Mentalization Based Treatment for Narcissistic Personality Disorder comorbid with Antisocial Personality Disorder
There has been increasing interest in antisocial and narcissistic personality disorder (NPD) over the past few years after decades of neglect. Narcissistic mechanisms are common in a range of personality disorders from avoidant to borderline (BPD) but are particularly pronounced in antisocial personality disorder (ASPD) and may be a factor interfering with good outcomes of treatment.
Personality functioning can be considered in terms of a propensity to lose mentalizing in interpersonal and social contexts, which in part is a result of hypersensitivity of the attachment system. But some patients deactivate the attachment system if possible and, as a result, distort their mentalizing process rather than lose it. So they may be abnormally good at certain aspects of mentalizing and as a consequence able to control their interpersonal interactions to satisfy their own wishes rather than engaging in ‘give and take’. The aim of mentalization based treatment is to increase or re-balance mentalizing capacities within social and interpersonal contexts. As a result MBT for personality disorder focuses on attachment processes and imbalances in mentalizing in terms of dimensions and modes. In this plenary session the attachment processes apparent during treatment of patients with ASPD/NPD will be outlined and a dimensional mentalizing profile discussed. Formulating narcissistic function in ASPD according to mentalizing dimensions and attachment strategies forms a rational basis for mentalizing interventions. These will be outlined and illustrated using clinical video.
Mentalisation-based Treatment (MBT) for narcissistic personality disorder (NPD) comorbid with antisocial personality disorder (ASPD): clinical dilemmas and recommendations.
In clients with antisocial personality disorder (NPD/ASPD)
1. Understand the mental processes leading to violence and other behaviours
2. Demonstrate an understanding of the mentalizing problems relevant to treatment
3. Recognise mentalizing and non-mentalizing interventions
4. Use some basic mentalizing techniques in everyday clinical work
Psych Consultant to Anna Freud National Centre for Children and Families
Visiting Professor University College London
Affiliate Professor in Psychotherapy
Copenhagen University, Denmark
The aims of the workshop
Mentalization Based Treatment for NPD/ASPD integrates cognitive and relational components of therapy and has a theoretical basis in attachment theory. MBT was developed for people with borderline personality disorder and therefore focused on mentalizing problems associated with high emotional arousal in the context of attachment relationships. Adaptation of this basic model is necessary for people with NPD/ASPD not only because their mentalizing problems differ from those found in BPD but also for a number of other descriptive reasons (Bateman, Bolton, & Fonagy, 2013). Firstly, people with NPD/ASPD are more likely to demonstrate over-control of their emotional states within well-structured, schematic attachment relationships rather than under-control in chaotic attachment relationships, which are more commonly found in people with BPD. Second, people with NPD/ASPD tend to seek relationships which are organized hierarchically with each person knowing their place whereas people with BPD aim for, but tend to struggle to reach, consensus and shared respect. Autonomy and capability and lack if need for others is given priority. Third, it is, specifically, threats to the hierarchical order of relationships or stimulation of need that lead to arousal within the attachment system (commonly dismissive) in people with NPD/ASPD; this triggers an inhibition of mentalizing. Loss of status is devastating as it potentially reveals shameful and vulnerable internal states that threaten to overwhelm, so any threat of loss of status becomes firmly rooted as a dangerous reality which has to be dealt with by physical force. Finally, in NPD/ASPD there is a reduction in ability to recognise others’ emotions which is more pervasive than being restricted to fear and sadness, so a focus in treatment on recognition of all emotions in others is essential. Fear for the self is often absent and violent impulses are uninfluenced by the emotional expressions of others, which go unrecognised. Indeed the consequences and dangers of aggression become secondary.
Key interventions for clinicians to address these problems of NPD/ASPD will be discussed.
Anthony W Bateman
Education and Appointments
Cambridge University and University College Hospital Medical School
1997 - 2000: Member of National Counselling and Psychological Therapies Clinical Guidelines Steering Group leading to – Treatment choice in Psychological Therapies and Counselling. Evidence based clinical practice Guideline. DoH.
2001 - 2002: Department of Health: Member Expert committee on treatment of personality disorder
2001 - 2014: Executive member British and Irish Group for Study of Personality Disorder
2002 - 2004: Psychotherapy Trainer Institute of Psychotherapy Hong Kong
2004 - present: Clinical supervisor De Viersprung Personality Disorder Unit, Holland
2005 - 2007: Visiting Course Organiser and Seminar Lead Continuing Education Diploma in Psychodynamic Psychotherapy City University of Hong Kong
2006 - 2008: National Institute for Clinical Excellence Member of development group for Guidelines for treatment of Borderline Personality Disorder
2006 - 2012: Chief Examiner of the Royal College of Psychiatrists
2007 - 2009: Chair Development of National Occupational Standards for Psychological Therapies – Psychodynamic Psychotherapy Working Group and Modality Working Group and Member of National Reference Group.
2007 - 2013: Member Psychotherapy Accreditation Committee Hospital Authority Hong Kong
2010 - 2013: President European Society for the Study of Personality Disorders (ESSPD)
2011 - 2013: Member National Advisory and Executive Group, Severe Mental Illness: psychological therapies. Department of Health, NHS, UK and Chair of Training Advisory Committee for Personality Disorder, Department of Health, NHS, UK
2012 - 2014: Member Department of Health IAPT-SMI Personality Disorder National Reference Group
2002/2004/2013/2016: Visiting Academic in Psychotherapy National University of Singapore.
2015 - 2017: Chair Guideline Development Group for Eating Disorders, National Collaborating Centre for Mental Health (NICE)
Consultant Psychiatrist and Psychotherapist and MBT Training Co-ordinator to Anna Freud Centre, London
Visiting Professor Psychoanalysis Unit, University College, London
Affiliate Professor of Psychotherapy, Department of Clinical Medicine at the Faculty of Health and Medical Sciences, Copenhagen University
2003 and 2007: Stanton Lecturer, McLean Hospital and Harvard Medical School Boston USA.
2008: Adam Corneel Major Teachers of Psychotherapy Lectureship, McLean Hospital and Harvard Medical School Boston USA.
2008: Scientific Paper Prize awarded by American Psychoanalytic Association for landmark studies in personality disorder.
2009: Distinguished Psychiatrist Lecture UCLA, California.
2012: Personality Disorder Research Prize British and Irish Group for Study of Personality Disorder.
2015: BPDRC: Award for “Achievement in the Field of Severe Personality Disorders".
- Randomised controlled trial of intensive out-patient treatment of borderline personality disorder. Borderline Personality Disorder Research Foundation (BPDRF). July 2003 – October 2008.
- Counselling in General Practice – moderator effects of personality disorder Wyeth Research Grant April 2003 – October 2004.
- Evaluation of new general adult community services for people with personality disorder NHS Service Delivery and Organisation R+D Programme– April 2005- March 2007 (Joint with Imperial College, London).
- Training the Trainers: training Mental Health professionals in Personality Disorder National Institute of Mental Health: London Development Centre. April 2005 – March 2007.
- Patients with Borderline Personality Disorder who have children. Haringey Teaching Primary Care Trust Service research grant April 2008-2010.
- Follow-up of borderline patients treated in out-patient randomised trial of mentalization based treatment. Anna Freud Centre Research Grant September 2009-2011.
- A Randomized Controlled Triial of Mentalization Therapy against Specialist Supportive Clinical Management in patients with both Eating Disorders and symptoms of Borderline Personality Disorder - TROUBLED Study October 2009-2012.
- Lewis Foundation. FACTS – Families and Carers Treatment Support. Development Grant 2012-2013.
- A Randomized Controlled Trial of a Mentalization-Based Intervention (MBT-FACTS) for Families of People with Borderline Personality Disorder. David & Ruth Lewis Family Charitable Trust (2013-2016).
- Mentalizing for Offending Adult Males (MOAM): A national community based randomised controlled trial to evaluate mentalization based treatment for antisocial personality disorder. National Institute for Health Research (current)