Mentalization and attachment the implication for community based therapies

Mentalization and attachment: The implication for community based therapies

Peter Fonagy PhD FBA

University College London

& the Anna Freud Centre

[email protected]

Some of the Mentalizing Mafia UCL/AFC/Tavistock

Prof George Gergely

Dr Pasco Fearon

Professor Mary Target

Prof Anthony Bateman

University of Leuven

Dr Patrick Luyten

Dr Liz Allison

Professor Alessandra Lemma

Professor Eia Asen

& UCL/AFC

Dr Trudie Rossouw

Dr Dickon Bevington

Some more maffiosi (The USA branch) Menninger Clinic/Baylor Medical College (The USA branch)

Dr Jon Allen

Dr Lane Strathearn

Dr Brooks King-Casas

Dr Read Montague

Yale Child Study Centre

Prof Linda Mayes

Dr Carla Sharp

Dr Efrain Bleiberg

Professor Nancy Suchman

Professor Flynn O’Malley

And European recruits to the ‘Family” Dawn Bales

Dr Mirjam Kalland

And Rose Palmer for help with the preparation of this presentation.

Professor Finn Skårderud

Professor Sigmund Karterud

•Cindy Decoste•Catherine Freeman•Ulla Kahn•Morten Kjolbe•Benedicte Lowyck•Tobi Nolte•Marjukka Pajulo

•Svenja Taubner•Bart Vandeneede•Annelies Verheught-Pleiter•Rudi Vermote•Joleien Zevalkink•Bjorn Philips•Dr Peter Fuggle

Let the boy dream Ivan, He is a born dilettante!

You will never amount to anything if you hold a ball like that!

I want to write my PhD on the “Use of low signal-to-noise ratio stimuli for highlighting the functional differences between the two cerebral hemispheres”.

You look smug now but you will lose your hair just like

Dad

Mentalization

What is it?How does it arise?Why does it matter?How do we use it in therapy?

A working definition of mentalization

Mentalizing is a form of imaginative mental activity, namely, perceiving and interpreting human behaviour in terms of intentional mental states (e.g. needs, desires, feelings, beliefs, goals, purposes, and reasons).

Brains and social behavior vary across different mammalian species

Insectivors: Regulated maternal behaviors

Chimpanzees: Societies of a few dozen

Modern Humans:Societies of millions of interacting people

Humans exceedingly skilled at large scale social interaction

Competition for social skills led to the evolutions of cognitive mechanism for collaborating with others

Fuelled evolution of human brain.

Therefore correlation in mammals between size of social group and volume of neocortex

The social brain: A variety of studies - stories, sentences, cartoon, animations

medial prefrontal cortex (mPFC), temporo-parietal junction (TPJ), posterior superior temporal sulcus (pSTS), amygdala, anterior cingulate cortex (ACC), anterior insula (AI), inferior frontal gyrus (IFG) and interparietal sulcus (IPS)

The uniqueness of homo sapiens

No animal, not even the most intelligent of non-human primates, can discern the difference between the act of a conspecific due to serendipity and one rooted in intention, wish, belief or desire.

The capacity to mentalize has also been argued to account for the other major difference between humans and other apes: self awareness and self-consciousness as a path to

emulation bringing with it social emotions such as embarrassment, shame and guilt

the species specific striving to be more than a ‘beast’, to live beyond one’s body, to aspire to a spirit that transcends physical reality and step beyond one’s own existence

social origin of the self (simulation).

Mentalizing: Further definitions and scope

To see ourselves from the outside and others from the inside

Understanding misunderstanding Having mind in mind Mindfulness of minds Introspection for subjective self-

construction – know yourself as others know you but also know your subjective self

Num

ber

of a

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on W

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ence

Dat

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Source: http://apps.webofknowledge.com, Data collected 10.1.2012

Articles using ‘mentalization’ in title or abstracts

Clear evidence of mentalizing?

2012American Psychiatric Publishing, Inc

JUST RELEASED!

NEW! IMPROVED!

Washes brains whiter!

Longer than allprevious versions!

Mentalization and Overlapping Constructs (Choi-Kain & Gunderson, Am J Psychiat 2008)

Measuring Mentalization (Baron-Cohen et al., 2001) Reading the Mind in the Eyes Test

Worried - DSurprised - C

Friendly - A Sad - B

Surprised-A Sure about something-B

Joking-C Happy-D


Joking-A Flustered-B

Desire-C Convinced-D


Mentalizing at the World Cup: How does Robert Green feel after letting in the USA goal?

Upset Angry

Disappointed Frustrated

Shared neural circuits for mentalizing about the self and others (Lombardo et al., 2009; J. Cog. Neurosc.)

Self mental state

Other mental state

Overlapping forSelf and Other

Relational Aspects of Mentalization Overlap between neural locations of mentalizing

self and other may be linked to intersubjective origin of sense of self We find our mind initially in the minds of our parents

and later other attachment figures thinking about usThe parent’s capacity to mirror effectively her child’s

internal state is at the heart of affect regulation Infant is dependent on contingent response of

caregiver which in turn depends on her capacity to be reflective about her child as a psychological being

Failure to find the constitutional self in the other has potential to profoundly distort the self representation (exaggerated mirroring of child’s anxiety aggravates anxiety rather than soothe)

The same applies to child with inadequate sense of independent self within therapeutic relationship

Psychological Self:

2nd OrderRepresentations

Physical Self:Primary

Representations

Representation of self-state:Internalizationof object’s image

Constitutional self in state of arousal

Expression

Reflection

Resonance

Infant CAREGIVER

symbolic organisation of internal state

contingent display expression of

understood affect

signal

non-verbal

expression

Affect & Self Regulation Through Mirroring

With apologies to Gergely & Watson (1996)Fonagy, Gergely, Jurist & Target (2002)

Theory: Birth of the Agentive SelfAttachment figure “discovers” infant’s mind (subjectivity)

Representation ofinfant’s mental state

Attachment figure Infant

Core ofpsychologicalself

Infant internalizes caregiver’s representation to form psychological selfSafe, playful interaction with the caregiver leads to the integration of primitive

modes of experiencing internal reality mentalization

Internalization

Inference

‘The baby looks at his mother’s face and finds himself there’

D. Winnicott

‘She/he thinks that I think, therefore I am’

Bidirectional Influences of the Development of Mentalization

Poor affect regulation obviously makes sensitive caregiving more challenging The impact of some environmental influences are evidently

exaggerated by certain genetic attributes (e.g. the short allele of the 5-HTT gene Barry, Kochanska, & Philibert, 2008).

Limitation of voluntarily directing attention and accurate and solid interpersonal understanding necessary for mature affect regulating attachment relationships. Inability to mentalize disrupts attachment relationships Disrupted attachments undermine further development of

mentalizing The very process that could help the child to overcome

the problems arising out of interpersonal challenges is undermined by the difficulties in the child’ attachment system

The development

of mentalization

from infancy to adolescence and beyond

The development of mentalization Weeks after birth the baby smiles at humans

(social beings) in preference to objectsCan tell its own body (shell) from that of another

person’s 2 months after birth infants prefer the subtle

patterns of contingency in face-to-face interactions, including turn taking and correlated affect (Gergely and Watson, 1999; Murray and Trevarthen, 1985).

By 9 months, infants are able to follow another person's gaze to a location outside of their visual fieldA key first step in establishing joint attention (Moore,

2008).

From 12 months babies deliberately engage and redirect attention of caregiver (pointing and vocalizing)

Joint ( “triadic”) attention provides a platform by which two or more people coordinate and communicate their intentions, desires, emotions, beliefs, and/or knowledge about a third entity (e.g. an object or a common goal) (Tomasello et al., 2005).

By 2.5 years children implement complex social tactics – teasing, lying, saving face (Reddy, 2008: How infants know minds)

False belief task: unexpected transfer

Maxi puts his book in the cupboard

Then he leaves to play in the garden

After that, Mum comes to tidy up

the roomMum takes the book out of the cupboard,

and puts it in the bookshelf

Then she leaves to do some work

in the kitchen.Now, Maxi returns looking for his book

Where will he look first for his book?

Test question

(Wimmer & Perner, 1983)

Effect of Age in 178 separate studies

4y 4y

Very robust developmental trends most manipulations ineffective

2nd ½ of 4th year 2nd ½ of 4th year

Meta-analysis of False Belief Studies (Wellman et al., 2009)

The embodied mind and research on the human infant Massive denial of infant mentation outside of

psychoanalysis until about 75 years agoHalf a century ago infants were commonly subjected to

surgery without anesthetic (curare was used to stop squirming inconvenient for the surgeon) Can infants have minds when they are no yet able to speak?

Astounding discoveries concerning early social awareness in infants Mentalization is embodied before it is cognitiveFreud may have been correct about the mental life

being somatically grounded (the body is at the root of meaning.

Sensitivity to others’ state of mind

Á M Kovács et al. Science 2011;330:1830-1834

False belief for babyTrue belief for Smurf

True belief for baby False belief for Smurf

Published by AAAS

The infant but not the Smurf believes thatthe ball should be there

Infant knows ball is not thereBut Smurf believes it should be there

Neither infant nor the Smurf believe thatthe ball should be there

Neither infant nor the smurf believethat ball is there

Ball Not There Ball Not There

Á M Kovács et al. Science 2010, 330:1830-1834

The two key conditions in Smurf Study: Infant of 7 months considers what agent (Smurf) believes about the status of ball

Sensitivity to others’ state of mind

False belief for babyTrue belief for baby False belief for Smurf

Principle of Fairness According to the Principle of Fairness,

agents should deal fairly with othersdistribution of resourcescompensation for work

Sloane, Baillargeon, and Premack (2010)9 months oldsAnimate or inanimate giraffesReasonable expectation applies only to

animate objects(e.g., Boyd & Richardson, 2003; Fehr et al., 2008; Haidt & Joseph, 2007;Jackendoff, 2009; Olson & Spelke, 2008; Premack , 2007; Sigmund et al., 2002)

Animate giraffes condition

Test trials

I have toys Yay! Yay!

Inanimate giraffes condition:

Same giraffes – no movement

Results–9 mnths olds: looking timeAnimate Giraffes

ConditionInanimate Giraffes

ConditionUnequally distributed toys

Equally distributed toys

*

Mean L

ooki

ng T

ime (

sec)

The infantile origins of psychopathology Infants have genetically inbuilt ‘healthy’ social

expectations Social experience to be developmentally ‘good

enough’ has to comply with these expectationsFit in with biologically prepared mechanisms which

evolved to transmit human cultureBe consistent with neural development (i.e. capacity

to integrate new information)Violations of expectations toxic because not only they

‘teach’ inappropriate content but undermine mechanisms for the social acquisition of knowledge and the emergence of an agentive sense of self

The role of contingent caregiver

responding in the

development of cognitions

Natural Pedagogy theory (Csibra & Gergely, 2006; 2009, in press) A human-specific, cue-driven social cognitive

adaptation of mutual design dedicated to ensure efficient transfer of relevant cultural knowledge

Humans are predisposed to ’teach’ and ’learn’ new and relevant cultural information from each other

Human communication is specifically adapted to allow the transmission of

a) cognitively opaque cultural knowledge b) kind-generalizable generic knowledge c) shared cultural knowledge

The Pedagogical Stance is triggered by

Ostensive-Communicative cues Examples of ostensive communication

cues eye-contactturn-taking contingent reactivityspecial tone (motherese)

Ostensive cues function:to signal that the other has a Communicative

Intention addressed to the infant/childto Manifest New and Relevant information

about a referent

Subjects : 4 groups of 18-month-oldsStimuli: Two unfamiliar objects

Experimental illustration of ostensive cues Gergely, Egyed et al. (in press)

1: Baseline – control group No object-directed attitude demonstration

Simple Object Request by Experimenter A

Subjects: n= 20 Age: 18-month-olds

Ostensive Communicative DemonstrationRequester: OTHER person (Condition 1)

Other person

Non-Ostensive (Non-Communicative) Demonstration Requester: OTHER person (Condition 2)

Other person

Condition 4: Non-Ostensive (Non-Communicative) Demonstration Requester: SAME person

Same person

Epistemic trust and secure attachment Secure attachment is isomorphic with inducing

in the infant/child a sense of epistemic trust that the information relayed by the teacher may be trusted (i.e. learnt from)

EvidenceCognitive advantage of secure attachmentContingent responsiveness to the infant’s own (at first,

automatic) expressive displays in secure attachmentDuring “mirroring” interactions, the other will “mark”

her referential emotion displays in a ‘manifestative’ manner to instruct the infant

How Attachment Links to Affect Regulation

DISTRESS/FEAR

Exposure to Threat

Proximity seeking

Activation of attachment

The forming of an attachment bond

Down Regulation of EmotionsEPISTEMIC

TRUST

BONDING

Implications: The nature of psychotherapy The mind is found within the other not within itself Evolution has ‘prepared’ our brains for

psychological therapy We are eager to learn about the opaque mental

world from those around us They are prepared to learn most readily about minds

in conditions of epistemic trust Epistemic mistrust follows maltreatment or abuse

and therapists ignores this knowledge at their peril Therapy is not just about the what but the how of

learningOpening the person’s mind via establishing

contingencies so (s)he once again can trust the social world by changing expectations

Not what is taught in therapy that teaches but evolutionary capacity for learning from other is rekindled

The role of oxytocin in

social understand

ing

Secure attachment is facilitative of mentalizing Children pass theory of mind tasks earlier

ifHad secure attachment relations with parents

in infancyIf parent’s own state of mind in relation to

attachment was secureFamily members relate to each other in payful,

mentalizing way Mechanism may well be mediated by

oxytocin

Oxytocin and performance on Mind in the Eyes test (Domes et al., 2008)

Shared characteristics

of evidence based therapies for BPD likely to

enhance the organization of mental states?

Clinical summary of MBT

Focus is on a break in mentalizing – psychic equivalence, pretend, teleological

Rewind to moment before the break in subjective continuity

Explore current emotional context in session by identifying the momentary affective state between patient and therapist

Identify therapist’s contribution to the break in mentalizing (humility)

Seek to mentalize the therapeutic relationship

So what should the therapist aim do? In MBT, the mind of the patient becomes the focus of

treatment. Help the patient learn about the complexities of his

thoughts and feelings about himself and others, how that relates to his responses, and how ‘errors’ in understanding himself and others lead to actions

It is not for the therapist to ‘tell’ the patient about how he feels, what he thinks, how he should behave, what the underlying reasons are, conscious or unconscious, for his difficulties.any therapy approach to BPD which moves towards

‘knowing’ how a patient ‘is’, how he should behave and think, and ‘why he is like he is’, could be harmful.

We recommend an inquisitive or ‘not-knowing’ stance. Conveys a sense that mental states are opaque

Evidence based or promising treatments DBTTFPMBTCATSTEPPSSFT

MBTDBT

MBT is in its infancy as an EST

Prof. Anthony Bateman, MD Prof. Peter Fonagy, PhD FBA

Psychotherapy for BPD A range of structured treatment programmes for

BPD shown to be effective in studiesDBTTFPSFTCBTSPTDDPCATGPMMBT

Do they work for

the reasons the

developers suggest?

Gaps in Therapy Outcomes Research

No solid evidence for who will benefit from what type of psychotherapy

‘Inexact therapies’ partial effectiveness

‘Attachment to methods’ ‘guildification’ of interventions

Mentalizing Elements of BPD Therapies (1)

Extensive effort to maintain engagement in treatment (validation in conjunction with emphasis on need to address therapy interfering behaviours) acceptance and recognition

Include a model of pathology that is explained to the patient increased cognitive coherence (early phase)

Active therapist stance: Explicit intent to validate and demonstrate empathy, generate strong attachment relationship foundation of alliance (epistemic trust)

Focus on emotion processing and connection between action and feeling (suicide feeling == abandonment feelings) restore cognitive representation of emotion

Mentalizing Elements of BPD Therapies (2)

Inquiry into patients’ mental states (behavioral analysis, clarification, confrontation) strengthen representations of mental states

Structure of treatment provides increased activity, proactivity and self-agency (eschew expert stance, “sit side-by-side”) enhance intentionality (mental state drives action)

Structure is manualized with adherence monitored support therapist in non-mentalizing context

Commitment to the approach ditto Supervision to identify deviation from structure and

support for adherence ditto (therapist needs lots)

Mentalizing Elements of Therapies (3): Components of the process of effective interaction Establishing attachment through contingent

responding epistemic trust (working alliance) opens ‘information superhighway to cultural knowledge”

Create compassion towards subjective experience enable ‘liberal’ attitude towards self-states mindfulness of minds

Enhance mentalized affectivity feeling of feeling felt inititiate virtuous cycle of finding self in other enable finding the other in the self

Social Systems Can be

Described as More or Less Mentalizing

Expanding the model to Social Systems Human beings were not designed to be

brought up in a nuclear family The human brain was designed to adapt to

social environments beyond childhood Current social conditions place intolerable

burdens on the nuclear familyEconomic pressures to be part of the workforceInadequate social support for parentingSocial isolation of the nuclear family

a “Perfect Storm” from perspective of human evolution

Alloparenting is not a new idea!

Typical Size of Human Family Group Across Evolution

05

101520253035404550

10,000BC 1,500BC 1850AD 1900AD 1980AD

Humans spent 99% of history living in groups of 35-40 people

Size

of

fam

ily

grou

p

Humans as part of a wider ecosystem

ConnectedMind

ConnectedMind & Body

ConnectedFamilies

ConnectedCommunities

ConnectedEnvironment

Some features of a successfully mentalizing social system

Is relaxed and flexible, not “stuck” in one point of view

Can be playful, with humour that engages rather than hurting or distancing

Can solve problems by give-and-take between own and others’ perspectives

Advocates describing ones own experience, rather than defining other people’s experience or intentions

Conveys individual “ownership” of behaviour rather than a sense that it “happens” to them

Is curious about other people’s perspectives, and expect to have their own views extended by others’

Some components of a successfully mentalizing social system1. Relational strengths - curiosity - safe uncertainty - contemplation and reflection - perspective taking - forgiveness - impact awareness - non-paranoid attitude

2. General values and attitudes - tentativeness - humility (moderation) - playfulness and humour - flexibility - ‘give and take’ - responsibility and accountability

Mentalizing and Non-Mentalizing Social Systems

Mentalization develops in and is sustained by the social system we live in

Social systems that are compassionate (care about us) have physical (oxytocin) and psychological (feel held in mind) impact which enhance accurate self-awareness and awareness of the mental state of others

Social systems that disrespect human subjectivity (how a person is likely to feel) recreate the evolutionary environment that encodes for self-sufficiency (dismissing of subjectivity) create environment for bullying

Non-Mentalizing Disorganized Social Systems

Social systems that create fear and hyperactivate attachment can destroy thinking capacity and force the system back to pre-mentalistic modes of social thinking

Such social systems can be self-reinforcing and therefore highly stable in their instability

They undermine the very social mechanism that could alter their character: human collaboration (negotiation and creativity)

Vicious cycles of inhibition of mentalizing within a disorganized social system

Powerful emotion

Poor mentalising

Inability to understandor even pay attention to feelings of others

Others seem incomprehensible

Try to control orchange others

Frightening, undermining, frustrating, distressing or

coercive interactions

Loss of certainty that thoughts are

not real

Powerful emotion

Poor mentalising

Inability to understand or even pay attention to feelings of others




Try to control or change others or oneself

Person 1

Powerful emotion

Poor mentalising

Inability to understand or even pay attention to feelings of others


Try to control or change others or oneself



Person 2

Vicious Cycles of Non- Mentalizing Within aDysfunctional Social System

Non-Mentalizing Disorganized Social Systems: Psychic Equivalence Systems

Mind-world isomorphism; mental reality = outer reality; internal has power of external

Attitudes to ideas and feelingsThoughts are real and therefore they have to be

controlled There are singular solutions to social reality,

there are no alternative ways of seeing things, there is intolerance to perspectives

Models of minds are simple (black and white), schematic and rigidly held acts of prejudice

Negative ideas (threats) become terrifying

Non-Mentalizing Disorganized Social Systems: Pretend systems

Ideas form no bridge between inner and outer reality; mental world decoupled from external reality

Attitudes to ideas and feelingsPeople think and feel but this can have no consequence

leading to an empty and meaninglessness social existence

There is selfishness and extreme egocentrism emerging out of the unreality of anything other than one’s own thoughts and feelings

Lack of reality of internal experience permits interpersonal aggression and deliberate harm because other minds are not felt to exist and the mind is no longer felt as contingent on continued existence of the physical self

Frequently there is endless ‘communication’ and searching but it is destined to yield no change

Non-Mentalizing Disorganized Social Systems: Teleological Systems Expectations concerning the agency of the other

are present but these are formulated uniquely in terms restricted to the physical worldOnly what is material can be meaningful

Attitudes to ideas and feelingsA focus on understanding actions in terms of their

physical as opposed to mental outcomesOnly a modification in the realm of the physical is

regarded as a true index of the intentions of the other. Only action that has physical impact is felt as potentially

capable of altering mental state in both self and othero Physical acts of harm aggression is seen as legitimate

o Demand for physical acts of demonstration of intent by others payment, acts of subservience, retributive justice

So how to create a mentalizing community? Activate attachment by creating contingent

responding an attitude of caring and genuine interest

Enhance the curiosity which members of the community have about each others’ thoughts and feelings mentalizing

Be careful to identify when mentalization has turned into pseudomentalization (pretending to know)

Focuses on misunderstanding (mentalization is the understanding of misunderstanding)

Curiosity coupled with respectful not knowing Maintain respectful distance from ideas

Neural dimensions of mentalization

in BDP: Controlled vs

automatic mentalization

The social brain: A variety of studies - stories, sentences, cartoon, animations

medial prefrontal cortex (mPFC), temporo-parietal junction (TPJ), posterior superior temporal sulcus (pSTS), amygdala, anterior cingulate cortex (ACC), anterior insula (AI), inferior frontal gyrus (IFG) and interparietal sulcus (IPS)

Implicit-Automatic-Non -conscious-Immediate.

Explicit-ControlledConsciousReflective

Mentalinterior cuefocused

Mentalexteriorcue focused

Cognitiveagent:attitudepropositions

Affectiveself:affect statepropositions

Imitativefrontoparietalmirror neuronesystem

Belief-desireMPFC/ACCinhibitorysystem

Multifaceted Nature of MentalizationFonagy, P., & Luyten, P. (2009). Development and Psychopathology, 21, 1355-1381.

amygdala, basal ganglia, ventromedial prefrontal cortex (VMPFC), lateral temporal cortex (LTC) and the dorsal anterior cingulate cortex (dACC)

lateral and medial prefrontal cortex (LPFC & MPFC), lateral and medialparietal cortex (LPAC & MPAC), medial temporal lobe (MTL),rostral anterior cingulate cortex (rACC)

Associated with several areas of prefrontal cortex

Associated with inferior prefrontal gyrus

the medial prefrontal cortex, ACC, and the precuneus

frontoparietal mirror-neuron system

medial frontoparietal network activated

recruits lateral fronto-temporal network




Externalvisible cuesfocused





BPD

BPD

BPD

BPD

Mentalizing Profile of Prototypical BPD patientFonagy, P., & Luyten, P. (2009). Development and Psychopathology, 21, 1355-1381.

Crucial role of Attachment History in facilitating/inhibiting Mentalization in the face of stress Arousal/stress inhibits controlled (‘reflective’)

mentalization This leads to automatic mentalizing dominated by

reflexive (unrerflective) assumptions regarding self and others under stress, which may not be obvious in low stress conditions

Reemergence of non-mentalizing modes

Luyten, P., Mayes, L. C., Fonagy, P., & Van Houdenhove, B. (2010). The interpersonal regulation of stress: A developmental framework. Manuscript submitted for publication.Fonagy, P., & Luyten, P. (2009). A developmental, mentalization-based approach to the understanding and treatment of borderline personality disorder. Development and Psychopathology, 21(4), 1355-1381.Fonagy, P., Luyten, P., Bateman, A., Gergely, G., Strathearn, L., Target, M., et al. (2010). Attachment and personality pathology. In J. F. Clarkin, P. Fonagy & G. O. Gabbard (Eds.), Psychodynamic psychotherapy for personality disorders. A clinical handbook (pp. 37-87). Washington, DC: American Psychiatric Publishing.

Controlled

Automatic

That handkerchief which I so loved and gave theeThou gavest to Cassio.By heaven, I saw my handkerchief in's hand.

Dimensions of mentalization: implicit/automatic vs explicit/controlled in Othello

Controlled Automatic

Why, how now, ho! from whence ariseth this?Are we turn'd Turks, and to ourselves do thatWhich heaven hath forbid the Ottomites?For Christian shame, put by this barbarous brawl:

Love Spurned/ Arousal

Controlled

Automatic


Dimensions of mentalization: implicit/automatic vs explicit/controlled in Othello


Lateral PFC Medial PFCLateral temporal cortex

Amygdala Ventromedial PFC

Controlled

Automatic

Arousal

Dimensions of mentalization: implicit/automatic vs explicit/controlled

Psychological understanding drops and is rapidly replaced by confusion about mental states under high arousal

Controlled

Automatic

Controlled

Automatic



Arousal

Dimensions of mentalization: implicit/automatic vs explicit/controlled

Arousal

Psychotherapist’s demand to explore issues that trigger intense emotional reactions involving conscious reflection and explicit mentalization are inconsistent with the patient’s ability to perform these tasks when arousal is high

Controlled

Automatic

Dimensions of mentalization: internally vs externally focused (mental interiors vs visible clues)

Internal External

I wonder if he feels his mother loved him?

He looks tired; perhaps he slept badly

With selective loss of sense of mental interiors, external features are given inappropriate weight and misinterpreted as indicating dispositional states

Internal

External

You’re covering your eyes; you can hardly bear to look at me

Dimensions of mentalization: Cognitive vs affective mentalization

Agent attitude propositions

“I think he thought that England would beat Germany”


Cognition Emotion

Self affect state propositions

“I feel sad about it too”


With diminution of cognitive mentalization the logic of emotional mentalization (self- affect state proposition) comes to be inappropriately extended to cognitions.

“I feel sad, you must have hurt me”

Dimensions of mentalization: Cognitive vs affective mentalization

Cognition

Emotion

A biobehavioral switch model of the relationship between stress and controlled versus automatic mentalization (Based on Luyten et al., 2009)

Attachment - Arousal/Stress

Maltreatment Maltreatment intensifies attachment relationships:

when there is distress / fear, the attachment system is triggered and the attachment figure is sought out

The attachment system of a maltreated child is

hyperactivated: there is a rapid escalation of intimacy and the child seeks comfort from an unsafe attachment figure. The child is therefore at risk of receiving more maltreatment – which gives rise to a cycle

During this episode mentalization is inhibited

DISTRESS/FEAR

Adverse emotional experience rooted in

traumatic relationships

Inhibition of mentalisation

Intensification of attachmentneeds

Inhibition of social understanding associated with maltreatment can lead to exposure to further abuse

Inaccurate judgements of affect, Delayed development of mentalization understanding

Failure to understand how emotions relate to situations and behavior

DISTRESS/FEAR

Exposure to maltreatment

Inhibition of mentalisation

Intensification of attachment

Inhibition of social understanding associated with maltreatment can lead to exposure to further abuse

Inaccurate judgements of facial affects, Delayed theory-of-mind understanding

Failure to understand the situational determinants of emotions

Theory: Mayes’ (2001) Adaptation of Arnsten’s Dual Arousal Systems Model

Per

form

ance

Arousal

Point 1a

Point 1

HighLow

Posterior cortex andsubcortical capacities

Prefrontal capacities

Changing switchpoint

threshold




Mentalexteriorcue focused





AROUSAL

Mentalizing Profile Associated with ArousalFonagy, P., & Luyten, P. (2009). Development and Psychopathology, 21, 1355-1381.

amygdala, basal ganglia, ventromedial prefrontal cortex (VMPFC), lateral temporal cortex (LTC) and the dorsal anterior cingulate cortex (dACC)

lateral and medial prefrontal cortex (LPFC & MPFC), lateral and medialparietal cortex (LPAC & MPAC), medial temporal lobe (MTL),rostral anterior cingulate cortex (rACC)



the medial prefrontal cortex, ACC, and the precuneus

frontoparietal mirror-neuron system

medial frontoparietal network activated

recruits lateral fronto-temporal network

AROUSAL

AROUSAL

AROUSAL

Implicit-Automatic

Explicit-Controlled

Mentalinterior focused

Mentalexterior focused





Impression driven

Appearance

Certainty of emotion

Treatment vectors in re-establishing mentalizingin borderline personality disorder

Controlled

Inference

Doubt of cognition

Emotional contagion Autonomy

Identity diffusion: The

functional overlap

hypothesis

Mentalizing as a multidimensional neuroscience construct

Two distinct neural networks are shared by self-knowing and knowing others (Lieberman, 2007; Uddin et al., 2007) frontoparietal mirror-neuron system (Keysers & Gazzola,

2006; Rizzolatti, Ferrari, Rozzi, & Fogassi, 2006). the medial prefrontal cortex, ACC, and the precuneus

(Frith, 2007; Frith & Frith, 2006; Uddin et al., 2007) The inhibition of imitative behavior involves cortical

areas that are also related to mentalizing, self-referential processing and determining self agency

Failure of medial prefrontal and temporo-parietal mentalizing function in BPD difficulties in decoupling their representations of another person’s experience from their self-representations.

Evidence for shared representations

DISCOS, LONDON 09

Cognitive psychology observation has a strong influence on movement execution (e.g. Brass et al., 2000, 2001, Kilner et al., 2003, Stuermer et al., 2000)

Social psychology chameleon effect (Chartrand & Bargh, 1999)

Cognitive neuroscience activation of motor related areas by action observation (e.g. Grezes & Decety, 1999, Iacoboni et al., 1999, 2001, Calvo-Merino et al., 2005, 2006)

Neurophysiology mirror neurons (e.g. Rizzolatti & Craighero, 2004)

The origins of shared representations

The imitation-inhibition task

congruent incongruentbaseline

The imitation-inhibition task

++

Lift the index finger when a `1` appearsand the middle finger when a `2` appears.

Results

Brass, Bekkering, Wohlschläger & Prinz, 2000

incongruentbaselinecongruent

The neural signature of imitation-inhibition

incongruent vs. congruent

Brass, Derrfuss & von Cramon, 2005

anterior fronto-median cortex (aFMC)

temporo-parietal junction area (TPJ)

Gilbert et al. (2006) Decety & Grezes (2006)

red= mentalizing (only BA 10) red=mentalizing yellow=agency

imitation-inhibition (Brass et al., 2009)

Functional role of aFMC and TPJ

Functional-overlap hypothesis

The inhibition of imitative behaviour involves

cortical areas that are also related to mentalizing, self-referential processing and determining self agency.

We assume that this overlap reflects common underlying processes such as self/other distinction and decoupling of self and other.

Capacity to inhibit imitative behavior may be key to enabling us to generate a sense of ‘me-ness’ through achieving a ‘not-other’-ness

DISCOS, LONDON 09

Implication for the phenomenology of borderline personality disorder

Failure of medial prefrontal and temporo-parietal mentalizing function in BPD difficulties in decoupling their representations of another person’s experience from their self-representations

Patients with BPD feel vulnerable to loosing a sense of self in interpersonal interchange because they cannot adequately inhibit the alternative state of mind which is imposed on them through social contagion.

Perhaps the apparent determination to ‘manipulate and control’ the mind of others characteristic of BPD patients should be best seen as a defensive reaction, defending the integrity of the self within attachment contexts. without such control, they might feel excessively vulnerable to

loosing their sense of separateness and individuality.

The Cassel Step-down Treatment Study (Chiesa & Fonagy, in press) 297 patients in personality disorder services

(112 complete data, 31 males 81 females, 40% with some tertiary education)

Recruited through Cassel Residential inpatient programme (n=120)Cassel Community stepdown/outpatient programme

(n=113)MAU: Devon Personality Disorder services (n=64)

Treatment input and staff resourcesTreatment hours 16.2-18.2 versus 3.2 hoursStaff wte’s: residential 8.5 versus community 2.6

Adolescent hypermentalizing as the

vulnerability to borderline

PD

Movie for the Assessment of Social Cognition (MASC) (Dziobek et al 2006)

Requires subjects to watch a 15 min movie about 4 characters at a dinner party

The 4 characters (Sandra, Betty, Michael & Cliff) each have different motives for attending the party

Video is paused 46 times for questions about characters’ feelings, thoughts and intentions

Friendship & dating issues are the predominant themes


Picture 1: Cliff is the first to arrive at Sandra’s house for the dinner party. He and Sandra seem to enjoy themselves when Cliff is telling about his vacation in Sweden


Picture 2: When Michael arrives, he dominates the conversation,directing his speech to Sandra alone


Picture 3: Slightly annoyed by Michael’s bragging story, Sandra shortly looks in Cliff’s direction and then asks Michael: ‘‘Tell me, have you ever been to Sweden?’’

Question: Why is Sandra asking this?


Example correct answers: To change to the topic that Cliff talked about before so

that he gets involved againTo redirect the conversation to CliffTo integrate Cliff

Example incorrect answers:To hear if Michael also has something interesting to say

about SwedenTo see which of the two guys has a cooler story to tellShe is very suspicious of Michael and thinks he is making

it up because he is the kind of person who tries to deal with his inadequacy by making up stories so she wants to see if Michael can corroborate Cliff’s story

Correlation Between Movie for the Assessment of Social Cognition (MASC) and Borderline Personality Features Scale for Children(Sharp et al., 2011)

-0.6

-0.4

-0.2

0

0.2

0.4

0.6

0.8

Total Theory of Mind Excessive Theory of Mind No Theory of Mind

N=107

Source: Sharp et al, 2011, J. Amer. Acad. Child & Adolesc. Psychiatry, 50: 563-573

p<0.02

p<0.00005

n.s.

Correlations between mentalizing and emotion regulation and borderline features (Sharp et al., 2011)

(**)

Source: Sharp et al, 2011, J. Amer. Acad. Child & Adolesc. Psychiatry, 50: 563-573

0.42*** (0.19*)

BPD

(BPFSC)

0.75** (0.69**)Hypermentalizing

(MASC)

Emotion Regulation

(DERS)

0.27*

*p < .05, **p < .01, ***p < .001

Hypermentalizing leads to emotion disregulation which leads to borderline personality features (Sharp et al., 2011, J.Am. Acad. Child. Adol. Psychiat., 60, 563-573.)

Variable B SE B ß R2 P

Step 1

Hypermentalizing 1.56 .370 .383** .15 .0001

Step 2

Hypermentalizing .793 .270 .194* .58 < .0001

DERS .375 .036 .686**

Hypermentalizing is reduced with BPD symptoms during inpatient treatment (Sharp et al., submitted)

Tendency to hypermentalize is malleable through milieu-based inpatient treatment: interpersonal-psychodynamic, although cognitive-behavioral, family systems, and psychoeducational approaches are incorporated into the treatment approach.

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Mentalization and attachment the implication for community based therapies

Technology

mentalization andattachment

mentalization intitle

mentalization baroncohen

social behavior

social emotions

social brain

self awareness

self simulation