They could be caught up in perceptions of themselves and others that were based more on a misinterpretation of the actual context and events than on what was “actually” going on. They would lose the ability to look at events from a broad perspective. They would lose the ability to mentalize. This is thought to be an essential trait in people with personality disorders.
The loss of the mentalizing capacity can happen for the therapist as well. The concept of countertransference can include this phenomenon. When the therapist loses the ability to mentalize, he or she has to restore this capacity before they can continue mentalizing the client. This is important because a client develops and learns to mentalize by being mentalized. So what does this imply? It implies that in order to help a person restore the mentalizing capacity we have to do two basic things: we have to help regulate the arousal level to the optimal level (not too much and not too little) and we have to help the person to start thinking about their own mental states (thoughts, feelings, actions, etc.). Emotions can be regulated in many ways, but the basic principal is to validate the client’s reality and to contain whatever emotions they experience and express.
Attunement and non-verbal communication are important here because the therapist not
only has to say that he or she accepts what the client experiences, but also has to
show that he or she accepts it through posture, tone of voice, and eye contact for
example. This process and these factors feature in the Boston Change Process Study
Group’s writings (
To work in the on-going here and now context is an essential part of gestalt therapy
and other existential therapeutic orientations. However, to choose this focus and to
combine it with a dynamic theoretical understanding of the treatment process and the
meta-psychological understanding of the client’s internal dynamic is new. When
arousal is optimal, the therapist has to introduce the next element in this phase of
the process. The therapist has to help the client to start reflecting. This is done
by asking, “what do you think?” or “I am wondering…” instead of telling them what you
think or interpreting what happened. In MBT this is known as the
Focus on the here and now;
Focus on both implicit and explicit levels of communication;
Cultivate a
Strive to maintain a mentalization-enhancing attitude towards the client in the conversation and in the non-verbal communication;
Identify dynamic patterns such as defense, transference, and counter-transference; but only use them to enhance understanding of the ongoing unfolding interaction;
Do not encourage fantasies and free associations about the therapist;
Do not use confrontation and frustration-inducing interventions such as long periods of silences;
Do not mirror unmarked emotions.
These guidelines have some implications for the music therapist and raise some
questions. First of all we have to find out how a person can mentalize through music.
In active music therapy we often use improvisation as a way to help the client to
engage and express themselves with less focus on words and more focus on emotion and
the body. Improvisation enhances the implicit level of communication and interaction
(
For example, a woman was playing with a male therapist. He felt the music was flowing
and began to be more initiating and active. After the music, the woman turned to the
therapist and shouted “is it you or me who is in therapy?” They listened to a
recording of the music, and the client was surprised when she heard what happened in
the music. She was surprised that she had experienced the episode so intensely. In
reality, the therapist had left his mirroring and attuning position for about
15-seconds, but it was long enough for the client to have a strong experience of loss
of attention and support. So, active music therapy and improvisation may create an
environment that enhances the implicit level of interaction, which might be a more
direct or a more subtle way of engagement, where the attachment system and the
relationship is primarily negotiated through the attachment system and implicit
relational patterns. This is another way of saying that improvisation also holds the
potential to trigger fear, flight, or freeze mechanisms as well as an attuned,
regulated optimal response. Or as Strehlow and Lindner (
MBT is understood as mental activity on both the implicit and explicit level, an
important point to consider in music therapy. This means that the treatment model
incorporates explicit thinking such as words, symbols, narratives, or the
Active music therapy may consist of songwriting where a personal statement or a
narrative can be expressed. Songwriting can help formulate and integrate the implicit
and explicit qualities of music as songwriting combines the implicit and dynamic
elements of active music therapy with explicit symbolic, verbal, and narrative
elements. It enhances the aesthetic element of music therapy and also includes a
gestalt or a final product. Songwriting may have two or more dimensions. It is
created in a therapeutic process, it is something final that can be sung, recorded
and listened to, and it can be shared if this does not violate the therapeutic frame
(
Active music therapy can also consist of playing pre-composed songs. Songs can
function as a safe haven and/or as a personal statement. Singing a pre-composed song
can function as a personal statement and also as a transitional object that provides
safety. The singing in itself has a therapeutic component since it activates
breathing, vocalisation, and emotional expression. These are often compromised for
people who enter psychiatric treatment (
Thus, the MBT model has many implications for music therapists, since musical
activities engage the therapeutic relationship on the implicit level. Working in the
here and now is an essential part of music therapy and the therapeutic process has a
natural focus on both implicit and explicit levels of communication. The
Working in the relationship and in the music with a dynamic perspective on the process is mandatory in analytical music therapy, and it requires advanced training. The element of free association about the therapist is difficult to control and regulate when the interaction is based on music and not words. This is why clients sometimes have strong negative reactions to free improvisation. It activates transference patterns. Even if the therapist reassures the client about being non-judgmental and everything in the music being allowed, this is sometimes not enough. The client has to experience this; building trust in the music takes time.
Finally, there is the element of marking emotions. Dynamics are different in a musical context. On one hand, there is no marking of anything by anyone, because improvised music is non-discursive and holds no exact meaning. We cannot take a musical statement and understand it in the same way as a verbal statement. So we can play anything and never know what it means. This can be an advantage, because it allows clients to express themselves without having to account for what it means. They can experience the power of expression and communication. But there is also the risk of both hiding in the music and lack of regulation and attunement. On the other hand, it is clear who played the loud angry note; who hit the drum, who played the sad melody, or who played the sad piano, particularly if the improvisation was recorded. Action and expression clearly mark the origin of an emotional expression, and therefore music expression also can be experienced as vulnerable communication.
Returning to the initial statement that we, as music therapists, should work from
some type of model when we do treatment, how can MBT influence our thinking? First of
all, we are aware of keeping our focus on what goes on in the here and now, and also
having a focus on the implicit and explicit level of interaction and mental activity.
At the same time, we must be very much aware about what happens to us while engaging
in the relationship in terms of emotions, thoughts, images, associations, bodily
sensations, impulses, and sudden ideas that emerge out of nowhere. We need to monitor
our own capacity to mentalize and to keep the focus on
We need to pay attention to the client’s cognitive style to see if there are signs of
pre-mentalizing states called: pretend mode, teleological stance, or psychic
equivalence. These different cognitive styles are often indicative of a low level or
lack of mentalization (
Laila was a woman in her early 40s. She was married and had two teenage daughters. She experienced a stress disorder, was sent on sick leave, and then was dismissed from her job. In her paperwork, she was described as being sad, having low self-esteem, and feeling unmanageable. She cried easily. She was diagnosed with paranoid personality disorder; compulsive personality disorder, and disturbed personality mixed type. Music therapy began a year after she experienced her stress disorder.
In the first session, as described initially, I (NH) met a woman who was not very tall, well-dressed, and with make-up in place. I experienced her as both inconspicuous and pretty at the same time. She began the session by telling me that she has been depressed for a long time, since losing her first big love who died in an accident some 20-years ago. She had only cried once. This traumatic event had never been processed, because her mother was always crying and did not pay attention to Laila’s sadness. There was no room for her grief. She quickly found another boyfriend and they married. She described her husband as a person she married for safety more than for love. She told her story with a neutral tone of voice and no emotions were shown. When asked why she stayed in her marriage, she said that she had no wish for a divorce, since the feeling of security was essential to her. She was a security addict.
She described her childhood as normal. Her parents spent a lot of time in the garden. She spent a lot of time on her own with her brother and she felt attached to her father. At the same time, she described her father by describing how he sometimes bragged about his pretty daughter in front of friends, and then asked her to leave so he could be with his friends without her. He sometimes made fun of her and humiliated her when she was standing in front of a mirror at home to make herself look pretty. She also talked about how she wanted her father to put her to bed, but that he refused because he was afraid it could be seen as incestuous. Her father had an alcohol problem for many years, but he did not drink anymore. Her parents were divorced. When describing her mother, she talked about the feeling of wanting to sit on her mother’s lap, and that she would do this a lot during childhood. She was anxious and needed her mother to calm her down. She described her mother as dominating. When they were together, her mother insisted that her opinion was the only valid one. If they ever disagreed about something, her mother would threaten to leave if her opinion was not respected. Laila had been dependent on her mother in her daily life because her husband was a sailor in the merchant fleet. Her relationship with her mother made her feel powerless and frustrated. Laila’s husband was a calm man and at the beginning of therapy she described him as someone who did not pay enough attention to her or notice her in the way she needed. Intimacy was difficult, and her sexual life was not satisfying. At the same time, her husband was also described as someone who listened to her and supported her. She gave me the impression of being bored with her marriage.
When Laila described her children, she said that she found it difficult to engage with them and to relax at the same time. She felt as if she was highly demanding of herself. She did not let anyone help when she cooked or worked because she did not want other people to take credit for her achievements. However, she felt that she was not valued and that her effort was not recognised or validated. She never seemed to have a sense of achievement and mastery. She was preoccupied with what other people thought about her or was over-involved with others.
Looking at her relational story from a transference perspective gave me the impression that there were many echoes of problems in the attachment relationship that could potentially trigger arousal. The general impression was that Laila could not mentalize when it came to her relationship with these primary people. Her attachment style was ambivalent or over-involved. She had some mistrust of other people that triggered paranoid thoughts about “the other”. She also had some unresolved grief from the traumatic loss that she had never processed. In combination, this pointed to potential problematic relational issues and patterns that might emerge in the therapeutic relationship. If Laila wanted admiration from men, there could be a fear of humiliation and exposure, or neglect and a lack of interest. If she needed support and help from women, there could be a risk of being dominated and also a threat of abandonment. There was no room for her point of view. If she needed to process loss and grief, she was afraid of being denied comfort and emotional support.
Laila attended 36 of 40 available sessions. Reflecting on these sessions, the therapy was divided into three phases from an intervention perspective. Three types of interventions were used. Active music therapy was used in the beginning and end of treatment to work with interpersonal issues. Receptive music therapy was used in the middle to access the traumatic events in her life, and verbal therapy was used throughout therapy.
In the first session, we played for 5-minutes. Laila was given the simple instruction to play one note at a time whilst I provided a regular pulse with a few notes. Her single tones related to my tones, and even though she did not play a melody that had clear phrases and melodic structure, we shared the volume, the tempo, and the tonality. We shared an experience of musical contact. The music was slow and gentle in quality. Suddenly she was very moved by the music. It made her feel at peace, but a feeling of peace associated with the wish to be dead. The emotions were mixed and confusing, and she seemed surprised by this experience. The event showed that these emotions were near to her psychological surface and that sharing them was unfamiliar. She also thought about her lost love.
In the context of attachment and mentalization the music seemed to promote both
positive and negative feelings, and this dynamic created a breakdown in her capacity
to mentalize as it brought her in contact with suppressed emotions. She was overly
concerned with exposing herself, and sharing emotional content made her feel unsafe.
The music had suddenly made her appear to say, “I want peace; I want to die.” The
musical experience and her inner response were linked. This is called the
In the second phase, the listening experiences moved her back on the therapeutic track. When lying down and listening to music, she could receive the music in a passive position and be in control. At the same time, she could surrender to the music and my voice. She worked hard. Her images revealed how her lost love constantly appeared in her thoughts, and how attractive and colourful he seemed in contrast to her grey and detached daily life. The images often included the element of jumping off something like cliffs or bridges. She was in touch with her grief and her desire to end her life. A more diverse picture of the relationship also began to emerge. In the verbal dialogue she included a more complex and less idealised picture of him and their relationship. She finally seemed ready to leave it behind – for now. Other issues emerged such as the disconnectedness that she experienced with her daily life. It appeared that she also experienced postpartum depression, a passive eating disorder, and bullying in the workplace.
From a mentalizing perspective, this receptive music therapy process seemed to enhance her ability to mentalize herself. I could validate and support her internal state and she could experience me in relation to herself unfolding. Her rigid representations of her loss and life began to crumble, and a more flexible and negotiable picture began to emerge.
Phase three was much more focused on relationships. There were issues such as conflicts with a neighbour, how to deal with the cooking on Christmas Eve, anxiety about her work situation, her fear of making mistakes because it is so difficult for her to remember things, and her need for admiration and confirmation, to mention only a few points. There was a special focus on her wish to be less concerned with what other people think about her. She used the music to explore emotions such as confusion and anger related to situations in her daily life. In the last session, she engaged in a musical improvisation about termination of therapy. The music was more fluid in style and dynamics. The roles in the music between Laila and me were the same as in the first example, but her ability to engage and cope with sudden changes was clear. She was not overwhelmed by emotions and her attachment system was not over-stimulated. We even played another improvisation about the future.
She reported afterward, when terminating therapy, that she experienced herself as more safe in relation to me and how annoying it was to have to start all over again in another setting. She felt more open and honest towards me. She was more aware of how she perceived others and wished she were less suspicious. Laila was still concerned about what other people said about her. She felt better, but still sad deep down. She had begun working a few hours a week and was managing the stress that being in a working environment sometimes creates. She began to enjoy things and not only to focus on whether everything was perfect.
In reflection, we would like to discuss how aspects of MBT and music therapy could contribute to one another and also reflect on ways in which MBT could impact our work as music therapists. The question still remains: can music therapy practice be altered by MBT or is MBT even directly transferable to music therapy?
To have the client’s mentalization as the focus of the treatment process can improve our
verbal therapy skills as music therapists. The guidelines described earlier provide
clear directions as to how the therapist can try to enhance the client’s mentalizing
capacity. In reality, some of the recommendations, such as the focus on the here and
now, the
In active music therapy, musical interaction can be viewed as preverbal interaction
(
In MBT it is recommended that the therapist stop and spool back to where the
mentalization capacity was influenced by the process. This movement is easily done in a
verbal context, but what does it imply in a music therapy context? Can we stop and spool
back? This is often not possible in the here and now of the process. It is simply too
difficult to identify when it happens. However, what does often happen when a client
loses the ability to mentalize is that they stop playing. They try to regulate the
emotional level of the situation by terminating the music and this is good. If the music
has been recorded, then the therapist and the client can listen back to the music
together and explore what happened as described above. Even without a recording it is
possible to investigate the incident retrospectively. So stopping and spooling back is
also possible in music therapy. The musical process can of course be investigated in the
verbal context as it was in the example above. This way of working has a long history in
music therapy (
Another issue relevant to music therapy is the element of pseudo-mentalization where the
client functions in pretend mode (
MBT in music therapy is in some sense analytical, dynamic, cognitive, and systemically oriented. But is it resource oriented? Essentially there is no specific goal in MBT guided treatment except constantly trying to keep a mentalizing perspective on the client with the intention of providing an environment where the client’s ability to mentalize becomes more explicit and flexible. When we as therapists keep this focus, we intend to empower the client and support their ability to “figure it out.” We think of this as a resource. But if the focus in therapy is only on “resources” it is not synonymous with MBT, because this implies, that the therapist focus on the process of therapy from a predefined perspective, and does not initiate the process of therapy from the mental state of the client. And that is what MBT is all about.
To conclude, MBT provides a very valid theoretical frame for music therapy with clients with personality disorders. We see MBT as a theoretical frame that fits well with what music therapists have been already doing for many years and believe that MBT challenges classical thinking about therapy and the role of the therapist. Keeping the focus on a person’s mentalization level and patterns is not easy without proper training, and that goes for both verbal and music therapy.
RIG: Representation of Interaction that has been Generalised
There are other recommendations such as the therapist’s ability to be warm and empathic. These are non-specific factors and therefore are not included here.