Introduction to Mentalization

A Training Workshop Summer School, Oxford

Mindblindness

Imagine what your world would be like if you were aware of physical things but were blind to the existence of mental things. I mean of course blind to things like thoughts, beliefs, knowledge, desires, and intentions, which for most of us selfevidently underlie behaviour

Baron-Cohen S (1995) Mindblindness

The Artful use of Science

To do anything well you must have the humility to bumble around a bit, to follow your nose, to get lost, to goof. Have the courage to try an undertaking and possibly do it poorly. Unremarkable lives are marked by the fear of not looking capable when trying something new.

Epictetus, Manual

Mentalizing: A new word for an ancient concept

Implicitly and explicitly interpreting the actions of oneself and other as meaningful on the basis of intentional mental states (e.g., desires, needs, feelings, beliefs, & reasons)

Introduction to theory of mentalisation

The normal ability to ascribe intentions and meaning to human behaviour Ideas that shape interpersonal behaviour Make reference to emotions, feelings, thoughts, intentions, desires Shapes our understanding of others and ourselves Central to human communication and relationships Underpins clinical understanding, the therapeutic relationship and therapeutic change

Mentalizing: further definitions and scope

To see ourselves from the outside and others from the inside Understanding misunderstanding Having mind in mind Past, present, and future Introspection for subjective selfconstruction know yourself as others know you but also know your subjective self

Characteristics of mentalising

Central concept is that internal states (emotions, thoughts, etc) are opaque We make inferences about them But inferences are prone to error Overarching principal is to take the inquisitive stance = Interpersonal behaviour characterised by an expectation that ones mind may be influenced, surprised, changed and enlightened by learning about anothers mind

Mentalizing: Implicit v Explicit

IMPLICIT EXPLICIT

Perceived Nonconscious Nonverbal Unreflective e.g. mirroring

Interpreted Conscious Verbal Reflective e.g. explaining

Parallel contributions to mentalizing: Meeting of minds

attachment & arousal Developmental competence Current performance

PATIENT
HEALTH CARE SYSTEM

mentalization attachment & arousal mentalizing mentalizing attachment & arousal

Current performance

CLINICIAN

mentalization attachment & arousal

Developmental competence

Failures of imagination in mindblindness

Dehumanising

Subjectivity & humanity

Demonizing

Concrete & Egocentric Non-mentalizing

Restrained imagination Mentalizing

Imaginary & projective Distorted mentalizing

Mentalizing and psychopathy: Compart-mentalization

Psychopathy entails elements of intact mentalizing Partial mindblindness:

Failure of imaginative empathy Failure to identify with victims distress Mind uninfluenced and unchanged easily control and protection of self from shame/humiliation paramount Distorted mentalizing paranoid demonizing e.g. interpreting the childs frustrating behaviour as intended to torment the parent

Being misunderstood
Although skill in reading minds is important, recognising the limits of ones skill is essential First, acting on false assumptions causes confusion Second, being misunderstood is highly aversive Being misunderstood generates powerful emotions that result in coercion, withdrawal, hostility, over protectiveness, rejection

Examples from the Reading the Mind in the Eyes (Baron-Cohen et al., 2001)
surprised sure about something

joking

happy

Examples from the Reading the Mind in the Eyes (Baron-Cohen et al., 2001)
friendly sad

surprised

worried

The development of regulated affect

Psychological Self: nd 2 Order Representation
Representation of self-state: Internalization of objects image
con ting ent disp exp lay met ressio abo n Expression lize of d af fect symbolic binding of internal state

..Symbolization of Emotion

Physical Self: Primary Representations

Reflection

signal

Constitutional self in state of arousal

rbal non-ve on si expres

Resonance

With apologies to Gergely & Watson (1996)

Fonagy, Gergely, Jurist & Target (2002)

Infant

CAREGIVER

Duration of Looking at Self During Three Phases of Modified Still Face Procedure
Insecure (n=47) 1.4 Secure (n=92)

% looking at self

1.2 1 0.8 0.6 0.4 0.2 0 Mother accessible Mother stillface Mother accessible again

(Gergely, Fonagy, Koos, et al., 2004) F(interaction)=6.90, df=2,137, p<.0001

Duration of Looking at Self During Three Phases of Modified Still Face Procedure
Organized (n=119) 1.8 1.6 1.4 1.2 1 0.8 0.6 0.4 0.2 0 Mother accessible Mother stillface Mother accessible again Disorganized (n=20)

% looking at self

(Gergely, Fonagy, Koos, et al., 2004) F(interaction)=12.00, df=2,137, p<.0001

The implication of the temporary loss of mentalising

1. 2. 3.

Psychic Equivalence Pretend Mode Teleological Stance

The Modes of Psychic Reality That Antedate Mentalisation and Characterize Suicide/Self-harm Psychic

equivalence:

Mind-world isomorphism; mental reality = outer reality; internal has power of external Experience of mind can be terrifying (flashbacks) Intolerance of alternative perspectives (I know what the solution is and no one can tell me otherwise ) Self-related negative cognitions are TOO REAL! (feeling of badness felt with unbearable intensity)

The Modes of Psychic Reality That Antedate Mentalisation and Characterize Suicide/Self-harm Pretend mode:
Ideas form no bridge between inner and outer reality; mental world decoupled from external reality Linked with emptiness, meaninglessness and dissociation in the wake of trauma Lack of reality of internal experience permits selfmutilation and states of mind where continued existence of mind no longer contingent on continued existence of the physical self In therapy endless inconsequential talk of thoughts and feelings o The constitutional self is absent feelings do not accompany thoughts

10

The Modes of Psychic Reality That Antedate Mentalisation and Characterize Suicide/Self-harm Teleological stance:
Expectations concerning the agency of the other are present but these are formulated in terms restricted to the physical world A focus on understanding actions in terms of their physical as opposed to mental outcomes Patients cannot accept anything other than a modification in the realm of the physical as a true index of the intentions of the other. Only action that has physical impact is felt to be able to alter mental state in both self and other
o Manipulative physical acts (self-harm) o Demand for acts of demonstration (of affection) by others

Understanding suicide and self-harm in terms of the temporary loss of mentalisation

Figure 2.x Understanding BPD in terms of the suppression of mentalization

Temporary Failure of Mentalisation

Pretend Mode

Psychic Equivalence

Teleological Mode

Pseudo Mentalisation

Concrete Understanding

Misuse of Mentalisation

Dysfunctions of Interpersonal Relationships Suicide Self-Harm Impulsive Acts of Violence

loss attachment needs failure of mentalisation intensification of unbearable experience dissociation teleological solutions to crisis of agentive self

11

Clinical Implications

Dysregulation of attentional capacities

With individuals whose attachment relationships have been disorganized we may anticipate quite severe problems in affect regulation and attentional control along with profound dysfunctions of attachment relationships Exploratory psychotherapy techniques are likely to dysregulate the patients affect It is wise to anticipate difficulties in effortful control

12

Disorganisation of self

The therapist should be alert to subjective experiences indicating discontinuities in self structure (e.g. a sense of having a wish/belief/feeling which does not feel like their own.) It is inappropriate to see these states of minds as if they were manifestations of a dynamic unconscious and as indications of the true but disguised or repressed wish/belief/feeling of the patient The discontinuity in the self will have an aversive aspect to most patients leading to a sense of discontinuity in identity (identity diffusion)

Projection of alien self

Patients will try to deal with discontinuous aspects of their experience by externalisation (generating the feeling within the therapist) The tendency to do this had been established early in childhood It is not going to be reversed simply by bringing conscious attention to the process therefore interpretation of it is mostly futile

13

Projective identification

Disowned mental states may include the internalisation of a frankly malevolent state of mind. Patient should be given some limited opportunity to create relationships where they involve the other in enactments Their experience is of a hostile/ persecutory state that must be got rid of to stop the experience of attack by the self from within The degree to which patients engage in externalisation must be carefully controlled Too many regressive enactments will undermine opportunity for using the relationship to enhance mentalisation

Core morbidities

The interrelated deficits associated with BPD include

Impulsiveness Emotion regulation Relationship problems Identity formation

Problems in mentalization may relate to any or all of these deficits Typical problems associated with BPD may be direct consequences of not perceiving the mental states of other with sufficient accuracy OR the re-emergence of nonmentalising modes of social cognition OR both

14

Context specificity

The quality of mentalisation varies widely in BPD, largely as a function of the patients interpersonal context The clinician should monitor several parameters in relation to the quality of mentalisation
Level of emotional arousal Intensity of attachment Need to avoid perceived threat from hostile other

Mentalisation is at least in part a function of the prefrontal cortex and any activity that leads to an inhibition of this part of the brain is likely to lead to the loss of mentalisation
Hyperactivation of the attachment system High levels of arousal

Mentalisation may be defensively inhibited in specific (traumatogenic) relational contexts

Psychic equivalence

Characterised by conviction of being right that makes entering into Socratic debates mostly unhelpful Patients commonly assume that they know what the therapist is thinking - claiming primacy for introspection (i.e. saying that one knows ones own mind better than the patient) will lead to fruitless debate The rigid character of the patients thoughts are made more aversive by hostile presuppositions of the patient Therapist may make ill advised attempt to defend position Grandiosity and idealization are also expectable consequences of an unquestioning mind

15

Psychic equivalence

It is not the action itself that carries most meaning in this mode but deviation from action that is contingent with the patients wishes Self-harm, suicide attempts and other dramatic actions tend to bring about contingent change in the behaviour of most people - patient experiences a sense of being cared about Misuse of mentalisation may be linked to such pseudo-manipulativeness and involve realistic risk of harm to the patient or interactive partner

Iatrogenesis

Therapeutic interventions run the risk of exacerbating rather than reducing the reasons for temporary failures of mentalising Non-mentalising interventions tend to place the therapist in the expert role declaring what is on the patients mind which can be dealt with only by denial or uncritical acceptance To enhance mentalising the therapist should state clearly how he has arrived at a conclusion about what the patient is thinking or feeling Exploring the antecedents of mentalisation failure is sometimes but by no means invariably helpful in restoring the patients ability to think

16

Therapist stance

Therapist/Patient Problem
THERAPY STIMULATES ATTACHMENT SYSTEM EXPLORATION DISCONTINUITY OF SELF

ATTEMPT TO STRUCTURE by EFFORT TO CONTROL SELF &/OR OTHER

17

Therapist/Patient Problem
ATTEMPT TO STRUCTURE by EFFORT TO CONTROL SELF &/OR OTHER

RIGID SCHEMATIC REPRESENTATION NON-MENTALIZING CONCRETE MENTALIZING (PSYCHIC EQUIVALENCE) PSEUDO MENTALIZING (PRETEND) MISUSE OF MENTALIZING

Therapist Stance

Not-Knowing
Neither therapist nor patient experiences interactions other than impressionistically Identify difference I can see how you get to that but when I think about it it occurs to me that he may have been preoccupied with something rather than ignoring you. Acceptance of different perspectives Active questioning

Monitor you own mistakes

Model honesty and courage via acknowledgement of your own mistakes
o Current o Future

Suggest that mistakes offer opportunities to re-visit to learn more about contexts, experiences, and feelings

18

Therapist Stance

Reflective enactment
Therapists occasional enactment is acceptable concomitant of therapeutic alliance Own up to enactment to rewind and explore Check-out understanding Joint responsibility to understand overdetermined enactments

Therapist Stance Implicit Mentalization

The therapist is continually constructing and reconstructing an image of the patient, to help the patient to apprehend what he feels Mentalizing in psychotherapy is a process of joint attention in which the patients mental states are the object of attention Neither therapist nor patient experiences these interactions other than impressionistically

19

Components of mentalizing the transference

Validation of experience Exploration in the current relationship Accepting and exploring enactment (therapist contribution, therapists own distortions) Collaboration in arriving at an understanding Present an alternative perspective Monitor the patients reaction Explore the patients reaction

Interventions: Mentalizing the Transference

Dangers of using the transference

Avoid interpreting experience as repetition of the past or as a displacement. This simply makes the borderline patient feel that whatever is happening in therapy is unreal Thrown into a pretend mode Elaborates a fantasy of understanding with therapist Little experiential contact with reality No generalization

20

Mentalisation and Aggression

An evolutionary framework

Interpersonal violence is an important evolutionary adaptation.

In certain human environments it is likely to contribute materially to the survival of the individual's genes. In other contexts it is seriously maladaptive
o it undermines the possibility of safe collaboration o the optimization of human capacities for meaning generation, communication and creativity.

21

An evolutionary framework
Human infants are born with the potential to be violent. In the majority of cases this potential is not fulfilled They gradually increasingly desist from physical aggression.

Three apparently contradictory findings on the development of violence

Most preschoolers use physical aggression. The earlier the onset of problem behaviours, the higher the risk for continued aggression and violence Only a small proportion of individuals are persistently physically aggressive The challenge is to distinguish between the normative patterns of aggressive behaviours and the more atypical pattern that may represent a risk for future difficulties

22

NICHD study: Trajectories of physical aggression from 24 months to age 9 (n=1,195)

3%

12% 15%

70%

Trajectories of Physical Aggression in Canadian Accelerated Longitudinal Study N=10,214

17%

52%

31%

23

What differentiates persistent violent trajectory?

The NICHD ECCRN (2004)

socio demographic risk (e.g., poverty, low maternal education, single parenting) less sensitive and involved parenting during the course of childhood

Nagin and Tremblay (2001), Tremblay et al. (2004)

have mothers with low levels of education. have mothers who started childbearing early

Shaw et al. (2003) study

Boys more fearless Experienced maternal rejection

The mechanism for the development of violence: A failure of inhibition

Family processes conceptualized as promoting aggression may interfere with the socialization of aggression
low income, low maternal education reflects family environments in which children have difficulty learning to inhibit their use of physical aggression, as well as difficulty learning alternative strategies to solve problems This relationship is mediated by parenting quality

24

Aspects of Parenting Associated with Aggression Trajectories in Canadian Study

Positve Interaction
14.4 14.2 14
12 11.5 11 10.5 10 Hostile ineffective parenting Hostile Ineffective parenting

p<.03*10-47 d=.39

13.8
9.5

13.6 13.4 13.2 13 Low Desister High stable

9 8.5 8 7.5 7 Low Desister High stable

p<.02*10-99 d=1.88

Consistent parenting
15.4

Consistent parenting

Family functioning
9.5

15.2 15

9 8.5 8 7.5 7

p<.01*10-64 d=.46

14.8 14.6 14.4 14.2 14 13.8 13.6 Low Desister High stable

p<.05*10-83 d=.53

6.5 6 Low Desister High stable

p<.02*10-99 IS p<.000000000000000000000000000000 000000000000000000000000000000 0000000000000000000000000000002 OR The likelihood of five hundred 13-spade bridge hands when getting one hand with all spades would take 20 million bridge players dealing 30 hands a week 20 years to get one all-spade hand.

25

The Role of Attachment

The developmental trajectory is established early on

The choice has to be made because there is an evolutionary cost to following the physical aggression trajectory.

Evolution uses the early attachment relationship as a signaling system to the newborn as to the kind of environment he/she might expect.
An environment where caregivers do not have the time or resources to devote attention to the infant is far more likely to necessitate the later use of violence in order to ensure the survival of the individual in subsequent struggles for limited resources.

John Bowlbys Discovery: The Nature of the Attachment System

26

Attachment security at 15 and 24 months predicts aggressive behaviour at 54 months

NICHD study of 1,000 mother infant pairs Secure attachment judged on bases of home observations at 24 months, predicts behavior problems, especially above-average levels of problems.
close to 90% of children whose mothers rated them as having externalizing problems were insecure based on Qset ratings.

Insecurity judged in laboratory assessments at 15 and 36-month predicted mothers and caregivers ratings of externalizing problems for boys. Maternal depressive symptoms predicted mothers ratings of externalizing problems.

Disorganised Attachment Classification

Disorganised-disoriented

infants

freezing, hand clapping, wish to escape

Arousal

of attachment system attachment figure is haven of safety and source of stress Associated with
severe neglect physical abuse sexual abuse

27

Disorganised attachment and externalising behaviour

Fear of an abusive or ill parent activates their need for proximity-seeking, which, in turn, increases their fear
results in a collapse of the infants behavioral and attentional strategies

van IJzendoorn, Schuengel, and BakermansKranenberg (1999) reviewed twelve studies on 734 children and demonstrated a clear association between disorganization and externalizing problems (r = .29, p<.00001).

Attachment as a Signal of Environmental Stress

Where caregivers do not have the time or resources to devote attention to the infant physical aggression is more likely to be needed to ensure survival This is the mechanism for the transgenerational transmission of violent interpersonal strategies. The childs mind and body needs to be prepared for violent competition for resources
Alternative but incompatible strategies for ways of relating to others (intra-species collaboration) are sacrificed.

What is sacrificed?
Namely, the uniquely human capacity to envision mental states in our fellow humans in order to understand their actions.

28

The Social Brain (Lieberman , 2007)

Genetics of Social Cognition: Passing ToM Battery

19%
33%

15%

genetic shared environmental common to verbal non-shared environmental common to verbal

67%

21%

non-shared environmental unique to ToM

45%

N=120 Hughes, C., & Cutting, A. (1999) Psychological Science, 10, 429-432.

N=1,116 Hughes, C., Jaffee, S. R., Happe, F., Taylor, A., Caspi, A., & Moffitt, T. E. (2005) Child Dev, 76(2), 356-370.

Bivariate model-fitting analyses yielded modest genetic effects

29

The quality of childrens primary attachment relationship facilitates theory of mind

development

Number of studies reported associations between secure attachment and passing standard theory of mind tasks somewhat earlier (e.g., de Rosnay & Harris,
2002; Fonagy & Target, 1997; Fonagy, Redfern, & Charman, 1997 Harris, 1999; Meins, Fernyhough, Russell, & ClarkCarter, 1998; Raikes & Thompson, 2006; Steele, Steele, Croft, & Fonagy, 1999; Symons, 2004; Thompson, 2000; Ontai & Thompson, 2002)

Not all studies find this relationship

More likely to be observed for emotion understanding then ToM

Oxytocin mind reading (Domes et al., in press)

Oxytocin and performance on Mind in the Eyes test (Domes et al., in press)

30

Mentalisation and Violence

Violence

unfortunately requires the possibility for the temporary inhibition or decoupling of mentalisation In a social context of adversity, the childs brain responds to the signal from the attachment system and places powerful limits on mentalisation. Mentalisation has the potential to advance culture and inhibit violence but is, at least partially, maladaptive in the context of life-and-death struggle.

Creating a peaceful school learning environment

Stuart W. Twemlow, Eric M. Vernberg, Edward J. Dill, John A. Sargent Peter Fonagy, Jennifer A. Mize, Todd D. Little,

31

Assumptions, Aims and Adjuncts

The whole school community contributes to bullying-related dysfunction Peaceful collaboration with others requires prioritizing their subjective states, thus placing limits upon the urge to violently control the behaviour of less powerful members of the group

Assumptions, Aims and Adjuncts

CAPSLE aims constantly to focus on the mental states of all those involved in the power dynamics of interpersonal violence (the bystander as well as the bully and the victim) through:
a positive climate campaign to draw attention to the subjective experiences of bully, victim, and bystander a classroom management plan that requires teachers to elaborate the thoughts and feelings associated with acts of aggression in the classroom a defensive martial arts program based on mindfulness peer or adult mentorship that create additional opportunities for reflective interpersonal interaction reflection time which offers opportunities for the class to consider shared immediate past experience together

32

Increasing Mentalization Should Reduce Violence: The Peaceful Schools Project 9 schools randomly assigned to
CAPSLE School Psychiatric Consultation Treatment as usual
oProgrammes as usual
Design

3 year study 2 years of formal manualized intervention 3rd year test of generalisation

19 Eligible Elementary Schools, Including 6,522 K-5th Grade Children 10 Elementary Schools Elected To Participate, Including 2,712 Children

10 Schools, including 2,712 Children, Stratified and Cluster Randomized

1 School (178 Children) Withdrew From Treatment as Usual Condition

1,035 Children CAPSLE In 3 Schools

824 Children SPC In 3 Schools Only 3rd-5th Grade Children Completed Research Instruments

675 Children Treatment as Usual In 3 Schools

CAPSLE Children Participating 391 in Year 1 356 in Year 2 395 in Year 3

SPC Children Participating 296 in Year 1 283 in Year 2 323 in Year 3 Multiple EM Imputation Used To Estimate Missing Data

Treatment as Usual Children Participating 271 in Year 1 221 in Year 2 217 in Year 3

563 Children In CAPSLE Schools Analyzed

422 Children In SPC Schools Analyzed

360 Children In Treatment as Usual Schools Analyzed

33

Key Results of The Peaceful Schools Project: Peer Nomination

SPC vs TAU
Increase in helpful bystanding (p<.05)
o evident only in the first year of the intervention

CAPSLE vs TAU
significant on four out of the eight primary outcome variables peer-reported aggression (p < .05) peer-reported victimization (p < .01) aggressive bystanding (p < .05) empathic mentalizing with victim (p < .01)

Mean Proportions of Observed Disruptive Behaviors Over Two Years of Active Intervention
0.35 0.3 0.25 0.2 0.15 0.1 0.05 0 Time 1 Time 2 Tests of simple effects between 1st and 2nd year of intervention CAPSLE: t(106) = 5.21, p < .001, d=.94 (95% CI: -1.0, 2.9) SPC: t(106) = .50, p > .05 TAU: t(106) = .13, p > .05 Control CAPSLE SPC

34

Mean Proportions of Observed Off-task Behaviors Over Two Years of Active Intervention
0.14 0.12 0.1 0.08 0.06 0.04 0.02 0 Time 1 Time 2 Tests of simple effects between 1st and 2nd year of intervention CAPSLE: t(106) = 8.26, p < .001, Cohens d=1.61 (95% CI: -.38, 3.6) SPC: t(106) = 1.19, p > .05 TAU: t(106) = .14, p > .05 Control CAPSLE SPC

Long-term Outcome of Day Hospital Study

35

Design of MBT Partial Hospital long-term follow-up study

41 (22 MBT v 19 TAU) patients followed up 8 years after they started treatment Contact was made by letter, via their general practitioner, and by telephone. Medical and psychiatric records were obtained for all 41 patients and relevant information extracted. Patients interviewed by research psychologists who remained blind to original group allocation. 5 patients (2 MBT/3TAU) refused interview 1 patient from TAU had died from suicide

Assessment at follow-up interview

Primary outcome Zanarini Rating Scale for DSM-IV BPD (ZANBPD) Global Assessment of Function (GAF) Secondary outcomes Number of self-harm and suicide attempts Number of emergency room visits Length of hospitalization Continuing out-patient psychiatric care Use of medication, psychological therapies, and community support. Vocational status

36

Conclusion
MBT-OP is surprisingly effective Most of the MBT subjects but also some of the SCM subjects lost their diagnosis Relatively few of the SCM patients improved in terms of subjective measures Very few of the MBT patients did not improve in way they were expected to Even when improved remains quite high scoring on pathology scales

37