Episode 274: Mentalization-Based Therapy (MBT) Explained: Practical Techniques to Improve Clinical Outcomes in Borderline Personality Disorder, OCD & Narcissism
This episode is awaiting CME Approval
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Introduction: Why Mentalization-Based Therapy Matters (00:00)
Puder:
Welcome back to the podcast. I am joined by Robert Drozek. He is the clinical director of Mentalization-Based Treatment [MBT] Clinic at McLean Hospital in Massachusetts. He is a teaching associate at the Department of Psychiatry at Harvard Medical School and specializes in borderline personality disorder, narcissistic personality disorder and PTSD. He is the author of a new book, Mentalization: Utilizing Reflection to Heal from Borderline Personality Disorder (2025). This is the first book for the general public about mentalization-based treatment.
Drozek:
Well, first of all, David, I am really happy to be back. I think you were the first podcast I was ever on [see episode 227] when we were releasing the narcissism book [Mentalization-Based Treatment for Pathological Narcissism: A Practical Guide (Drozek et al., 2023)] a few years ago . And I just love that conversation. And so I'm excited to talk with you again. So I'm really happy to be here. And where to start.
Puder:
We want to, like I'm mentalizing the audience, right? Which means, I am imagining what they're feeling, thinking, desiring. They want practical knowledge that helps them be better clinicians. And so, how are you mentalizing the audience? Maybe we can start there.
What Is Mentalization? A Simple Definition for Clinicians (01:16)
Drozek:
Well, it's a good question. I guess my first question is, do you feel like your audience knows what mentalizing is even, in the first place, you would say?
Puder:
Yes, maybe. I think it's a good place to start and there's actually some “code words” that I feel like are used in the sort of subgenre, mentalization-based therapy. So maybe we could start by defining it.
Drozek:
Oh, cool. Yes. Well, basically, for those, I think this podcast, I think more than any other, you really spend a lot of time thinking about mentalizing and reflective function (RF) and really have [been], in my opinion, like leaders in the field to talk about that. So for those of you who might be newer, or need a refresher, mentalizing is the ability to read, access, and reflect on mental states in ourselves and other people. And really, mental states, it's like all the invisible stuff of the mind. So thoughts, emotions, desires, attitudes, values. So that is the core aim of MBT, which is to sort of stimulate reflection in the areas where patients tend to really struggle. So for BPD (borderline personality disorder), we would be trying to really help folks with their insecure attachment, with their difficulties with self-injury, with maybe their anger issues. If we're helping folks with narcissism, we would want to aim mentalizing at their conditional sense of self-worth, maybe an elevated sense of self or a dismissiveness of other people's perspective. So depending on what the problem area is, the shape the mentalizing takes is different, but the through line is that it's reflecting on what's going on inside of ourselves and other people.
Puder:
Okay. Yeah. So it's different from empathy. Because, how would you define empathy compared to this?
Drozek:
Well, I would suggest empathy is like a species of mentalizing. Because there are different components of it. Like, so basically, one way I like to define it, it's like reflect and connect. You know, we've got to get patients considering their minds and the minds of others, but not just thinking about them. We actually have to help our patients connect with their own emotions and connect with the emotions of others. And so empathy is really not just reading others, but caring about others. And that is a part of mentalizing, but it's like a sub part of it, basically.
Puder:
Okay. So like, let's say you have someone who's newly in a relationship. They're over the moon. They're having a great time. They're in the honeymoon phase of the relationship. They're just overjoyed. All positive. And then they notice a slight withdrawal of the other person and this triggers intense abandonment.
Drozek:
Yes.
"What, Why, and How" Model of Mentalizing (04:39)
Puder:
What do you think? Now they feel this, maybe there's some truth, maybe there is some withdrawal. But then how can someone, let's say, with more of an insecure attachment style, add into that their own fears, their own stuff. Right? Because mentalizing would be accurately seeing reality, accurately seeing what's going on in the other person.
Drozek:
Yes.
Puder:
So it's like they're adding in some extra stuff there.
Drozek:
Yes. The idea that almost their own insecurities are leading them to interpret the other as potentially as, “This person's pulling away from me.” Where, really, it could be a range of other different things that could be happening. Is that the idea?
Puder:
Sure. Or maybe they are pulling away a little bit, but it feels so awful.
Drozek:
Definitely. It feels so horrible.
Puder:
It feels catastrophic to them.
Drozek:
Yes. If you're a therapist, how do you show your patients how to mentalize in scenarios like the one you've just described? And essentially, one way to spell it out in a really clear, step-by-step fashion, is the what, the why, and the how. So I'll say it again, because it's so important. The what, the why, and the how. So when we're mentalizing, the first step is we've actually got to put words on what's going on for us and what's going on for others. [Toolkit: Considering What People Are Feeling; Toolkit: Considering What People Are Feeling-2]
Drozek:
And for this patient, the hypothetical patient, you're describing, you know, we would want to be understanding… “What is this bringing up for you? What are you feeling?” Right? And obviously, we'd ask any patient that, and we would want to really be considering the partner's mental states. How do you interpret, what's your sense of what could be going on for that person? And then, also broaden it. Because often with these patients, there are what we call “biases in mentalizing.” There's been research on this in BPD, that neutral facial expressions will be read as negative. Right? So in those moments, we're going to try to do, clinically, to try to expand the array of mental states we're considering in the other. [Expand the Emotional Picture Mentalizing Toolkit]
Drozek:
That's like base level mentalizing. The next level is what we call “why” mentalizing. What could this be about for the partner or the new person? Could it be about something going on in their life? Could it be something that you actually are doing to potentially push them away?
Drozek:
You see, that's higher level mentalizing, not just putting words on feelings, but broadening it out a little bit.
Puder:
Okay.
Drozek:
And that's sort of the second tier of mentalizing. And then, really where the money is, is looking at disruptions in how the person, really, the process that they're engaging in to read others' mental states. And I think right now, that really gets at the heart of what you're saying, which is, for a lot of folks with BPD and insecure attachment, there are problems with certainty. You know, “I know he's pulling away from me, or she's pulling away, or they're pulling away. I know that without this relationship, I'm not going to be okay. I need this relationship in order to be okay.” Something like that. So then, the highest level of mentalizing is process mentalizing, where really what we're trying to do is help patients see how they can get a little stuck in their perspectives and hopefully help them to be more flexible in their way of seeing or interpreting relationships in themselves.
Why Certainty Keeps Patients Stuck (08:28)
Puder:
Okay. So, this is good. So think about the why. Okay. Help me think through the why on this specific scenario. So like, “Why are they pulling away?” Is that it?
Drozek:
Yes. Yes.
Puder:
And, “Well, so Bob, they're pulling away because they don't want to be with me anymore. They figured out I'm defective. And I'm sure about that.”
Drozek:
Okay.
Puder:
It feels a hundred percent true.
Drozek:
Okay. Okay.
Puder:
So, what I'm doing right now, by the way, it's just a pullback from this. I'm not thinking I'm going to go through a role play with you. I'm thinking what we want to really talk about is that we're seeing this in this session, we're seeing this air of mentalizing. For us, as the outsider, we're looking at this and we say to ourselves, “Well, there's this certainty…..”
Drozek:
Yes.
Puder:
“...that this person has, and it's creating this awful, awful feeling inside of them, of abandonment. Maybe they're suicidal now. Maybe they're going to act erratic. Maybe they're going to do something in the relationship that is going to create a real conflict.”
Drozek:
Yes.
Puder:
Okay. And so, the why is so certain. The why that they perceive as certain.
Drozek:
Definitely. They know the reason, they know what's going on.
Puder:
Right?
Drozek:
Okay. Well, so this is essentially the clinical question here, which is worth thinking about for your listeners: In the moment that we're encountering that certainty in the mind of the patient, what can we do about it? That's one question. What I'm trying to do in this new model of mentalizing is, let's say, outside the heat of the moment, how would we teach patients to target and address their own certainty? So they're different questions clinically, and a lot of our work in MBT thus far has been teaching clinicians how to address it when it arises in the session. And essentially, there's this other technical option. Right? Which is how, for our patients who struggle with that certainty outside the heat of the moment, how do we actually teach them to look at their certainty? So it's a choice point, if that makes sense.
Puder:
Right. Yes. It's like in the moment it's hot. So you don't always strike the iron when it's hot.
Drozek:
Totally. Yes. Yes. Strike when the iron is cold.
Four MBT Techniques for Challenging Rigid Thinking (10:57)
Puder:
Okay. Yes. So in the moment of hotness, for a patient, they may have a different set of things that may help them cool down a little bit and to create some ability to then reflect.
Drozek:
Yes.
Puder:
So in that moment, they've lost their ability to mentalize and their reflective function would be low. It would, there would be assumptions. There would be this they’re mind reading, they’re in more of a CBT model. Right? They're all or nothing thinking. So then, what do you do in the moment? What's the tendency of an MBT clinician?
Drozek:
Okay. Do in the moment? Well, so the first step is to invite the patient to reflect on how they get there. So we don't challenge it in the moment. That's always the first step. So you [say], “It's really clear to you that your partner's pulling away from you. What clues you into that?” Don't challenge it. Ask them to start making their case.
Puder:
Okay.
Drozek:
And the patient may say, “Well, he hasn't responded to my text in three hours.” Or, “We haven't been having sex as frequently as we had when the relationship started,” or something like that. Right? And then you're just, as a therapist, you're just trying to gather. And then you empathically summarize all the case. Right? “He hasn't responded to your texts. You're not having sex as frequently. He hasn't yet invited you to visit his parents or get to meet his parents. So that feels for you, that really shows that he is pulling away from you.” And so that's the first step. The second step, according to MBT, is to examine or explore the impact of the certainty. So then you ask the patient, “So for you to have this sense that he is pulling away from you, what does that do to you?”
Drozek:
And then the patient will share about their feelings and basically all the emotional consequences of feeling quite certain of this thing. And then, once we get there, that's all within the patient's viewpoint, now we've got to start working towards seeing things more broadly, from a broader perspective. And the best, this is what Anthony Bateman, who I know has been on this podcast before [see episode 206], will say, “You got to find, in the armor, you got to find some area of flexibility or nuance within the patient's perspective.” You know? And it may be something, because actually, when I think when you were laying this out, I just say, “I just want to check in. You said earlier that it, quote, ‘Seems like he's pulling away’ from you. What were you getting at there?”
Puder:
Okay, interesting. You caught that. Right? It's maybe not how it was felt by the patient, but I added that as someone who's mentalizing the patient's experience. But for the patient themself, he is pulling away.
Drozek:
It's true. But when patients talk about it, and as you ask them these questions, what's the case? What clues you in? How does this impact you? You will hear, and often if you're listening, you will hear something that will just be slightly more multifaceted or nuanced, slightly more flexible.
Puder:
Okay. You're noticing a higher, the moment of higher reflectiveness. You're noticing this chink in the armor. So to speak.
Drozek:
Yes. And so then, but then when you do that, when you find it, the job there is to open it up. Don't make your case. I'll say, “You said, ‘seems.’ Can you say more about what led you to say ‘seems’?” And then just have them open it up. So it's a cool technique. It's not CBT. It's not like “try to argue against your own perspective or try to revise it.” It's that we've got this pathway of certainty, now let's open up this other pathway right alongside it.
Drozek:
So that's step three. Okay. So we have: examine the case, examine the impact, explore nuance from within the patient's viewpoint, and then the final step of how we treat..and then we're calling a certainty, in MBT, the technical language is quote, “psychic equivalence mode.” Like, basically, because I think it, it makes it true. So the final step in treating psychic equivalence or certainty in MBT is to share our own perspective. And this is something that I think is really important because, especially for therapists who are a little more exploratory in nature or they are taught to be very client centered and be a little more validating of what patients are bringing, a lot of times therapists will not actually share their view in MBT because it's about two minds in the room. We have to share our view at the end of the sequence. So in this case, for me, it could be me saying something like, my different view might be, “As you share about this, I hear all your points and it's not quite clear to me yet how much of this is that he's pulling away versus could this be somewhat of how the relationship is just unfolding. Because in my experience with relationships, they don't tend to be at the same level of intensity, like all throughout. What do you think about that?”
Drozek:
You share your mind and ask the patient to consider your mind. There might even be a side move. You do though, too. You may end up saying something like, “You know, this makes me think a little bit about the last relationship and you had a similar concern.” Right? That may be the move. We don't actually take issue with it, or we just broaden it a little bit and then have the patients consider our mind. So those four steps are the steps that clinicians can engage in or use in the moment to try to address patients’ rigid thinking. [Mentalizing Your Certainty Toolkit; Mentalizing Additional Perspectives Toolkit; Mentalizing Additional Perspectives Toolkit-2; Mentalizing a Broader Perspective Toolkit]
Puder:
Okay. Yes. So it's like you're taking your own reflective stance and then asking them to reflect on your reflective stance.
Drozek:
Exactly. Yes. Definitely. But do it at the end, not the beginning. Because if you do it too early, patients will feel like we're invalidating them.
Puder:
Okay.
Drozek:
So always start within the patient's viewpoint. They need to feel seen by us. They need to feel like we're really getting what it's like to be them. And at the end, they've got to actually get a sense of what it's like to be us. You know, we include that at the end of the sequence, but we, you got to have both for it to be MBT.
Understanding Pretend Mode in Mentalization-Based Therapy (18:30)
Puder:
Yes. So, okay. How would you know? We've talked a little bit about psychic equivalences. Tell me about how “pretend mode” might apply in this scenario.
Drozek:
Yes, definitely. Well, in this scenario, this does feel more like psychic equivalences, but we could talk if you want.
Puder:
So it's like the person is talking about something detached, not really emotionally congruent. They're emotionally decoupled from the real experience. So it's like, “Oh, what's happening is my insecure attachment and my…”; and they're using these big words to describe, maybe that they don't really feel resonating, they're not resonating with these big words.
Drozek:
Yes, definitely.
Puder:
So it's like, or how would you define how this could be taking place as…?
Drozek:
Well, so “pretend mode” is essentially disconnection from authentic mental states in self and other. And there's really, I would say, like three types of “pretend mode”. There's disconnection from self, disconnection from others (In other words, like problems in empathy), or disconnection from reality, which is something that we see a lot in narcissism. So there are these three kinds of forms of “pretend mode”. So this is one of the hardest things, in my opinion, to treat in therapy. So that was one of the things I was most excited about in terms of actually, because essentially the broad technique we use in MBT for “pretend mode” is challenge. It's getting more in reality asking factual, clarifying questions and ultimately bringing in our mind in a way that disrupts the patient’s.
How do we help patients do this themselves? A little challenging, right? Or maybe because there's no therapist. If you don't have a therapist to challenge you, how do you then get more connected? So basically, one sort of, I think this is sort of what, how do we teach patients to get connected to themselves is essentially the question. And the first step is helping them identify, essentially, what is the emotion they need to connect to. Like, you can't access it if you don't know what might be there.
Puder:
It's definitely not anger, because I would never feel anger.
Drozek:
Okay. Well, see, this is the thing I would propose, David, you're playing the patient there. That's certainty. Right? So I wouldn't be treating…you know what I mean?
Puder:
But I think what I'm hinting at is that, for good reason, people may not want to say that they would feel various emotions.
Drozek:
Definitely. Definitely. And if that's the case, then it's a problem of certainty. You got to treat the certainty first.
Puder:
Okay.
Drozek:
Because there's often self-judgments around what emotions they're feeling and they can't find them because they make them feel bad about themselves.
Puder:
Yes. Self-judgment. Okay. So the self-judgment keeps people from being congruent or seeing what they feel. So then getting back into “pretend mode," so they might pretend in a way to be disconnected from what they're really feeling.
Drozek:
Yes. It's a good point. That's one of the challenges of the term “pretend mode," is that literally the word pretend is in it. But in general, the way that it's used is, it's just that often people when they're in “pretend mode," they don't know what they're feeling. They really are just, they're really just disconnected or they know, but they're just not feeling it.
Helping Patients Reconnect with Difficult Emotions (22:28)
Drozek:
So, an example, basically what their proposal is: we can treat it in session, but what I'm proposing now is that in addition to that, we've actually got to help patients access emotions outside of sessions as well and teach them how to do that. So for example, if you think of a patient who really struggles to feel a certain feeling, can you either, hypothetically, or a real patient you have, what's a specific emotion that you think that you think one of your patients struggles with to find?
Puder:
Let's go with the anger.
Drozek:
Perfect.
Puder:
So let's put it to a clinician. So let's imagine a clinician coming to you that struggles with the thought that they could ever be angry.
Drozek:
Yes. Love it.
Drozek:
Okay. That's very common. Very, very common. You know, anger can feel very dangerous to people. And they can struggle to find it. So there's the one pathway to treat it, is the certainty stuff. The other pathway is to just really try to help them connect more with the anger. So basically just to go through if you wanted to work with, and if you're going to help a patient with that, it can't just be in the moment. Like, you're going to need to, I would propose there's going to need to be work done outside of session. You need to give some mentalizing assignments, so to speak. [Getting Connected to Yourself Toolkit]
Drozek:
They're trying to, they're putting the emotion they're trying to find and access. So they would write down “anger.” The first step is to actually try to essentially imagine what it would look like. What would it look like for me to access this anger? Try to really envision the accessing of it. You know, have them imagine, “I could see myself doing this.” So I actually spelling it out. The other is what we call “invoking an emotional memory,” and they've got to do this on their own. You can help them with this. But say, “I'm just curious, is there a time in your life where you can remember actually feeling angry?”
Drozek:
“Tell me about it.” And then you invite them into that. The other is, and this is something that ACT (acceptance and commitment therapy) [see episode 103] does a little bit too, but you sort of imagine somebody being with you where if they were relating to you in a certain way, it would be easier to find the emotion. So, “Is there anybody in your life that you find it easier to access that anger with?”
Puder:
Okay.
Drozek:
And so you then instruct patients, “I want you to write about that. Write about what it would look like for you to be with that person and to feel or access that feeling.” Additional steps…self-validation. A lot of times, cutting to your point that you were making, patients who struggle to feel a certain thing will have judgments of themselves for feeling it. They actually write out: “It's reasonable that I would feel this way because….” And then finally, the last step is just having them close their eyes to really try to inhabit the emotion in question. So this is an example of what it looks like to teach the skill of treating “pretend mode.” And my experience is, as patients are practicing this more and more, over time they get better at feeling the feeling.
Puder:
Yes. So, it seems like this is like intellectualization, isolation of affect, rationalization, denying the emotional reality. Sometimes there's some somatization that takes place, like distancing from the actual motion. I like how you're pulling together these different types of lines of “reflecting upon.” So these are reflecting upon, writing upon, both of a time where you were angry, and a time where you were with a person you're better able to connect with in the midst of anger, or the person you feel the safest with. Right?
Drozek:
Exactly. Yes.
Intellectualization vs. Emotional Awareness (27:08)
Puder:
I was thinking about how, so I've been teaching cohorts and we will do writing assignments, and some people will heavily intellectualize early on. They have maybe the language of a psychotherapist. Right? They have big words that they can pull upon. And they'll throw in all those big words together. And it distances themself from….
Drozek:
Definitely.
Puder:
What they're actually feeling. And in the process of leading these groups, one thing I've realized is that it's almost like you have to start with trying to get to a lower reflective function writing.
Drozek:
Nice. Oh, say more. I love that.
Puder:
So the lower, because people think that they have to articulate in a certain way to be accepted. Right? They're imagining me wanting a certain, you know, these more psychodynamic language or more, they want to be appearing, articulate, or all put together. And so they write in a certain way that's distancing themself from their own internal experience.
Drozek:
Definitely. Yes. It's a huge thing. Previous to that, what I start by saying is that we need to actually [do is what I call] “stop dissociative behaviors.” Literally stop doing actions that disconnect you from yourself. Because then you're working across purposes. Right? For a lot of people, especially smart people, one of the biggest behaviors you can engage in to disconnect yourself from your emotions is talking, like talking to people. I see this in groups when somebody starts to feel something and then they start talking and they choke up, and then they start talking and they leave the emotion. So there, from an MBT perspective, we'd want to say, “I just want you to pause, don't say anything.”
Puder:
Yes.
Drozek:
“What were you just feeling?” And you're right. The more words, the less feeling, and you've got to start it more basic or else the person's going to lose the emotion.
Puder:
It's right. More words, especially, you know, like the doctors and the higher, you know, professors, it's like words are a way of obfuscating away from. Right? So it's like, just because the words are articulate words doesn't mean that there isn't a heavy degree of intellectualization.
Drozek:
Definitely.
Puder:
And the more primitive stuff can seem like a lower reflective function starting point, you know?
Drozek:
Yes. It's a good point. Yes. That's why I like to say, I like to define mentalizing as “reflect and connect.” Sometimes we need more reflection, other times we need more connection. And so you're right, you're going to turn down the reflection a little bit and beef up the inhabiting. [Find Your Location on the Dimensions of Mentalizing Toolkit; Contrary Moves Mentalizing Toolkit]
Puder:
The inhabiting. Right? So I think, so I like how you are assigning people or sort of getting people to think about things like, “Okay, what is a time that you did feel angry? Talk about that.” Right? And you could get someone to do that and then they could almost distance themself in the talking about it. So that's, as a clinician, we're looking at that. Right? And we're being curious about, are they, the more they talk, are they distancing themself from it?
Drozek:
Definitely.
Puder:
And then in the midst of, you know, finding that person that they're most able to share that emotion with, which, it could be you, it could be the therapist. Right? Like, potentially long term.
Drozek:
Oh, that's true.
Puder:
You know, like this, you know, how many times have you heard from a patient, “I feel safe being angry or feeling something that I don't feel safe with other people.”
Drozek:
So true. Definitely.
Puder:
So, okay, so we're talking about how do we overcome the intellectualization, the isolation of affect? How do we get back to the real emotion without hypermentalizing, right? Which is another thing you guys talk about.
Drozek:
Yes.
Puder:
This distancing yourself with a lot of words overanalytical, hyperactive RF.
Drozek:
Definitely.
Puder:
And I think that's where it's tricky. So when I talk about writing a lower reflective function, it's like getting more in touch with the raw feeling, I think. And then, from there, it's like, “Okay, why am I feeling this raw? The rawness of this?”
Drozek:
Well, this is a good question. So basically, “why” questions in general in MBT, we don't ask explicit why questions for a couple of reasons. One is exactly what you're saying, when we ask why that pulls more cognitive. Right? So in general, we're not going to ask why, we are probably going to be curious about where it comes from. But if the person is more disconnected, we would not want to be like, “Where is this coming from?” We just want to say, “I just want you to pause, try to find, tell me what are you feeling right now?” We want “what” questions when the person is more disconnected, and then if they start talking, “Well, I think what's going on for me is I'm….” “No, no, no. ‘What’ is the emotion you're feeling?” Like you almost got to get them to stop talking and just focus on what's happening for them in the moment. Or can you just put words on what you're wanting right now: “Well, I think what's important to me is that I really get better.” “No, no, no. I'm saying, right now, in your interaction with me. What's the wish?” So you almost have to stop the intellectualization and its tracks and reorient to present affect. If you're working on it in the session, we would have to be very active in MBT. That's what we'd be proposing.
Puder:
Okay. So, this is the interesting conundrum, because the “why” questions are the demand reflective questions in the Adult Attachment Interview (AAI) [see episodes 213, 249, and 260].
Drozek:
Okay.
Puder:
And so, this has always been a puzzle, but I think we can make sense of what's going on here. Right?
Drozek:
Right.
Puder:
So in the Adult Attachment Interview, when you're trying to gauge a reflectiveness, you're asking a why question. “Well, why do you think your parents behaved the way they did? Why do you think you felt that way?” Which, and interestingly, when they looked at transference-focused therapy (TFP), which is the therapy where they've looked at reflectiveness before and after [see episodes 234 and 239].
Puder:
Which is, it's a funny research competition between you guys and transference-focused therapists, because they used your own early research to show that their research was superior to, not to your research, but to the other, you know, things like dialectal behavioral therapy (DBT) and such. Right?
Drozek:
Right. Yes. Yes.
Puder:
So they were looking and there's more why questions in their therapy profile.
Drozek:
Oh, in TFP-specifically?
Puder:
Yes. There's more demand questions. Something like twice as much in this one study they did where they were looking at transcripts.
Drozek:
Okay.
Puder:
So, but I remember the words of my mentor, Dr. Tarr [see episode 233], and he was like, “Be careful with why questions, because it can induce shame, because a lot of times people don't know why.”
Drozek:
Exactly.
Puder:
And what I found with clinicians, in asking the why questions, is sometimes it can induce shame because they may not know why. Right?
Drozek:
Exactly. Yes. Definitely. And also, I would propose that one of the challenges here is that often when we're asking why questions that presume that the “why” matters.
Puder:
Okay. Okay. But going back to this initial example of this person that felt abandoned by their partner.
Puder:
Okay. If you were to ask them early, “Well, why did this happen?” Right? They would give a low reflective answer. “Well, obviously with a hundred percent certainty they're rejecting me, they're tired of me, they're they've lost interest in me.” Right? Whereas, if you did all these steps that you gave me and you ask that why question again then they would say, “Well, at first I felt like I was a hundred percent sure that they had abandoned me.”
Drozek:
Yes, yes.
Puder:
“But now, after talking with you, I'm realizing that this is this pattern that I've been having throughout my life where I will jump to certainty that this person has rejected me maybe before they fully have. And with that certainty, I'll act in a way that maybe pushes them away.”
Drozek:
Love it. Yeah.
Puder:
“But what I'm realizing is that it's because I've had this deeper longing for this type of love, and I'm just so hungry for it, because I didn't get this maybe in a stable way.”
Drozek:
Yeah.
Puder:
Okay, so maybe, I don't know, do you see what I’m talking about?
Drozek:
You're making the point that if we target the certainty and essentially what we call “process mentalizing,” that patients will then be able to reflect on where this is coming from in a more flexible, nuanced way, which is definitely MBT's argument. Essentially, stimulate a process of reflection and then patients are going to be in a spot where they can see things from a variety of perspectives. We need to give patients more resources to understand where all these things are coming from. And so, part of it is if people are trying to…oh, let's say they know…Okay, so in this case they feel clear that…what's a mental state that they think is going on in their partner…
Drozek:
It's like, “The partner's pulling away from me, I guess.” So the question would be, “Alright, so let's presume that there's some way in which your partner is not wanting to engage with you as much.” That's a mental state, right? Then there are basically arguably three things that could be causing that something in the partner's life, some other emotions the partner might be feeling, or behaviors that the partner or the patient are engaging in. So essentially, situations, emotions, behaviors. So that, and it's very, very common for people with BPD to not know why they're feeling what they're feeling or why others are feeling what they're feeling. Alright, “Think about it. What other situations are going on in your partner's life that could be affecting their wish to engage with you? Consider that. What other emotions could be actually happening in the partner that could be impacting this wish?”
Drozek:
And then finally, “I'm just curious, is there anything you've been doing that has been impacting your partner's level of interest in connecting with you?” “Well, I was critical of him last week.” “Okay. Tell me more.” So the idea is if we can sort of, there's a whole structure to do this that patients can do on their own, where they can basically try to see things more broadly. And that would be the hope, that if they are able to consider situations, emotions, and behaviors that actually can broaden out the reflection. But we got to give them some education about the ways to do it. Because a lot of times in therapy, to your point, patients don't know how to do it yet. [Stop and Rewind Mentalizing Toolkit; From Behaviors to Feelings Mentalizing Toolkit; From Feelings to Behavior Mentalizing Toolkit]
Puder:
I think we're sort of watching, as well, for the second portion. Right? Are they starting to over intellectualize? Are they isolating away from their affect? But I love those steps. I think that is great. I think that maybe the pet peeve of modern therapy is that instead the therapist goes bad on the partner.
Drozek:
Oh, okay. Wait, sorry, what do you mean how…?
Puder:
I mean, this guy is pulling, he is gaslighting you. He….
Drozek:
Oh, yes, yes. I get it. I get it.
Puder:
He's stonewalling you, is what's really going on. He's love bombed you and now he's withdrawn. Right? And that withdrawal is part of the game that he's playing.
Drozek:
Oh man. Yeah.
Puder:
Go ahead.
Drozek:
No, I just totally hear that point. Like, you're right. Therapists can almost align with the patient's certainty and then get what we, at MBT, we call “teleological,” that we're like, the solution is leaving these losers. And sometimes that's absolutely right. Like obviously in situations of abuse or real maltreatment, we do need to not be in relationships with those people and a more reflective or mentalizing therapy would want to be trying to see it from a broader perspective. “What more is going on in you? What more is going on in the other?” And hopefully, not just arrive at a concrete behavioral solution. But I totally agree with you. This is a thing in the therapy world.
Puder:
Well, it could be. It could be like a lens. Right? A pop culture lens that could be overly placed on the situation. Right? And then once you have it, it does increase certainty in a way. Right?
Drozek:
Oh, yeah.
Puder:
And I think this is what sometimes friends will do for their friends. Right? Totally. They'll go bad on the partner to allow some sort of psychological escape. Right? So yeah, it can be helpful in the moment to psychologically stabilize someone by making the other person all bad. Right? But it can be harder. The harder work is to increase the uncertainty to allow for accurate understanding of the self and the other.
Drozek:
Definitely. Absolutely. And that's the good news. In my opinion, a lot of patients, well, a lot of times when patients are caught in certainty, what they go back to is, “Well, sure I'm certain, but I'm right.” And that's the case. “But I'm right. I'm right to be certain.” And then we also have to dodge that a little. It's like, “I'm not denying that you do have a point. I see the point, but I'm wondering, could we also look at what's leading you to feel so certain, as well as other ways to see it too? Would you be up for that?” And my experience is if we do that, things tend to go in the right direction. Problems happen in treatment when we just either ignore or align with patient certainty. But if they're up for trying on multiple perspectives, and that's what I'm trying to do as a clinician, things tend to move the way that they're supposed to move.
OCD, Reassurance Seeking, and the Quest for Certainty (42:54)
Puder:
What do you think about OCD? It is a big disease of uncertainty.
Drozek:
Oh, yes.
Puder:
You know, so it's a quest for certainty.
Drozek:
Yes.
Puder:
So OCD is like the doubting disease. The most simplest is, “I think my hands are dirty. I think they're contaminated.” And then, to create certainty, “I'm gonna go wash my hands.”
Puder:
Then they're clean. Okay. And then 10 minutes later, “I think my hands are dirty,” and so they do it again. Right? So then they're doing this quest for certainty over and over again.
Drozek:
Definitely.
Puder:
And then, that is also the case in some of these more anxious attached folks, where it's like, “I'm feeling anxious about the relationship. I need a quest for certainty. I need reassurance.” So the compulsion is to then seek it through a different, maybe, reassurance. Right? Reassurance is a form of compulsion.
Drozek:
Well, I like what you're doing. Because in some ways, just by the nature of your questions, you have begun to cover all of our nonmentalizing modes. So, in MBT, we essentially say there are three non- mentalizing modes: certainty or psychic equivalences, disconnection or pretend, and then, the last one, which I think is implicit in your question, is what's called “teleological mode” or an excessive focus on what's visible. And behaviors are visible. Right? So this idea that if I experience uncertainty, I need to take this action, that's the heart of OCD or any other sort of compulsive, checking, interpersonal process as well. So in MBT, I mean, I do tons of that work with patients, like I do exposure-based work using exposure and response prevention (ERP) for OCD [see episodes 119, 126, 228, and 248]. But if we want to see it through a mentalizing lens, “It's certain that in order to avoid this feeling, I need to take this action.”
Drozek:
And Peter Fonagy, I don't think he's written this, but it's a very simple line, but Peter Fonagy, when I was first learning MBT, he said something very simple that I'll never forget. He said, “When somebody is not mentalizing, you need to stop it.” Which is so obvious, but checking, asking those questions, that's got to stop. And so a lot of times in the treatment of BPD, all those behaviors that patients engage in kick up more dust or cause more trouble in their life. Any effective treatment needs to organize itself around that, I would propose. So if it's asking constantly, “How do you feel about me?” If I'm in a relationship with you, that's going to have to be a treatment target. And, we would work on helping patients not do that by mentalizing rather than acting. So I would say any treatment is going to have a version of what you're describing. And, we need to help patients not engage in those behaviors.
Puder:
So “teleological mode.” Okay, we’ve got to make this more concretely understood. We need to make this like completely observable. Right?
Drozek:
All right. Good.
Puder:
So that only the action counts. No, that's a joke. So the “teleological mode,” it's like if the patient that I had brought up before said, “You know, I want you to cancel. If you really cared about me, you would cancel your fun adventure with your guy friends and stay with me tonight.”
Drozek:
Wait, wait, stay with you tonight? Wait, what do you mean?
Puder:
Like, me not leaving town is the point. Not leave town with your guy friends.
Drozek:
Okay. Good. All right. So basically you caring equals you staying; and then if you go, then that means you don't care.
Puder:
Yes.
Drozek:
Okay. Perfect.
Puder:
Is that “teleological mode”?
Drozek:
That's a beautiful description. Yes. And so if you want, I can go through, because this is what, another thing, is that when patients are in “teleological mode,” how do we teach them to treat those tendencies in themselves? Essentially, the first step is. Whenever somebody's in a teleological state, there's an equation, they're linking some outside thing to some inside thing. So in your case, the teleological equation is either, there are two options. One, “you care” equals you don't go on the trip with your friends. [The Teleological Equation Toolkit; Mentalizing the Teleology Toolkit; Challenging the Teleology Toolkit; The More than Meets the Eye Toolkit]
Drozek:
The other equation is if you go, that means you don't care. Right? So basically, what I'm doing with patients now is, “What are your teleological equations?” and then work, “What would it look like to work on that?” And the early part of it follows the similar steps that I mentioned earlier, which is “What's your case for that connection? That the therapist, David, going means he doesn't care? How does it impact you to see it that way?” Right? Those are the early two steps. The next step is trying to envision things more broadly. So let me just make it very concrete for your listeners. The first step is, “So can you imagine, just take a minute and consider this possibility that essentially David cares about you, but still goes on the trip.”
Drozek:
“Can you just picture that possible world?” “Well, I know that.” And I said, “No, I don't want you to just say, you know. Take a minute and just picture him caring about you while he's on the trip.” And so, people will write this out. They'll actually write it out, “Okay, I can see David on this trip, and I can imagine that even though I'm not the most important thing to him, that he still does value me as a person.” Okay. That's one way to treat it. And it's really pretty cool that patients start to do that on their own. Things start to get a little more flexible, but we're not done yet. “What about, now I'd like you to imagine—this is going to sound really aggressive, what I'm about to say, but try it on for size—“I would also like you to envision me staying here, not going on the trip with my friends, but not caring about you.”
Puder:
Okay.
Drozek:
And then I can imagine that, “Okay, I'm going to picture it. You stay, but you really don't care about me. It's just about the paycheck. It's just that you know, whatever, don't want to get into a fight with me.” Okay. So then, you're basically, what you're doing is, you're taking issue with both sides of that equation, David and patients themselves. And then you envision it. Okay. ”So imagine all the feelings David could have on that trip with his friends.” You know, just broaden it out. “He could care. He could not care. He could want to spend time with his friends. He could want to maintain professional boundaries.” It actually is letting patients, not just therapists doing this for patients, but patients starting to do that for themselves and to start to challenge their own teleology, if that makes sense.
Puder:
Okay. So you, you're having them challenge both sides of this thing.
Drozek:
Exactly. Yes. Try it out. It actually is really Anthony's genius. It really works in a cool way.
Puder:
Okay, so it's because in the certainty, you're challenging both sides of the certainty. “I do think if I imagined him home, not caring about me because he's upset at me because secretly he knew. Now he's really upset at me. Now he's really pulling away because he gave up his time with his guy friends, so he's upset.”
Drozek:
Oh, I see. Okay. Yeah. So that he resents you. For your point, is that he could be resentful of you because he didn't go on this trip.
Puder:
Yes.
Drozek:
Okay. But, “I want to propose another possibility. Just imagine him not going with these friends. Can you picture him caring about you? Just take a minute and really see that.”
Puder:
Yes.
Drozek:
Okay.
Puder:
I'm thinking like, so you're trying to get them to imagine that he could go with his friends and also care about me.
Drozek:
Exactly. Yes.
Puder:
Okay.
Drozek:
And he could stay home and not care about you. And we do the same with this version. It's such an elegant set of interventions, but it also works with ourselves. So, for example, let's say you have a patient who is feeling like all of their worth derives from having a specific type of job. And that if they don't have that job that's successful enough, then they're bad.
Drozek:
“Well, I want you to do the teleological equation toolkit and see what's the equation here?” And they'll say, “Okay, it's that my worth depends on me having this job. My worth equals having the job.” “Okay, great. So what's the case for that? How does that impact you?” But then getting to the intervention point we're discussing, “I want you to imagine, can you imagine having this job and still feeling bad about yourself?” “Of course. I always feel bad about myself.” “Interesting.”
Puder:
Okay.
Drozek:
“Okay. Can you also imagine not getting the job in a world in which you could still feel like you had value? Can you just even picture it if it's highly unrealistic?”
Puder:
Oh, okay. I'm seeing something else that you're doing here. It's like, you have this in “teleological mode,” you have this concrete, you know, like my concreteness and you're asking them to go into a pretend or playful place, I guess. “Can you imagine?” Right? “Can you picture something the opposite? Can you picture the opposite?”
Drozek:
Exactly. Yes. I like your point. That's a good point. It is like inviting imagination of these possibilities that may not be true. But mentalizing is itself imagination. Right? Because we don't see mental states.
Puder:
Yes. So you're imagining the opposite in both situations as a way to bring some looseness or flexibility.
Drozek:
Exactly. You're disrupting the equation. That's what we’ve got to do. We’ve got to help patients disrupt their own equations. And the cool thing is, when they do, everything feels less pressured. So with that patient who feels like you don't care about them when you leave and they consider it more broadly, most likely they're going to put a little less pressure on you if they really do the exercise. Similarly, the person, this a little harder, but the person who believes that all their self worth resides in this job, then if they have moments of really imagining that, “It's true. If I got the job, I would still hate myself. Because I've hated myself since I was like 16 years old.” It puts a little less pressure on getting that job. And so once we loosen the equation, everything that stems from the equation gets more flexible and open in a way.
Puder:
Okay. You said earlier you want people to stop doing the things that dissociate them.
Drozek:
Definitely.
Dissociation, Technology, and Modern Avoidance (54:52)
Puder:
One thing that jumped into my mind was like, short form video. You know how prevalent that's becoming. And how many hours we can watch that. Or, you know, binging on Netflix or video games. You know, there's all these modern ways that we dissociate into other worlds. Right? Into, you know, are they all bad? Are you saying we need to stop all of those things? Or, what are we actually talking about?
Drozek:
Thank you. Yes. It's a really, really thoughtful question. So it's not categorical. So there's no list of these dissociated behaviors in MBT. It's got to be tailored. How does the person use them? And what is their impact? So that's ultimately when you're working with a patient in MBT and sort of building the formulation. Patients will list all the behaviors that they feel compelled to engage in. Or they're going to list the behaviors that they feel like separate themselves from their emotion. And there are lists that people can choose from to arrive at that. So it's tailored to the individual. And then the question is, if you view with your own patient really get at, “Wow, it seems like you're using these things to get away from yourself.”
Drozek:
“Would you be up for working on that?” So I will tell a story about a patient that I published about in a psychoanalytic journal. So I'll go to the de-identified root of this, but I have a patient that I started seeing when he was in his early twenties, who had never been in a relationship, had tried dating women but struggled with ED (erectile dysfunction) whenever they would sort of come close to like, you know, fooling around. And he would feel humiliated by that. And so he was very isolated, didn't date, just focused on work all the time. But he spent all of his time with technological devices. You know, he was basically playing video games all the time, watching YouTube all the time. It was all just porn. It was just all screens all the time.
Drozek:
And I don't know how this happened, but I started to become concerned. It's like he was so disconnected, so wooden in his presentation. You could tell, it's like he would talk in a monotone. So I basically stated, “It really seems to me like you're using these things to not feel your feelings.” Like, “Oh yeah. Definitely. Blah, blah.” Like, “Well, would you be interested in not doing that?” And so he says, “Okay.” So he starts gradually shedding these things and he basically, we ended up, it was really hard, David. It was like he, we had to do like, he had those, I dunno what they're called, but parental locks on some of these things. So he couldn't visit certain websites and all this stuff. But what was amazing about it, is this man would just start to show affect spontaneously.
Drozek:
He just would start to feel his feelings. And he ended up basically, it turns out this is going to sound like totally out there, but this is a true story. Turns out he's gay. And he had no idea he was gay and he had no idea he was attracted to men. And through this work, he started realizing like, “Oh man, I'm not attracted to women at all.” And you know, he ended up basically starting to date. It had never worked out with women for reasons he could never quite explain. So he wouldn't ask him the why question about that because he has no idea why. Right? And now, he's in a long-term committed relationship with somebody that he's been with for five, six years. And he actually says says, “If I had not stopped using those screens, I never would've realized this about myself.” So this is not me making an argument against screens. This is me making an argument against dissociative behaviors. If our patients are engaging in these behaviors, that are separating themselves from themselves, that should be a treatment target.
Puder:
You know, it's interesting, I was reading some of the research on short form video.
Drozek:
Oh, cool. Okay.
Puder:
Like how toxic it is to the brain and when it's toxic to the brain. And the piece of the literature that I think directly connects with what you just shared is that it was the worst when people were going to it for anxiety or going to it cope. So if they were turning to this thing to help them dissociate in the midst of distress, that's when actually there was negative, the most negative impacts of it (Tang et al., 2026).
Drozek:
There we go. Yeah, you're right.
Puder:
And so this guy, you know, and people hide all sorts of things from themself. Right? And for good reason. Maybe there were good reasons why he hid that piece of himself from himself. Right? And, you know, for him it was so horrific that he had to continually find ways to dissociate. And so that, I think, is the beauty of psychotherapy. It's like, what is this thing that you find so reprehensible that you're dissociating from yourself all the time.
Drozek:
Definitely.
Puder:
And is it really as bad as you imagine? Like, is it definitely as awful as you think it is?
Drozek:
Well, you're really underscoring there is a sort of conjoining of “pretend mode” with “teleological mode.” So let me explain. It's that if I think this quality or characteristic, like say, the one sexual orientation or something makes me bad, then I'm going to be disconnected from those desires. Right? So the certainty is linked with what we're dissociating. So we got to hit it on both fronts. We’ve got to treat the certainty, the self-judgment, the shame, all the opinions or both the convictions the patient has about what makes them bad. But then we’ve got to help them access those parts of themselves. And we’ve got to, I would say, we’ve got to hit it on both fronts.
What Tolstoy Can Teach Us About Mentalizing (01:01:27)
Puder:
Have you ever read Tolstoy?
Drozek:
Any Tolstoy? No, I haven't. I've never read Tolstoy.
Puder:
The biggest books wereAnna Karenina and War and Peace.
Drozek:
Okay. No, I never read them.
Puder:
Later in life he wrote this book The Kreutzer Sonata. And it was fairly autobiographical in a lot of ways. And so, it's a short story in which a man murders his wife.
Puder:
He imagines his wife is starting to have this affair and he comes to this point in this argument in this book that if you're really a Christian, you should be completely abstinent from sex. Completely.
Drozek:
Okay.
Puder:
And then he wrote a follow up saying that he actually believed this to be the truth.
Drozek:
Tolstoy believed that?
Puder:
Tolstoy. Yes. Later, in his later life. And his wife was very upset that he wrote this story because she, so The Kreutzer Sonata is this musical piece where his wife is playing a duet with this man, and this is what angers him to this point of killing his wife. Right?
Drozek:
Okay. Yeah.
Puder:
In the short story. He didn't actually kill his wife, but he had that degree of he understood envy to that degree. Right? And he understood this murderous rage.
Drozek:
Yes.
Puder:
And through his writing and through his belief structure, he felt like the real problem was sex and sexuality, so we should be completely abstinent.
Drozek:
Wow. Okay. I didn't know that about Tolstoy. This doesn't seem healthy.
Puder:
And so it's interesting because, in his journals, he was very obsessive. He was very self-punitive.
Drozek:
Oh yeah. There we go.
Puder:
His wife wrote about his marriage and stuff, and she wrote about, she paints a more narcissistic picture of him. His kids write long things about him as well. He had [13] kids. A couple of them wrote, some were more idealizing of him, but he was a little bit more distant than I think he likes to portray. And so he's a complicated person. But what made me think about it was, here's the guy before psychotherapy existed, who was incredibly insightful about the human, about human nature. You know, about internal emotions. But he was never able to come out the other side into a connectedness. It always stayed in a very obsessive narcissistic or masochistic depressive, like very punitive towards himself. Very, very regimented.
Drozek:
He sounds a little OCPD (obsessive-compulsive personality disorder) too.
Puder:
Maybe OCPD. Yes. A little bit. Some people have thought that. And you know, at one point he tries to give away his estate. He was very, he was born wealthy. He tries to give it away and his wife and his kids try to stop him. And so he [eventually transfers most of the property and earlier copyrights to the family as a compromise, while still wanting a more complete renunciation].
Drozek:
Wow.
Puder:
He's left with very little. But anyways, the thing that made me think about this was one, because I've been reading it recently and just it's, I've been trying to think about, okay, what were his gaps in mentalizing? Where was he? Because he saw it, I think in this character, he saw this murderous rage and he wasn't like, he saw it from the perspective of this person and this envy, but he never had a second person in the room.
Drozek:
Meaning what?
Puder:
He never had a person to bounce off.
Drozek:
Oh, right, yes.
Puder:
The other. So he had characters in his stories that would bounce off the things, but not in a way that would actually change him.
Drozek:
I love it.
Puder:
Because to be changed, you have to have another mind.
Drozek:
I love that. I love that point. Yes. It's consistent with what you were saying about the therapist who colludes with a patient's devaluation of their partner. Like that's, I would say that's partly the problem in that setup is it's only one mind. You know, if the therapist is aligning with the patient's mind and you're really making the point that psychotherapy, MBT really believes this, that psychotherapy, by definition, is about the collision or engagement of two minds.
Puder:
Of two minds. Yes.
Drozek:
I hadn't known about all that about Tolstoy. And so I really think it highlighted a couple things clinically that are really important that I would want to underscore from a mentalizing problem. When you talk about what are his gaps in mentalizing: one, it definitely seems like there's a ton of self-judgment around desire.
Drozek:
And really, like self-punishment around desire. Not just the certainty that “I'm bad,” but an almost effortful way to extinguish desire and then certainty that these desires are bad. And then, the idea is that certainty ultimately perpetuates dissociation. Like, my guess is, despite the fact that he had 10 kids….
Puder:
Yes.
Drozek:
That there's a way in which he wasn't able to comfortably inhabit his own sexual wishes. And really, to that point, I mean, I see this with patients all the time, where oftentimes the patients who really struggle to comfortably inhabit their wishes, they can speak very, very cruelly to themselves. They can be mean to themselves. They can talk to themselves in a really, really aggressive manner. And I would say there, David, that's the dissociative behavior. Self-criticism is also a dissociated behavior. So then I have to, with patients, I'm going to say, “Listen, I know you believe all these negative things about yourself, and I don't know what we're going to be able to do to fully address that. We can work on it, but I'm interested in this question. I'm also concerned about the language you use, the way you speak to yourself.”
Drozek:
“Would you be up for actually trying to work on this in this treatment and do it less?” And, a lot of times, I think that when patients, just like the patient who stops using the screens, because that's his dissociative behavior, when other patients stop being as cruel to themselves, then they experience different emotions and desires. But often I think about self-criticism as an effort to cauterize desire in wish. You know? And once we can, if we can disrupt that, then you'll start to see patients start to have a broader array of their own experiences.
Puder:
Okay. Yes. Interesting. So it's the self-criticism as a form of dissociating. What are they dissociating from then?
Drozek:
Oh, I mean, I see this vulnerable narcissism all the time. It's often the desire for care.
Puder:
So the desire for care is more scary than the desire to be punitive towards themself?
Drozek:
Oh, definitely. Because self-punishment is, it's like “I'm in charge. I'm relying on me. I'm bad. It's about me and my standards.” And so, oftentimes they'll just be really mean to themselves and try to push down those wishes for connectedness, because it's easier to be mean to themselves than it is to face rejection or abandonment actually.
Puder:
Okay. Yes. I see that.
Drozek:
So yes, I think those are really important processes and that's the progress in treatment. A lot of people with narcissism, when you're working with them in treatment, think, “I need to, I need to make it less about my desires.” And I'm like, “Well, yeah, maybe, and maybe we should actually help you experience some of those desires without being mean to yourself for having them.” And that can be a part of these treatments actually.
Puder:
Yes. I was thinking about that. If I had Tolstoy in my office, maybe the envy is an awakening of his care and love, because at times he feels very loveless towards this other person. You know? But then, what if we were to put these things to words? The protectiveness. How do we protect the connectedness rather than murder his wife, for example? It's the furthest extreme, but this, the murderous rage, is to protect the family. Right? To connect, to protect. And is there a positive sort of understanding of the emotion in an adaptive sense? Right? The envy is there as an adaptive way of protecting something that's very important to you. If this were to be lost, if the connectedness to this person would were to be lost, which he devalues simultaneously. Right? So he's devaluing of her all the time. And then he's also like this extreme envy. I actually think it would be a lot of fun for you to read this and for us to have a longer discussion on this.
Drozek:
Yes, that'd be very fun. One of my favorite books was Crime and Punishment by Dostoyevsky. I love Crime and Punishment. It's actually similar themes. Maybe because they're both Russian? I guess, right?
Puder:
You know, I find Tolstoy is harder for me to connect with. [There’s a severity and a kind of moral isolation in him that stays unresolved.] Like, I feel like Dostoyevsky arrives at this, “There's beauty, there's an existential beauty,” [even inside the brokenness, the suffering, the contradictory parts of people,] and there's this, it's like I feel like he arrives at a place that I feel more resonant with [a place where connectedness and compassion can still exist alongside the darkness].
Drozek:
Oh, absolutely. Well, I mean, I'm not saying by comparison, but I really resonate with Dostoyevsky. It's quite beautiful.
Puder:
Tolstoy, I'm left with this feeling of like, okay, I feel like this was a really difficult read. [There’s something unrelenting and unresolved in it, the intensity of the rage, the envy, the moral severity, that doesn’t let you off the hook.] Like I'm thinking about having the cohort read it and discuss it on the podcast [because it so clearly shows the cost of those mentalizing gaps we’ve been talking about].
Drozek:
Oh, really? That's so cool.
Puder:
But then I'm simultaneously hesitant to, because it's such a painful read.
Drozek:
This makes me think, I mean, granted, I'm learning this all from you and, you know, we are never supposed to diagnose somebody through another person's reports. However, this is the experience that you can have with people with sort of like, really notable obsessive compulsive personality disorder. Because there's a way in which in OCPD, it's such a world of “shoulds,” that breath and life get strangled.
Puder:
Yes.
Drozek:
And there can be this experience. I do a lot of treatment of folks with OCPD and some folks, there's just so many “shoulds.” It almost feels like there's a sense of dread or deadness, or something like that. And so it's an interesting thought of like, to what extent can that be communicated through art? Actually, you know, and that if there's a way in which our character structure has to be communicated through what we create. I wonder if what you're describing is almost like, it reminds me a little bit of how I can feel with some patients who are very, very strict with themselves and very masochistic, actually masochistic.
Puder:
Yes. Definitely. Masochistic is like, how do I get love? I have to suffer to get love. Right?
Drozek:
Yes.
Puder:
Yes. And what is the meaning? What is meaningful? I have to suffer for something to be meaningful. Right?
Drozek:
Definitely. Yes. It's got to be earned, in a way.
Puder:
It's got to be earned. Yes. So, whereas obsessive, it's like I have to create order to feel ok, like in the orderliness and the obsessions through just the thoughts. Right? Someone could be just very much caught in their thoughts and they could do very little action, or they could be very compulsive and do not have a lot of thoughts, but just do compulsive behavior. It's a little bit different than the OCD in my mind, because with OCD, it's more of that doubting and doubt leads to the compulsion and they're doing it four to six hours a day. [The symptoms feel intrusive and ego-dystonic.] Whereas, like OCPD, it's more of the personality organization [a broader, ego-syntonic style of needing control, order, and perfection that shapes how the person relates to themselves and others].
Drozek:
Yes. And the other part, you know, I think that, and this is where some of these constructs can converge, is with OCPD, there's obviously the scrupulosity, this excessive focus on ethics, this need to always perfect oneself, ethically. You know, which can be absolutely exhausting. And it sounds like, you know, to some degree that was present with Tolstoy. And it also makes me think, because a lot of the work that I did prior to coming to mental health was when I was in grad school for philosophy and my favorite philosopher was Kant. I don’t know how much you know about Immanuel Kant, but he has a very beautiful model of ethics, organized around the inherent worth of the person, which I bring into mentalizing and think about a lot, still. And he was so self-negating and feeling like the only ethically good act that we, that the only thing that had ethical value is essentially if it could often work against our wishes and desires. You know, so there is this sort of moral perfectionism that you can see.
Puder:
There's a little bit of masochism in that. Right?
Drozek:
Exactly. Yes. It's interesting to think about masochism as part of the moral perfectionism of OCPD.
Puder:
Well, it could be this persona, where in order to do something truly good, I have to suffer, or I have to basically take away my own desire. Whereas I'm more in the lens that it's good to operate where there's a multiplicity of wins.
Drozek:
Yes. Yes.
Puder:
You know, we enjoy our patients. Our patients get better. Our patients get helped. It's okay to enjoy this job. Right? And to enjoy the connection that we feel with people. It's such an honoring place to actually enjoy the work, too. I can't imagine my own therapist, that I see secretively, not enjoying it.
I Mode, You Mode, and We Mode (01:16:43)
Drozek:
Oh, absolutely. I like what you're saying. And I mean, I think about there's this, I don't know how much you talked about this in this podcast, but essentially MBT has been about this construct that's probably the newest theoretical innovation in MBT, that Anthony has really developed with Peter's help, is called the “vantage points for mentalizing.” Actually, I call them that. Anthony will refer to it as “social mentalizing,” but it relates to what you're talking about, which is, “What's the position that we're standing in to try to understand self and other?” And so, essentially, there's “I mode,” “you mode,” and “we mode.” So, “I mode” is where it's really all about our perspective. Right? And what we want, what we, how we are experiencing things. And a lot of our patients
Puder:
Wait, wait, you just went, you said “I,” but then we.” You said “we,” what “we” want.
Drozek:
Oh, I'm sorry. I shouldn't have. Okay, good point. Good point.
Puder:
That's interesting though? Because it's so hard for you, in your experience, to ever think purely about yourself.
Drozek:
That's funny. Okay. Good catch. I love that. So, “I mode” is my perspective: what I want, how I see it, right? Some patients, we all know those patients, right? Whether it's more “I mode,” we all can fall into that ourselves as well. Then there's “you mode,” where it's more of where we get caught up in the other person's perspective and we're prioritizing what they're going through. And a lot of patients can just flip flop between those two modes. And really what I think you're talking about when you're talking about the just joy of connectedness is really what MBT says we're going for now, which is “we mode,” which is where I'm in my own experience, I'm simultaneously considering yours, and together we are working to do something and to collaborate and be connected to each other from a shared position.
Drozek:
And so that's really the idea MBT is proposing. Now that's the point of psychotherapy, is we are trying, that's why we need two minds in the room, because if not, patients will just easily fall back into “I mode.” And so it's this idea that if we can consider each other and work towards something beyond each of us, that we are going to actually have a greater sense of meaning, purpose, and connectedness. So that's MBT’s newest theoretical innovation, which also has, as you can imagine, really important implications for clinical practice, as well.
Puder:
Really good. Yes. Wonderful place to stop. I think that's a good place to stop. I think the “we-ness,” it makes me think of Dr. Tarr. He always talked about the importance of the “we” right in the room. What are we thinking about? And I also think about this pop culture. Codependency is a word that's often used. I dislike that word.
Drozek:
Okay.
Puder:
Because I think we're all interdependent.
Puder:
Yes. And I think of enmeshment, you know.
Drozek:
Oh, enmeshment. Yes.
Puder:
It's like another buzzword. Right? Whereas, we all are very much connected in a way. Right? It's torture to not be connected. It's isolation in a prison. Is torture for the worst psychopath.
Drozek:
Absolutely.
Puder:
Even for the worst psychopath, it damages their brain permanently to be in isolation for years [see episode 172].
Drozek:
Yes, definitely.
Puder:
So, there is a strong importance of connectedness.
Drozek:
I love the point, and there's a way in which I think with those ideas about enmeshment or codependency, there can be a pathologization of the need for connectedness. And that's not good for any of us. And oftentimes, when we're too enmeshed it's because we're actually, that's not real connectedness. That's more like “you mode,” really. Where it's just sort of like, it's all about you. There's none of me. Right? And so we need to, how do we treat that? How do we help patients increase their connectedness themselves while also considering others more? And that will lead to actual we-ness. And so we don't want to pathologize the need for connectedness because that's what we're working for.
Codependency, Enmeshment, and Healthy Connectedness (01:21:36)
Puder:
Right. I think that what you're saying is that we could over pathologize good things in pop culture vernacular. Which is something I've been thinking a lot about.
Puder:
But enmeshment, and it's where it is toxic, right? Because there is a place of true toxicity when someone enters into a cult, right?
Drozek:
Oh, totally.
Puder:
A cult being a singular leader, his needs are the only needs that matter. Right? And everyone is there to serve this person's needs. Those environments do exist. To say that they don't exist is silly, you know? There are some people who create cults and operate cults for their own pleasure and for the lack of pleasure of anyone else in the cult. Right? But I think a lot of enmeshment or codependency is really interdependency. Like we're synergistically connected in a positive way with people.
Puder:
And sometimes it's more intense than others and sometimes less intense. And so there's probably good reasons for it to be intense at times and good reasons for it to be less intense at other times.
Drozek:
Totally. And I think the best case scenario is if we can be connected, as long as there's enough us and enough other. That would be the idea. So, I do think that's been a bit of a theme of the discussion today is the two-mindedness of psychotherapy. But in this model, the two-mindedness of relationships that make sure we are in the room and then there's another person in the room. And that, I think, from an MBT perspective, that's going to be their best recipe for feeling connected to others, but also for helping patients change through psychotherapy.
Key Takeaways: The Future of Mentalization-Based Therapy (01:23:46)
Puder:
Okay. So in summary, mentalization, the approach is to mentalize their own internal experience, to not dissociate from their own internal experience; to mentalize the experience of others, including you, the therapist; and then the togetherness is its own mentalizing process. There's a we-ness in the room and we're looking at that as well.
Drozek:
Exactly. Perfectly said.
Puder:
Okay. All right. We'll leave it there for today. Thank you so much for coming on. I think that this book that you have written, we’ll put links in the show notes and on the website, and if people want to check it out and give you feedback, if they want to send me a message or send it directly to you, I'll forward it to you. If it's been helpful. And you know, I think it'll be a good addition to the importance of psychotherapy and the importance of the two person connectedness.
Drozek:
Awesome. Well, David, I always love talking with you. I just really just enjoy you as a person and just love the conversation. So thank you for having me.
Puder:
All right. Good to talk with you. Okay. We'll leave it there for today.
References
Drozek, R. P., Unruh, B., & Bateman, A. (2023). Mentalization-based treatment for pathological narcissism: A handbook. Oxford University Press. https://doi.org/10.1093/med-psych/9780192866134.001.0001
Drozek, R. P. (2025). Mentalization: Utilizing reflection to heal from borderline personality disorder. Oxford University Press. https://doi.org/10.1093/oso/9780198916857.001.0001
Tang, D., Zhang, X., Gou, P., Feng, J., Hu, R., & Sum, K.-W. R. (2026). Association between short-form video use and mental health: Systematic review and meta-analysis. Journal of Medical Internet Research, 28, Article e82503. https://doi.org/10.2196/82503