Table Of ContentMentalization-Based Group
Therapy (MBT-G)
Mentalization-
Based Group
Therapy (MBT-G)
A theoretical, clinical,
and research manual
Sigmund Karterud
1
1
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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 refer-
ences 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 fore-
most 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 mod-
ernization 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more profoundly from the (individual) psychoanalytic (outdated) concepts of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 con-
tained 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 para-
digmatic disorder for the understanding of the essence of the self and the cor-
responding 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 pow-
ers. 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 explor-
ations of group dynamics and the self (Karterud & Stone, 2003; Stone & Karter-
ud, 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
vi 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 her-
meneutic 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 devel-
oped by the world. In other words, the understanding of the world (others)
comes prior to understanding oneself.
In “Group analysis and psychodynamic group psychotherapy” (Gruppeana-
lyse 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, scat-
tered 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 individ-
ual 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 (Fon-
agy 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 implica-
tions for the practice of psychotherapy. And most important for scientific rea-
sons, the phenomena of mentalization/interpretation (hermeneutics) were now
grounded in an evolutionary frame of reference. By that, a whole new set of
PREFACE vii
approaches and experiments were subsequently applied to the study of thinking
and understanding of mental phenomena, for example, comparisons of menta-
tion among chimpanzees and children. The results have far-reaching conse-
quences 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 mentalization-
based 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 ana-
lytic 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” (Man-
ual for mentaliseringsbasert terapi (MBT) og MBT vurderingsskala. Versjon indi-
vidualterapi; Karterud & Bateman, 2010). Thereafter followed the “Manual for
psychoeducational mentalization-based group therapy” (Manual for psykoedu-
kativ 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 (MBT-
ACS), are available at different websites (e.g., <http://mentalisering.no/index.
php?page=English>). 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 Norwe-
gian 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 pur-
poses. 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.
viii PREFACE
A psychotherapy manual should specify guidelines for how to practice a par-
ticular 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 psychother-
apy. 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 mentaliz-
ing 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 psycho-
dynamic 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 ix
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 Nør-
gaard, Kraka Bjørnholm, Ann Nilsson, Kirsten Grage Rasmussen, Per Sørensen,
Fransisco Alberdi, Henning Jordet, Bjørn Philips, Anna Sten, and Niki Sund-
strøm. From the MBT program of the Bergen Clinic Foundation there are Kari
Lossius, Nina Arefjord, Fredrik Sylvester Jensen, Turi Bjelkarøy, Randi Abra-
hamsen, 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 publica-
tion 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 demon-
stration of how the MBT-G adherence and quality scale works.
This English version of the manual has been partly translated by Paul Johan-
son, 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 Bate-
man. 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
