One of the best ways to learn Mentalization-Based Treatment (MBT) therapy is to record your sessions. The content here is transcribed from a real session, with signed consent for educational use, and then de-identified. I think there is not an easy way to learn MBT without this kind of practice. The person who shared these experiences did so after extensive conversations about the value of doing so, the risks, and the benefits. It is adapted with that consent. I also write this other newsletter and would be thrilled if you’d subscribe to it.
This session is early in the course of MBT treatment, for an individual with multiple prior serious suicide attempts in the past. This article assumes some familiarity with MBT terminology.
[February 2018 (fake date, right era)
DR. MUIR: …for money. Why is that a thing?
PATIENT: I just don’t understand. Like, I don’t know if he’s afraid, if there’s like a shame factor about it, but it’s been like this since probably the past decade, honestly. And it’s weird. I mean, my parents paid for his wedding, his rent when he used to live in New York, and I’m pretty sure they help him out now.
DR. MUIR: What does he do for work? [clarification]
PATIENT: He’s an entertainment lawyer.
DR. MUIR: So he’s an entertainment lawyer who needs money to buy sneakers.
[challenge]
PATIENT: Yeah. He supposes that he needed them to play basketball, like he always plays basketball in unofficial leagues and shit like that, but like, you have sneakers to ball in all the time.
DR. MUIR: His shoe size hasn’t changed.
[Challenge]
PATIENT: No, if anything, it’s actually gotten smaller. He used to be a size 9, but now he needs an 8 ½. All this, I don’t get it.
[pretend mode? It is a concrete response]
DR. MUIR: So how do you understand that dynamic, that your brother’s asking for shoe money from your folks, but he’s not asking, he’s asking you to ask for him. And you sound, if I’m hearing you right, conflicted, at best.
[validating, clarification]
PATIENT: Yeah, because it’s kind of distressing because, if I don’t do it, I know my brother will give me shit, or at least he used to. And if I do do it, it’s like it feels dirty, guilty as hell. It’s like, here I am asking you guys- and it’s already kind of fishy because, not for nothing and I don’t blame them, asking my parents for money ever since the whole, like, Xanax thing, they’re kind of hesitant. I don’t blame them, you know? It’s like, what are you going to use this hundred dollars on? I’m like, oh, sneakers. And they’re like, why do you want to buy sneakers?
[I think we are still in pretend mode, a bit disconnected from the experience]
DR. MUIR: Wait, so does he want you to buy the sneakers for him?
[curious stance, clarification]
PATIENT: No, what had happened was, finally, I just didn’t end up asking. And what he does was he asked my mom when she went to the mall, and she didn’t buy his sneakers there, she just did her things, went to work the next day, and asked one of her employees to go to the Adidas store and buy it for him. And that just made him feel like crap. I’m like, what do you expect? Mom’s not going to buy you sneakers, you know, she doesn’t have time for you because she has work and everything. It just leaves me in a very weird spot. Like, so many people expect such dumb shit from me for no reason.
DR. MUIR: Yeah. Wait just a second…
[“marked” response—I’m validating the concern by using this slightly humorous response to mirror the patient’s feelings]
PATIENT: It’s just weird.
DR. MUIR: It is weird. I’m struggling to understand. What do you think was going on for your brother when he asked you to ask mom, who eventually asked her secretary to go to the Adidas store.
[not knowing stance]
PATIENT: There’s definitely like a sense of shame that he’s afraid off the bat to ask my parents for money, you know? It’s like… I don’t get it. I just don’t get it. So I usually just say I’m going to ask for money, but I don’t anyway.
[the word “just” is the key…might be psychic equivalence as the mode?]
DR. MUIR: So this sounds like a really weird dynamic. It’s like there’s this swirling- I mean, the tone of your voice, if I’m hearing it right, is that you’re stressed about this?
[more not-knowing, and clarification]
PATIENT: Yeah, it’s because it’s annoying. I mean, I’m 26 and he’s 30-something at this point. It’s like, if you want something, just ask for it, you know? It’s like, dude.
DR. MUIR: What has stopped you from saying that to your brother?
[more curious stance]
PATIENT: Because I don’t want to argue with him anymore. Like, I spent literally 23 years of my life arguing with this dude, and just every single time, we come to blows, it just ends the same way- we don’t talk for a few weeks, then he contacts me or I contact him and we pretend it never happened. It’s like nothing gets resolved. If anything, issues pile up, and that’s it.
[seems like mentalizing…]
DR. MUIR: So, you remember me introducing that kind of mentalizing idea last time or the time before?
[now that I think the patient is mentalizing, some psycho-educaiton is “safe”]
PATIENT: Yeah. I don’t know if I’m assuming that it’ll end the same way, but it’s like we had this argument before, me and my brother in the past, and nothing has changed, so. I mean, I hate to think that people are incapable of changing, but if they’re unwilling to change, then that’s that. And it’s not even like me who’s like, I’m the only one calling him out on it. Of course my parents don’t want to give him money for, like, sneakers because they’re like you have your own apartment in San Francisco and you live with your wife, you both work.
DR. MUIR: He’s an adult. Couldn’t he ask his wife for sneakers?
[validation, with humor]
PATIENT: Even his wife tells my mom and dad, like, don’t give Eric money for sneakers. Like he thinks he’s slick.
DR. MUIR: So, it’s not about the sneakers.
[validation]
PATIENT: It’s just about I think he just likes to spend money on things, honestly.
[mentalizing slipping—that “Just” word is the tip off]
DR. MUIR: Well, some people do.
[challenge, low risk in terms of it not being a very provocative one]
PATIENT: Yeah, I’m like, I buy dumb shit all the time, but it’s like I don’t…
[I interrupt as this is non-mentalizing and thus iatrogenic in the MBT model]
DR. MUIR: Now, here’s what I don’t get. Do you think he literally does not have the money for the sneakers?
[clarifying]
PATIENT: Oh, no. I know he has the money. He just doesn’t want to spend his own money because he busy other sneakers with his, like, sneaker money.
DR. MUIR: So, what’s his sneaker budget?
[this is kinda a sneaky challenge—it’s a strange question that requires thinking about numbers but for an absurd reason]
PATIENT: Honestly, probably around a thousand bucks, honestly.
DR. MUIR: In what time frame?
[trying to use focus on budgeting to cool down otherwise too hot affect]
PATIENT: I’d say every two months. Because he’s gotten into the whole business of downloading bots to buy easy sneakers on online drops.
[now, I’m genuinely surprised, so I use it to our therapeutic advantage]
DR. MUIR: So, wait, you’re going to have to explain that to me because I have a few patients who are sneakerheads, actually, but I still don’t understand how this stuff works, so if you could help me get that, that would be great.
[curious stance]
PATIENT: So basically, online sneakers, like online drops now, they have a certain day. So, say Champs or footaction.com, they’ll announce that they’re coming out with the new Yeezy or Jordan at like 10 a.m.
DR. MUIR: So it’s like the world premiere of a movie or something, like the sneakers are coming, they’re dropping, come get them, they’re going to run out.
[clarification]
PATIENT: And now people have coded these bots to instantly smash all your personal information that you wrote down, along with any card or bank account information you have.
DR. MUIR: So the program buys the sneakers.
PATIENT: Buys the sneakers for you so you don’t have to keep clicking refresh and hoping to get onto the page that’s about to be bombarded by thousands of people trying to get the same pair of sneakers.
DR. MUIR: I mean, I can see why you’d want to avoid that, but like… So, he puts you in this position, and it seems like you’ve explained to him, if I’m getting it, you don’t want to do this.
[validation]
PATIENT: I don’t know if there’s a nice way of saying, like, I don’t care as much as you think I do about sneakers. Like, he always comes to me thinking that I would be interested on his scheme and stuff, but I’m just like, I don’t care.
[“I don’t care”…sounds like a slip into pretend mode…so I intervene]
DR. MUIR: So let’s take a moment. We talked last time about that mentalizing idea, right? And how – and this seems like a thing where – remind me of what you heard from me as like what mentalizing is, and we’ll just kind of start with that.
[challenge—re-directing to something else]
PATIENT: Mentalizing is trying to – well, empathy sounds like a really funny word – well, trying to I guess understand what the person you’re talking to is about without jumping to conclusions or using your own emotions to cloud your judgment about what they could be thinking.
DR. MUIR: It’s about that and it’s about yourself, so it’s basically like doing that for both another person and for you at the same time. What’s behind what a person’s saying, what might be going on in their mind if they’re saying this. For you, what am I thinking or feeling that’s leading me to do what I do? Curiosity.
PATIENT: Right.
DR. MUIR: You know, in an interpersonal context. Yeah. So let’s use that idea and try to think from your brother’s perspective, what in the hell is going on for him that this employed, married, thousand-dollar-a-month sneaker guy is asking his brother to ask his mother to ask her secretary to go buy shoes at the Adidas store.
[re-presenting the emotional content in the context of MBT idea]
PATIENT: I can’t wrap my head around it.
[actually thinking about it, and confused, not certain…aka, progress!]
DR. MUIR: Now, I think that’s important. It’s hard for you to understand where he’s coming from, but let’s try to – I mean, you know the guy, he’s your brother. We’re not going to necessarily be right, and we don’t have to be, but what could be going on for him?
[move from self to other]
PATIENT: I don’t know. Like, financially, they seem pretty stable because they regularly go to their other friends’ weddings, be it in another state or something.
[considering the context of the other’s perspective]
DR. MUIR: That’s expensive stuff, you’re right.
[validating, nudging onward]
PATIENT: Yeah, they had just actually flown back to San Francisco. They were here for Christmas and New Year’s and stuff and my sister-in-law’s mom’s birthday.
DR. MUIR: So the financial equation doesn’t sound like it makes sense to you.
[curious]
PATIENT: Exactly. Honestly, it just sounds like he has the financial means to get these sneakers on his own. He has the time, obviously, because if he could do research on what pair of new Kevin Durant’s are dropping and stuff and where and when he can get them.
[mentalizing back!]
DR. MUIR: But for some reason, he’s not just asking mom, he’s asking you to ask mom. How did you get inserted in this relatively simple equation of, ‘mom, can I have a hundred bucks for sneakers?’
[encouraging more mentalizing with curious stance]
PATIENT: Because, I mean, off the bat, I’m pretty sure my parents at this point are like kind of – not fed up, but they expect my brother to sort of be self-sustaining. I mean, my sister has her own family, and my brother chose to move out of New York with his wife. I mean, in my opinion- of course this is my personal belief- but if you make the choice to move away from your family to a whole ‘nother state, it’s understood that you are prepared for all the financial burdens that come with that. That’s like the next step.
DR. MUIR: Or sneaker fetish.
[humorous challenge]
PATIENT: Yeah, exactly. It’s like, you should be prepared.
DR. MUIR: But that’s your thought and feeling. You think, understandably, if I’m hearing you right, that once you peace out with your wife to live across the country, you’re buying your own sneakers.
PATIENT MT: And like, he made a big deal about it and had a going-away party, bought an apartment.
DR. MUIR: Great! Bought an apartment, bought some more sneakers.
[validation]
PATIENT: Exactly.
DR. MUIR: But here’s what I’m not getting. Why are you in the middle of it?
[curious stance, encouraging more mentalizing]
PATIENT: He has this – ever since we were growing up, he’s always had this idea that I could get away with anything I want, even though that’s the complete opposite- I can’t do anything.
DR. MUIR: It does seem like when you first described your brother to me, this was someone who was kind of idealized in the family, not so much maybe as your sister. So his perception of you is someone who can kind of get away with anything, so you can kind of weasel your way into getting sneakers.
PATIENT: I live in a very hypocritical household because my mom and dad will complain about any time Eric comes home from – like he used to live in New Jersey, so him coming over would be like he’d bring laundry over to do or whatever and then drive back to Jersey. And now, since he’s visiting from California.
DR. MUIR: Can’t be doing laundry.
[validating]
PATIENT: It’s kind of like the same thing but no laundry. But every time, he announces, like oh, he’s coming home. My parents, of course, they complain, yet my mom – literally she just did this two days ago before the blizzard and everything- she went to the supermarket and bought all of his favorite foods to cook, and his flight made him arrive Friday morning while my parents were at work, so what my mom did was she woke up extra early to set up all the food on the stove so he could immediately get it right away, as soon as he got in. But this is coming from people who constantly complain about it.
DR. MUIR: So you’re seeing these actions which say we really care…
PATIENT: They don’t match the words.
[mentalizing!]
DR. MUIR: And they don’t match the words.
[restate! I am listening to you, and I prove it by saying the thing right back]
PATIENT: They don’t at all.
DR. MUIR: And so what are the feelings if the actions don’t match the words?
PATIENT: Confusion.
[this is not really a feeling…]
DR. MUIR: For you, what are they? You’re confused.
PATIENT: I’m definitely confused. Definitely, like, it used to piss me off when I was younger, but now it’s just like it’s my parents’ thing, my parents handled it.
DR. MUIR: But your parents are your parents, but like, what I’m curious about is, for you, like you see this and this is mixed messages because you’re there for the complaint and you’re there for the totally prepared extra-early morning food bonanza for your brother, which says kind of I love you.
[presenting a hypothesis for him to think about that increased the affective temperature]
PATIENT: Like, I know they love my brother, of course, like as a son. But my parents have always complained about his personality traits. Like, one of the things is he’s like super-duper arrogant. Honestly, when he talks about himself, he calls it over-confidence, but he’s kind of an arrogant asshole, like that’s just how he is. And my mom says she hates that. Meanwhile, my mom loves bragging about my brother when he’s not around to her friends and stuff like that. It’s like, “Oh, well my son’s a lawyer and he lives in San Francisco.”
DR. MUIR: Is that understandable in any way?
PATIENT: Not to me.
[concrete]
DR. MUIR: Not to you, but try to stretch a little bit. Like, you wouldn’t do that is kind of what you’re saying, if I’m hearing you, but why would your mom maybe do that?
[I think he’s still close to mentalizing, needs this nudge]
PATIENT: I mean, she’s still proud of him as like a son and all that, but of course there are things about people you love in your life that just are part of them, you know?
DR. MUIR: But it sounds like the hypocrisy here bothers you.
[validating being bothered]
PATIENT: Yeah, it does. Because again, I’m the person who mistrusts a lot of things.
DR. MUIR: Yeah, so if you hear these things, it’s like, what are they saying about me even?
[risk taken—is this your feelings? A little off-model, I could have been more curious]
PATIENT: Oh, I have a huge, huge thing about how my family talks about me.
DR. MUIR: So is the hypocrisy about your brother, is that tied into how you feel your family talks about you?
PATIENT: Oh, yeah, all the time. Because they hold me to some like weird, I don’t even want to call it a double standard, it’s like a quadruple standard.
DR. MUIR: What’s a quadruple standard? I’m not following.
[back on model for me—straight curiosity!]
PATIENT: My mom and dad know that my sister and brother tried pot, like in high school and in college, but when it came down to me being in high school and college when I tried pot, my mom immediately- this was back in like 2009-2010- she ran to the closest pharmacy, bought like one of those over-the-counter drug tests to see what else I was on. I was like, so, I was a bit skeptical. It was like, huh, it’s just pot. The test result of course when I peed in the cup and all that, after like a 30-minute wait, of course, it was just pot. And it’s just I don’t know why I was singled out like this. So I called my sister and my brother, so what did mom do to you when she found out you guys were smoking? My sister said, oh, nothing. My brother was like, oh, nothing.
DR. MUIR: And you were treated differently.
PATIENT: Yeah, I was treated immensely differently.
DR. MUIR: Did you ask your mom why she did that?
[challenge— mother’s are affectively “hot”]
PATIENT: Yeah. She didn’t have an answer. She was just like, “I was concerned about you.”
DR. MUIR: She didn’t have an answer.
[validating]
PATIENT: Yeah, she didn’t have an answer.
DR. MUIR: Maybe that’s true. So, another kind of mentalization moment…
PATIENT: But that makes it even worse because I hate when people do things without logic behind them.
DR. MUIR: Yeah, well, if you’re not sure if you trust someone if you can’t understand why….
—scene for today—