MBT for avoidant personality disorder (AvPD) targets hypermentalizing and hypomentalizing modes along with the problems associated with mentalizing problems found in the polarities of self/other mentalizing which become apparent when the patient engages with their social world. Reducing overuse of the self is central to treatment. The experience of shame is activated during social interaction, and therefore avoidance of social situations maintains a sense of personal comfort and safety. The chapter discusses ways to help the patient to overcome this. Clinician counter-responsiveness, which often relates to feelings of helplessness and hopelessness, can also interfere with engagement and treatment, as the patient may avoid interaction in therapy.

A mentalizing framework for understanding narcissism is outlined, and the resulting modifications of basic mentalization-based treatment (MBT) for narcissistic personality disorder are discussed. Treatment of patients with pathological narcissism requires an emphasis on empathic validation and support of the vulnerable “I-mode.” The dangers of not recognizing low mentalizing in narcissistic functioning are also discussed, as both patient and clinician can fail to recognize pretend mode, which may masquerade as “we-mode.” Together the patient and the therapist may then set up a pretend therapy that can be interminable and that functions only to fuel the mental narcissistic structure. A clinical example of a patient in treatment is used to illustrate the process of treatment.