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Mentalization and attachment the implication for community based therapies

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Mentalization and attachment the implication for community based therapies

  1. 1. Mentalization and attachment: The implication for community based therapies Peter Fonagy PhD FBA University College London & the Anna Freud Centre P.Fonagy@UCL.AC.Uk
  2. 2. Some of the Mentalizing Mafia  UCL/AFC/Tavistock  Dr Liz Allison  Prof George Gergely  Professor Alessandra Lemma  Dr Pasco Fearon  Professor Mary Target  Professor Eia Asen  Prof Anthony Bateman  Dr Trudie Rossouw  University of Leuven & UCL/AFC  Dr Patrick Luyten  Dr Dickon Bevington
  3. 3. Some more maffiosi (The USA branch)  Menninger Clinic/Baylor Medical College (The USA branch)  Dr Jon Allen  Dr Carla Sharp  Dr Lane Strathearn  Dr Efrain Bleiberg  Dr Brooks King-Casas  Professor Flynn O’Malley  Dr Read Montague  Yale Child Study Centre  Prof Linda Mayes  Professor Nancy Suchman
  4. 4. And European recruits to the ‘Family”  Dawn Bales  Professor Finn Skårderud  Dr Mirjam Kalland  Professor Sigmund Karterud •Cindy Decoste •Svenja Taubner •Catherine Freeman •Bart Vandeneede •Ulla Kahn •Annelies Verheught-Pleiter •Morten Kjolbe •Rudi Vermote •Benedicte Lowyck •Joleien Zevalkink •Tobi Nolte •Bjorn Philips •Marjukka Pajulo •Dr Peter Fuggle And Rose Palmer for help with the preparation of this presentation.
  5. 5. Let the boy You will never dream Ivan, amount to anything He is a born if you hold a ball dilettante! like that! I want to write my PhD on the “Use You look smug of low signal-to- now but you noise ratio stimuli will lose your for highlighting the hair just like functional Dad differences between the two cerebral hemispheres”.
  6. 6. Mentalization What is it? How does it arise? Why does it matter? How do we use it in therapy?
  7. 7. 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).
  8. 8. 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
  9. 9. 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)
  10. 10. 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).
  11. 11. 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
  12. 12. Articles using ‘mentalization’ in title or abstracts Number of articles on Web of Science Database Source: http://apps.webofknowledge.com, Data collected 10.1.2012
  13. 13. Clear evidence of mentalizing? JUST RELEASED! NEW! IMPROVED! Longer than all previous Washes brains versions! whiter! 2012 American Psychiatric Publishing, Inc
  14. 14. Mentalization and Overlapping Constructs (Choi-Kain & Gunderson, Am J Psychiat 2008)
  15. 15. Measuring Mentalization (Baron- Cohen et al., 2001) Reading the Mind in the Eyes Test Friendly - A Sad - B Surprised - C Worried - D
  16. 16. Measuring Mentalization (Baron-Cohen et al., 2001) Reading the Mind in the Eyes Test Surprised-A Sure about something-B Joking-C Happy-D
  17. 17. Measuring Mentalization (Baron- Cohen et al., 2001) Reading the Mind in the Eyes Test Joking-A Flustered-B Desire-C Convinced-D
  18. 18. Mentalizing at the World Cup: How does Robert Green feel after letting in the USA goal? Upset Angry Disappointed Frustrated
  19. 19. Shared neural circuits for mentalizing about the self and others (Lombardo et al., 2009; J. Cog. Neurosc.) Self mental state Other mental state Overlapping for Self and Other
  20. 20. 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 us  The 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
  21. 21. Affect & Self Regulation Through Psychological Representation of self-state: Mirroring Self: co n ting Internalization e nt d 2nd Order of object’s image ex p ispl ay Representations und ressio erst ood n of Expression affe ct symbolic organisation of internal state Physical Self: Reflection Primary Representations signal Constitutional self al Resonance no n-verb in state of arousal pressio n ex Infant CAREGIVER Fonagy, Gergely, Jurist & Target (2002) With apologies to Gergely & Watson (1996)
  22. 22. Theory: Birth of the Agentive Self Attachment figure “discovers” infant’s mind (subjectivity) Internalization Representation of infant’s mental state Core of psychological self Inference Attachment figure Infant Infant internalizes caregiver’s representation to form psychological self Safe, playful interaction with the caregiver leads to the integration of primitive modes of experiencing internal reality  mentalization
  23. 23. ‘The baby looks at his mother’s face and finds himself there’ D. Winnicott ‘She/he thinks that I think, therefore I am’
  24. 24. 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
  25. 25. The development of mentalization from infancy to adolescence and beyond
  26. 26. The development of mentalization  Weeks after birth the baby smiles at humans (social beings) in preference to objects  Can 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 field  A key first step in establishing joint attention (Moore, 2008).
  27. 27. 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)
  28. 28. False belief task: unexpected transfer (Wimmer & Perner, 1983) Test question Where will he look first heshe Mum After that, leaves Thenfor putsbook? Then hisleaves to Maxi to tidy up his comes somein book Mumdothe garden Now,takes it work to in Maxi returns and puts the play book in the thethe room book out in bookshelf of the kitchen. looking forcupboard, the his cupboard
  29. 29. Effect of Age in 178 separate studies 2nd ½ of 4th year 4y 2nd 4y of 4th year ½ Very robust developmental trends most manipulations ineffective Meta-analysis of False Belief Studies (Wellman et al., 2009)
  30. 30. The embodied mind and research on the human infant  Massive denial of infant mentation outside of psychoanalysis until about 75 years ago  Half 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 cognitive  Freud may have been correct about the mental life being somatically grounded (the body is at the root of meaning.
  31. 31. Sensitivity to others’ state of mind False belief for baby True belief for Smurf True belief for baby False belief for Smurf Á M Kovács et al. Science 2011;330:1830-1834
  32. 32. Sensitivity to others’ state of mind Ball Not There Ball Not There True belief for baby False belief for baby False belief for Smurf The infant but not the Infant knows ball is not there Smurf believes that But Smurf believes it should the ball should be there be there Neither infant nor Neither infant nor the smurf believe the Smurf believe that that ball is there the ball should be there The two key conditions in Smurf Study: Infant of 7 months considers what agent (Smurf) believes about the status of ball Á M Kovács et al. Science 2010, 330:1830-1834 Published by AAAS
  33. 33. Principle of Fairness  According to the Principle of Fairness, agents should deal fairly with others distribution of resources compensation for work  Sloane, Baillargeon, and Premack (2010) 9 months olds Animate or inanimate giraffes Reasonable 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)
  34. 34. Animate giraffes condition
  35. 35. Test trials I have toys Yay! Yay!
  36. 36. Inanimate giraffes condition: Same giraffes – no movement
  37. 37. Results–9 mnths olds: looking time Animate Giraffes Inanimate Giraffes Condition Condition Unequally distributed toys Equally distributed toys Mean Looking Time (sec) *
  38. 38. The infantile origins of psychopathology  Infants have genetically inbuilt ‘healthy’ social expectations  Social experience to be developmentally ‘good enough’ has to comply with these expectations  Fit in with biologically prepared mechanisms which evolved to transmit human culture  Be 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
  39. 39. The role of contingent caregiver responding in the development of cognitions
  40. 40. 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
  41. 41. The Pedagogical Stance is triggered by Ostensive-Communicative cues  Examples of ostensive communication cues eye-contact turn-taking contingent reactivity special tone (motherese)  Ostensive cues function: to signal that the other has a Communicative Intention addressed to the infant/child to Manifest New and Relevant information about a referent
  42. 42. Experimental illustration of ostensive cues Gergely, Egyed et al. (in press) Subjects : 4 groups of 18-month-olds Stimuli: Two unfamiliar objects
  43. 43. 1: Baseline – control group No object-directed attitude demonstration Simple Object Request by Experimenter A Subjects: n= 20 Age: 18-month-olds
  44. 44. Ostensive Communicative Demonstration Requester: OTHER person (Condition 1) Other person
  45. 45. Non-Ostensive (Non-Communicative) Demonstration Requester: OTHER person (Condition 2) Other person
  46. 46. Condition 4: Non-Ostensive (Non-Communicative) Demonstration Requester: SAME person Same person
  47. 47. 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)  Evidence  Cognitive advantage of secure attachment  Contingent responsiveness to the infant’s own (at first, automatic) expressive displays in secure attachment  During “mirroring” interactions, the other will “mark” her referential emotion displays in a ‘manifestative’ manner to instruct the infant
  48. 48. How Attachment Links to Affect Regulation DISTRESS/FEAR BONDING Down Regulation of Emotions Exposure to Threat Activation of attachment EPISTEMIC TRUST Proximity seeking The forming of an attachment bond
  49. 49. 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 learning  Opening 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
  50. 50. The role of oxytocin in social understanding
  51. 51. Secure attachment is facilitative of mentalizing  Children pass theory of mind tasks earlier if Had secure attachment relations with parents in infancy If parent’s own state of mind in relation to attachment was secure Family members relate to each other in payful, mentalizing way  Mechanism may well be mediated by oxytocin
  52. 52. Oxytocin and performance on Mind in the Eyes test (Domes et al., 2008)
  53. 53. Shared characteristics of evidence based therapies for BPD likely to enhance the organization of mental states?
  54. 54. 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
  55. 55. 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
  56. 56. Evidence based or promising treatments SFT CAT MBT TFP DBT STEPPS DBT MBT
  57. 57. MBT is in its infancy as an EST Prof. Anthony Bateman, MD Prof. Peter Fonagy, PhD FBA
  58. 58. Psychotherapy for BPD  A range of structured treatment programmes for BPD shown to be effective in studies DBT TFP  Do they work for SFT CBT the reasons the SPT developers suggest? DDP CAT GPM MBT
  59. 59. Gaps in Therapy Outcomes Research  Nosolid evidence for who will benefit from what type of psychotherapy  ‘Inexacttherapies’  partial effectiveness  ‘Attachment to methods’  ‘guildification’ of interventions
  60. 60. 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
  61. 61. 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
  62. 62. 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
  63. 63. Social Systems Can be Described as More or Less Mentalizing
  64. 64. 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 family Economic pressures to be part of the workforce Inadequate social support for parenting Social isolation of the nuclear family  a “Perfect Storm” from perspective of human evolution
  65. 65. Alloparenting is not a new idea!
  66. 66. Typical Size of Human Family Group Across Evolution 50 45 Size of family group 40 35 30 25 20 15 10 5 0 10,000BC 1,500BC 1850AD 1900AD 1980AD Humans spent 99% of history living in groups of 35-40 people
  67. 67. Humans as part of a wider ecosystem Connected Connected Connected Connected Connected Mind Mind & Body Families Communities Environment
  68. 68. 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’
  69. 69. Some components of a successfully mentalizing social system 1. 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
  70. 70. 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
  71. 71. 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)
  72. 72. Vicious cycles of inhibition of mentalizing within a disorganized social system Powerful emotion Frightening, undermining, frustrating, distressing or coercive interactions Poor mentalising Loss of certainty Inability to understand or even pay attention that thoughts are to feelings of others not real Try to control or Others seem change others incomprehensible
  73. 73. Vicious Cycles of Non- Mentalizing Within a Dysfunctional Social System Powerful emotion Powerful emotion Frightening, undermining, Poor mentalising Frightening, undermining, Poor mentalising frustrating, distressing or frustrating, distressing or coercive interactions coercive interactions Person 1 Inability to understand Person 2 Inability to understand or even pay attention or even pay attention to feelings of others to feelings of others Try to control or Try to control or change others or change others or oneself oneself Others seem Others seem incomprehensible incomprehensible
  74. 74. Non-Mentalizing Disorganized Social Systems: Psychic Equivalence Systems  Mind-world isomorphism; mental reality = outer reality; internal has power of external  Attitudes to ideas and feelings Thoughts 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
  75. 75. 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 feelings  People 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
  76. 76. 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 world  Only what is material can be meaningful  Attitudes to ideas and feelings  A focus on understanding actions in terms of their physical as opposed to mental outcomes  Only 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 other o 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
  77. 77. 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
  78. 78. Neural dimensions of mentalization in BDP: Controlled vs automatic mentalization
  79. 79. 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)
  80. 80. Multifaceted Nature of Mentalization Fonagy, P., & Luyten, P. (2009). Development and Psychopathology, 21, 1355-1381. Implicit- Explicit- amygdala, basal ganglia, lateral and medial prefrontal cortex Automatic- ventromedial prefrontal (LPFC & MPFC), lateral and medial Controlled Non -conscious- cortex (VMPFC), parietal cortex (LPAC & MPAC), Conscious lateral temporal cortex (LTC) medial temporal lobe (MTL),rostral Immediate. and the dorsal anterior anterior cingulate cortex (rACC) Reflective cingulate cortex (dACC) Mental Mental interior medial frontoparietal recruits lateral fronto-temporal exterior network activated network cue cue focused focused Cognitive Affective agent:attitude Associated with several areas Associated with inferior prefrontal self:affect state propositions of prefrontal cortex gyrus propositions Imitative Belief-desire the medial prefrontal cortex, frontoparietal frontoparietal mirror-neuron ACC, and the precuneus MPFC/ACC system mirror neurone inhibitory system system
  81. 81. Mentalizing Profile of Prototypical BPD patient Fonagy, P., & Luyten, P. (2009). Development and Psychopathology, 21, 1355-1381. BPD Implicit- Explicit- Automatic- Controlled Non -conscious- Conscious Immediate. Reflective Mental BPD External interior visible cue cues focused focused BPD Affective Cognitive agent:attitude self:affect state propositions propositions BPD Imitative Belief-desire frontoparietal MPFC/ACC mirror neurone inhibitory system system
  82. 82. 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.
  83. 83. Dimensions of mentalization: implicit/automatic vs explicit/controlled in Othello That handkerchief which Iariseth this? and gave thee Why, how now, ho! from whence so loved Thou gavest to Cassio. Are we turn'd Turks, and to ourselves do that By heaven, Ihath forbid the Ottomites? in's hand. Which heaven saw my handkerchief Cont For Christian shame, put by this barbarous brawl: rolled Controlled Automatic Autom atic Love Spurned/
  84. 84. Dimensions of mentalization: implicit/automatic vs explicit/controlled in Othello That handkerchief which I so loved and gave thee ThouLateral to Cassio. gavest temporal PFCAmygdala Lateral Medial Ventromedial PFC PFC By heaven, I saw my handkerchief in's hand. cortex Cont rolled Controlled Automatic Autom atic Arousal
  85. 85. Dimensions of mentalization: implicit/automatic vs explicit/controlled Psychological understanding drops and is rapidly replaced by confusion about mental states under high arousal That handkerchief which I so loved and gave thee Thou gavest to Cassio. By heaven, I saw my handkerchief in's hand. Cont rolled Controlled Automatic Autom atic Arousal
  86. 86. Dimensions of mentalization: implicit/automatic vs explicit/controlled 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 Cont rolled Autom atic Arousal
  87. 87. Dimensions of mentalization: internally vs externally focused (mental interiors vs visible clues) Internal External I wonder if he feels He looks tired; his mother loved perhaps he slept him? badly
  88. 88. With selective loss of sense of mental interiors, external features are given inappropriate weight and misinterpreted as indicating dispositional states Intern al Exter nal You’re covering your eyes; you can hardly bear to look at me
  89. 89. Dimensions of mentalization: Cognitive vs affective mentalization Cognition Emotion  Agent attitude  Self affect state propositions propositions “I think he thought that England would beat “I feel sad about it too” Germany” Associated with inferior Associated with several prefrontal gyrus areas of prefrontal cortex
  90. 90. Dimensions of mentalization: Cognitive vs affective mentalization  With diminution of cognitive mentalization the logic of emotional mentalization (self- affect state proposition) comes to be inappropriately extended to cognitions. Cogn ition Emot ion “I feel sad, you must have hurt me”
  91. 91. A biobehavioral switch model of the relationship between stress and controlled versus automatic mentalization (Based on Luyten et al., 2009) Attachment - Arousal/Stress
  92. 92. 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
  93. 93. Inhibition of social understanding associated with maltreatment can lead to exposure to further abuse DISTRESS/FEAR Adverse emotional experience rooted in Intensification of attachment traumatic relationships needs Inhibition of mentalisation Inaccurate judgements of affect, Delayed development of mentalization understanding Failure to understand how emotions relate to situations and behavior
  94. 94. Inhibition of social understanding associated with maltreatment can lead to exposure to further abuse DISTRESS/FEAR Exposure to Intensification of attachment maltreatment Inhibition of mentalisation Inaccurate judgements of facial affects, Delayed theory-of-mind understanding Failure to understand the situational determinants of emotions
  95. 95. Theory: Mayes’ (2001) Adaptation of Arnsten’s Dual Arousal Systems Model Prefrontal capacities Posterior cortex and subcortical capacities Changing Point 1a Performance switchpoint threshold Point 1 Low High Arousal
  96. 96. Mentalizing Profile Associated with Arousal Fonagy, P., & Luyten, P. (2009). Development and Psychopathology, 21, 1355-1381. AROUSAL Implicit- Explicit- amygdala, basal ganglia, lateral and medial prefrontal cortex Automatic- ventromedial prefrontal (LPFC & MPFC), lateral and medial Controlled Non -conscious- cortex (VMPFC), parietal cortex (LPAC & MPAC), Conscious lateral temporal cortex (LTC) medial temporal lobe (MTL),rostral Immediate. and the dorsal anterior anterior cingulate cortex (rACC) Reflective cingulate cortex (dACC) Mental AROUSAL Mental interior medial frontoparietal recruits lateral fronto-temporal exterior network activated network cue cue focused focused AROUSAL Affective Cognitive agent:attitude Associated with several areas Associated with inferior prefrontal self:affect state propositions of prefrontal cortex gyrus propositions AROUSAL Imitative Belief-desire the medial prefrontal cortex, frontoparietal frontoparietal mirror-neuron ACC, and the precuneus MPFC/ACC system mirror neurone inhibitory system system
  97. 97. Treatment vectors in re-establishing mentalizing in borderline personality disorder Impression driven Controlled Implicit- Explicit- Automatic Controlled Mental Appearance Inference Mental interior exterior focused focused Certainty of emotion Doubt of cognition Affective Cognitive agent:attitude self:affect state propositions propositions Emotional contagion Autonomy Imitative Belief-desire frontoparietal MPFC/ACC mirror neurone inhibitory system system
  98. 98. Identity diffusion: The functional overlap hypothesis
  99. 99. 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.
  100. 100. Evidence for shared representations 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) DISCOS, LONDON 09
  101. 101. The origins of shared representations
  102. 102. The imitation-inhibition task congruent baseline incongruent
  103. 103. The imitation-inhibition task Lift the index finger when a `1` appears and the middle finger when a `2` appears. + +
  104. 104. Results congruent baseline incongruent Brass, Bekkering, Wohlschläger & Prinz, 2000
  105. 105. The neural signature of imitation-inhibition incongruent vs. congruent anterior fronto-median cortex (aFMC) temporo-parietal junction area (TPJ) Brass, Derrfuss & von Cramon, 2005
  106. 106. Functional role of aFMC and TPJ Gilbert et al. (2006) Decety & Grezes (2006) imitation-inhibition (Brass et al., 2009) red= mentalizing (only BA 10) red=mentalizing yellow=agency
  107. 107. 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
  108. 108. 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.
  109. 109. 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 resources  Treatment hours 16.2-18.2 versus 3.2 hours  Staff wte’s: residential 8.5 versus community 2.6
  110. 110. Adolescent hypermentalizing as the vulnerability to borderline PD
  111. 111. 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
  112. 112. Movie for the Assessment of Social Cognition (MASC) (Dziobek et al 2006) 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
  113. 113. Movie for the Assessment of Social Cognition (MASC) (Dziobek et al 2006) Picture 2: When Michael arrives, he dominates the conversation, directing his speech to Sandra alone
  114. 114. Movie for the Assessment of Social Cognition (MASC) (Dziobek et al 2006) 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?
  115. 115. Movie for the Assessment of Social Cognition (MASC) (Dziobek et al 2006)  Example correct answers:  To change to the topic that Cliff talked about before so that he gets involved again  To redirect the conversation to Cliff  To integrate Cliff  Example incorrect answers:  To hear if Michael also has something interesting to say about Sweden  To see which of the two guys has a cooler story to tell  She 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
  116. 116. Correlation Between Movie for the Assessment of Social Cognition (MASC) and Borderline Personality Features Scale for Children (Sharp et al., 2011) 0.8 p<0.00005 N=107 0.6 0.4 n.s. 0.2 p<0.02 0 -0.2 -0.4 -0.6 Total Theory of Mind Excessive Theory of Mind No Theory of Mind Source: Sharp et al, 2011, J. Amer. Acad. Child & Adolesc. Psychiatry, 50: 563-573
  117. 117. 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
  118. 118. Hypermentalizing leads to emotion disregulation which leads to borderline personality features (Sharp et al., 2011, J.Am. Acad. Child. Adol. Psychiat., 60, 563-573.) 0.42*** (0.19*) 0.27* 0.75** Hypermentalizing Emotion (0.69**) BPD Regulation (MASC) (DERS) (BPFSC) *p < .05, **p < .01, ***p < .001 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**
  119. 119. 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.
  120. 120. MBT IS CHEAP AND COMFORTABLE AND HELPFUL IN A RANGE OF WAYS!!!
  121. 121. For Electronic version please e-mail: P.FONAGY@UCL.AC.UK

Hinweis der Redaktion

  • There is fairly general qgreement where mentalization is located in the brain.
  • The capacity to mentalize has also been argued to account for the other major difference between humans and other apes: (1) self awareness and self-consciousness as a path to simulation bringing with it social emotions such as embarrassment, shame and guilt; (2) 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; (3) the social origin of the self in the recognition of oneself in the mental state of the other as the root to a sense of selfhood (see Allen, Fonagy, &amp; Bateman, 2008 for a more comprehensive review of the concept)
  • This Venn diagram maps the conceptual overlaps between mentalization and four related concepts including mindfulness, psychological mindedness, empathy, and affect consciousness, which are represented by the four circles. The lines which bifurcate the diagram according to its three dimensions (i.e., self-/other-oriented, implicit/explicit, and cognitive/affective) are dashed to illustrate the permeable and nonabsolute nature of these divisions. In the self/ other dimension, mindfulness focuses more on mental states within oneself, while empathy is primarily understood in terms of one’s imagination of mental states within others. Both affect consciousness and psychological mindedness concern both sides of the self and other distinction. While mindfulness and psychological mindedness emphasize both cognitive and affective aspects of mental states and function explicitly, affect consciousness and empathy relate more primarily to affective mental contents and function both explicity and implicity. Mentalization lies at the intersection of these concepts but the boundaries between them are not distinctly drawn.
  • Mentalization allows us to have common experiences – we need to coordinate our emotional experiences to function in large social groups. Imagine what would happen if we all felt differently about Lampard’s disallowed goal! Fortunately not the case.
  • Have to be able to step into the shoes of another person -
  • CAN DEVELOPMENTAL PSYCHOLOGUY RESEARCH HELP US GET CLOSER TO THE POTENTIAL SOCIAL EXPEREINCES THAT COULD SET OF THE EPIGENETIC CASCADE THAT Dr Moshe Szyf was describing to us yesterday? INTERSUBJECTIVE ORIGINS OF THE SELF
  • JUST HOW IMPORTANT CONTINGENT RESPONDING TO AFFECT IS WE KNOW FROM STILL FACE PARADIGM (GERGELY)
  • What is the control syste
  • There has been formidable resistance to envision the rich affective and mindful life that we now know infants do have from birth, probably for a considerable time prior to birth to the small person who cry when hungry or smile after a good feed. Psychoanalysts who dared attribute complex mental states to infants were ridiculed and pilloried (e.g. Glover, 1945). Half 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? Modern cognitive and affective neurosciences confirms Freud’s assumption that mental life was somatically grounded, the body being at the root meaning making. Neuroscience findings consistently suggest that higher order representational systems (abstract and metaphoric thought, social cognition) are reliant on bodily markers and simulation of how we perceive and experience our body in action (e.g. Barsalou, 2008; Gallese, 2007).
  • Logical structure of events in Experiment 1. ( A ) In all four conditions, the agent enters the scene, placing a ball on a table ( 13 ) (Movie S1). The ball then rolls behind an occluder. ( B ) In the agent’s presence, the ball stays behind the occluder (a and c), or leaves the scene (b and d). As a result, the agent (A) “believes” either that the ball is behind the occluder or that there is no ball behind the occluder. Then, the agent leaves the scene. ( C ) In the agent’s absence, the ball leaves the scene (c), returns behind the occluder (d), or does not move (a and b). Thus, the participant (P) either believes the ball to be behind the occluder (a and d), or to have left (b and c). ( D ) The agent reenters the scene, and the occluder is lowered. In half of the trials of all conditions, participants see the ball behind the occluder. We measure ball detection latencies as a function of (i) the participant’s belief (P+, ball behind occluder, versus P–, no ball behind occluder) and (ii) the agent’s “belief” (A+, ball behind occluder, versus A–, no ball behind occluder), resulting in two true belief conditions and two false belief conditions. The figure does not reflect the actual timing of the events. To control for the timing differences, we used pairs of conditions matched for their timing properties ( 13 ).
  • Results of Experiments 4 to 7. Looking times in 7-month-old infants. Bars represent average looking times, and error bars show SEM (see Fig. 1 for condition labels). (A) Results of Experiment 4 (true belief). Looking times for the condition when infants (and the agent) believed the ball to be behind the occluder (P+A+) and for the condition when neither the infants nor the agent believed the ball to be behind the occluder (P–A–). (B) Results of Experiment 5 (false belief; agent present in the last scene). Looking times for the condition when only the agent (falsely) believed the ball to be behind the occluder (P–A+) (Movie S1), and for the condition when neither they nor the agent believed the ball to be behind the occluder (P–A–) . (C) Results of Experiment 6 (no outcome control). Looking times for two conditions that were identical to the ones used in Experiment 4, except that the occluder was not lowered at the end of the movies. Thus, infants did not see whether the ball was present behind the occluder. As a result, there were no confirmed nor violated beliefs. (D) Results of Experiment 7 (false belief; agent absent in the last scene). Looking times for the two conditions where the agent was replaced with a pile of boxes in the very last scene (corresponding to Fig. 1D). We compared the condition where only the agent (falsely) believed the ball to be behind the occluder (P–A+) with the condition where neither the infants nor the agent believed the ball to be behind the occluder (P–A–). n analogy to Experiment 2, Experiment 7 asked whether infants would maintain others’ beliefs even in the agent’s absence. Specifically, infants were presented with the baseline condition (where both the infant and the agent believed that the ball was not there) and a condition where only the agent believed the ball to be behind the occluder. Before the occluder was lowered, however, a pile of boxes, rather than the agent, entered the scene. As in Experiment 5, infants looked longer than in the baseline condition when the agent (who was not present when the occluder was lowered) believed that the ball was behind the occluder [ F (1,13) = 6.75, P = 0.02] ( Fig. 3D ). Hence, like adults in Experiment 2, infants seem to compute others’ beliefs online and to maintain them even in the absence of the agent. Possibly, the boxes could have prompted participants to think of the agent and his beliefs, although there was no relation between the boxes and the agent. However, even if the boxes reminded participants the agent, our results can be explained only if participants computed the agent’s beliefs and sustained them even though the agent was not present. Together, our results suggest that the mere presence of social agents is sufficient to automatically trigger online belief computations not only in adults, but also in 7-month-old infants. Once the beliefs have been computed, adults and infants maintain them even in the absence of the agent, presumably for later use in social interactions. Hence, from 7 months on, an age by which infants attribute goals and intentionality ( 14 ), humans automatically compute other’s beliefs and seem to hold them in mind as alternative representations of the environment. As a result, at least in implicit tasks like ours, others’ (false) beliefs can influence infants’ and adults’ behavior similarly to their own (true) beliefs. The finding that others’ beliefs can be similarly accessible as our own beliefs might seem problematic for an individual, because it may make one’s behavior susceptible to others’ beliefs that do not reliably reflect the current state of affairs. However, the rapid availability of others’ beliefs might allow for efficient interactions in complex social groups. These powerful mechanisms for computing others’ beliefs might, therefore, be part of a core human-specific “social sense,” and one of the cognitive preconditions for the evolution of the uniquely elaborate social structure in humans.
  • Hyperactivation of attachment system may be core aspect of BPD 2c
  • Just how important contingencies are for all of us
  • Oxytocin is the VIAGRA of mentalization
  • Around in great quantity (breast feeding) when the infant needs it most – when it totally depends on being understood Oxytocin turns us towards the face to try to find the mind therein
  • Psychic equivalence : Mind-world isomorphism; mental reality = outer reality; internal has power of external  Fran Intolerance of alternative perspectives  ”YOU LOOKED AT YOUR WATCH” Pretend mode : Ideas form no bridge between inner and outer reality; mental world decoupled from external reality  FRAN “ dissociation” of thought, hyper-mentalizing or pseudo-mentalizing  ENDLESS HOURS OF ‘THERAPY’ Teleological stance : A focus on understanding actions in terms of their physical as opposed to mental constraints Cannot accept anything other than a modification in the realm of the physical as a true index of the intentions of the other. Long version2 has some new slides in it
  • Long version2 has some new slides in it
  • NOT ALL PROTOCOLS HAVE THE SAME EVIDENCE BASE WE ARE UNDER NO ILLUSIONS ABOUT MBT AS AN EST
  • ONE MAY BE FORGIVEN FOR CONTEMPLATING IF ANY Treatment WITH A 3 LETTER ACRONYM HAS A CHANCE OF IMPROVING THE WELLBEING OF INDIVIDUALS WITH BPD All provide structure – Perhaps it is the structure that is crucial because allows people to think. If we just provide a structure that tells therapists what to do will we remove the effective component.
  • The brain is not organized into neural networks localized based on professional associations.
  • 2c
  • Extensive effort to maintain engagement in treatment (validation in conjunction with emphasis on need to address therapy interfering behaviours) Includes a model of pathology that is explained to the patient ( Active therapist stance: Explicit intent to validate and demonstrate empathy, generate strong attachment relationship Focus on emotion processing and connection between action and feeling (suicide feeling == abandonment feelings) Inquiry into patients’ mental states (behavioral analysis, clarification, confrontation) Structure of treatment provides increased activity, proactivity and self-agency (eschew expert stance, “sit side-by-side”) Structure is manualized with adherence monitored Commitment to the approach Supervision to identify deviation from structure and support for adherence
  • Extensive effort to maintain engagement in treatment (validation in conjunction with emphasis on need to address therapy interfering behaviours) Includes a model of pathology that is explained to the patient ( Active therapist stance: Explicit intent to validate and demonstrate empathy, generate strong attachment relationship Focus on emotion processing and connection between action and feeling (suicide feeling == abandonment feelings) Inquiry into patients’ mental states (behavioral analysis, clarification, confrontation) Structure of treatment provides increased activity, proactivity and self-agency (eschew expert stance, “sit side-by-side”) Structure is manualized with adherence monitored Commitment to the approach Supervision to identify deviation from structure and support for adherence
  • Extensive effort to maintain engagement in treatment (validation in conjunction with emphasis on need to address therapy interfering behaviours) Includes a model of pathology that is explained to the patient ( Active therapist stance: Explicit intent to validate and demonstrate empathy, generate strong attachment relationship Focus on emotion processing and connection between action and feeling (suicide feeling == abandonment feelings) Inquiry into patients’ mental states (behavioral analysis, clarification, confrontation) Structure of treatment provides increased activity, proactivity and self-agency (eschew expert stance, “sit side-by-side”) Structure is manualized with adherence monitored Commitment to the approach Supervision to identify deviation from structure and support for adherence
  • Long version2 has some new slides in it
  • Long version2 has some new slides in it
  • Long version2 has some new slides in it
  • Long version2 has some new slides in it
  • Long version2 has some new slides in it
  • Thoughts are real and therefore they have to be controlled – Orwellian thought police There are singular solutions to social reality, there are no alternative ways of seeing things, there is intolerance to perspectives (concrete and egocentric – if I thought it it is real, no self questioning) Models of minds are simple (black and white), schematic and rigidly held (demonization and dehumanization) – distorted mentalizing ( Negative ideas (threats) become terrifying Long version2 has some new slides in it
  • People 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 Long version2 has some new slides in it
  • A focus on understanding actions in terms of their physical as opposed to mental outcomes Only 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 other Physical acts of harm Demand for acts of demonstration of intent by others Long version2 has some new slides in it
  • Long version2 has some new slides in it
  • C
  • Early in the play Othello is presented as a reasonable man who tries to calm his hot-headed fellows, asking them to think about the reasons for their impulsive behaviour when they get into a brawl. However, later on as Iago’s insinuations plant the seed of doubt about his wife Desdemona’s fidelity in his mind, his arousal level increases to the point where he leaps to conclusions about her thoughts and feelings without controlled explicit mentalizing)
  • Early in the play Othello criticises others for their inability to control their impulse
  • This Venn diagram maps the conceptual overlaps between mentalization and four related concepts including mindfulness, psychological mindedness, empathy, and affect consciousness, which are represented by the four circles. The lines which bifurcate the diagram according to its three dimensions (i.e., self-/other-oriented, implicit/explicit, and cognitive/affective) are dashed to illustrate the permeable and nonabsolute nature of these divisions. In the self/ other dimension, mindfulness focuses more on mental states within oneself, while empathy is primarily understood in terms of one’s imagination of mental states within others. Both affect consciousness and psychological mindedness concern both sides of the self and other distinction. While mindfulness and psychological mindedness emphasize both cognitive and affective aspects of mental states and function explicitly, affect consciousness and empathy relate more primarily to affective mental contents and function both explicity and implicity. Mentalization lies at the intersection of these concepts but the boundaries between them are not distinctly drawn.
  • SO What is the idea behind MBT?
  • Powerful activation of the attachment system is incompatible with meaningful (as opposed to ruminative) contemplation of mental states As attachment intensifies and arousal increases, mentalization switches from a primarily controlled, reflective, internally focused cognitively complex prefrontally guided process to an automatic, externally focused emotionally intense posterior cortically and sub-cortically driven one Emotional arousal in BPD  lose explicit mentalizing and become particularly attuned to the states of mind of individuals around them Able to perform experimental mentalizing tasks relatively well under low arousal (Arntz, Bernstein, Oorschot, Robson, &amp; Schobre, 2006) Cannot explain the states of mind they experience under high arousal Show confusion about mental states as they are dominated by reflexive assumptions about the internal states of others psychotherapists of many orientations often aim to address and provide broader understandings for issues that trigger intense emotional reactions (challenging interpersonal situations, issues of shame, guilt, feelings of inadequacy etc). The demand for conscious reflection and explicit mentalization is inconsistent with the patient’s capacity to perform these tasks under high levels of arousal. This makes it particularly hard to change deeply ingrained implicit dispositional interpersonal ideas which rely on automatic and preconceived judgments of self and others.
  • Why is engaging the carergiver so important for the infant? Infant acquires affect regulation through close interaction with caregiver – comes to understand own emotional state Discovers himself through mirroring interactions
  • The TPJ is involved in perspective taking (Ruby &amp; Decety, 2001, 2003, Aichhorn et al., 2006), in sense of agency (Farrer et al., 2002, 2003, Decety &amp; Grezes, 2006) and mentalizing (Frith &amp; Frith, 1999) The aFMC is involved in mentalizing (Frith &amp; Frith, 1999, Firth &amp; Frith, 2003, Amodio &amp; Frith, 2006, Gilbert et al., 2006) and self-referential processing (Northoff and Bermpohl, 2004)
  • In fact, recent work by Brass’s group, using a within-subject experimental design with reflective mentalizing and imitation-inhibition tasks, suggests that there is a functional relationship between the inhibition of imitative behavior and the capacity for belief-desire reasoning (Brass et al., 2007). Thus it appears that the inhibition of imitative behavior 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.
  • In fact, recent work by Brass’s group, using a within-subject experimental design with reflective mentalizing and imitation-inhibition tasks, suggests that there is a functional relationship between the inhibition of imitative behavior and the capacity for belief-desire reasoning (Brass et al., 2007). Thus it appears that the inhibition of imitative behavior 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. the capacity to inhibit imitative behavior may be key to enabling us to generate a sense of ‘me’-ness through achieving a ‘not-other’-ness. In other words, each time we interpret the actions of another, there may be a sequence in which an initial imitative matching response with the other within a motor neuron self-other system interacts with the reflective mentalizing self-other system. Thus by necessity this involves an inhibition of the mirror system and reduces the extent of ‘primary identification’ with the other. Long version2 has some new slides in it
  • Thus,, we might extrapolate the hypothesis that the failure of medial prefrontal and temporo-parietal mentalizing function might leave the individual with difficulties in decoupling their representations of another person’s experience from their self-representations. Hence, if this is correct, 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, then, the evident determination to ‘manipulate and control’ the mind of others that is so characteristic of BPD patients should be best seen as a defensive reaction, defending the integrity of the self within attachment contexts. Otherwise, without such control, they might feel excessively vulnerable to loosing their sense of separateness and individuality. Long version2 has some new slides in it
  • Consistent findings show that the stronger the alliance the greater the therapeutic change (eg Horvath &amp; Bedi 2002; Orlinsky et al 2004) Therapeutic alliance is therefore often posited as a mediator and mechanism of therapeutic change Studies evaluating alliance during treatment often show that alliance predicts improvement in symptoms at end of treatment However, this in itself does not show that alliance plays a causal or mediational role
  • Subjects are asked to watch a 15-minute film about four characters getting together for a dinner party. Themes of each segment cover friendship and dating issues. Each character experiences different situations through the course of the film that elicit emotions and mental states such as anger, affection, gratefulness, jealousy, fear, ambition, embarrassment, or disgust. The relationships between the characters vary in the amount of intimacy (friends – strangers) and thus represent different social reference systems on which mental state inferences have to be made. During administration of the task, the film is stopped at 45 points during the plot and questions referring to the characters&apos; mental states (feelings, thoughts, and intentions) are asked (e.g., “What is Betty feeling?”, “What is Cliff thinking?”). Participants are provided with four responses options: (i) a hypermentalizing response, (ii) an undermentalizing response, a (iii) no mentalizing response and a (iv) accurate mentalizing response. To derive a summary score of each of the subscales, points are simply added, so that, for instance, a subject who chose mostly hypermentalizing response options would have a high hypermentalizing score. Similarly, participants&apos; correct responses are scored as one point and added. To calculate an overall mentalizing score, mentalizing errors are subtracted from accurate mentalizing, such that for the overall score, a higher score indicates accurate mentalizing. The MASC is a reliable instrument that has proven sensitive in detecting subtle mindreading difficulties in adults of normal IQ41, young adults63, as well as patients with bipolar disorder42, and autism64
  • Borderline Personality Features Scale for Children (BPFSC). The Difficulties in Emotion Regulation Strategies Scale (DERS). The DERS59 provides a comprehensive assessment of difficulties in ER, including awareness and understanding of emotions, acceptance of emotions, the ability to engage in goal-directed behavior and refrain from impulsive behavior when experiencing negative emotions, as well as the flexible use of situationally appropriate strategies to modulate emotional responses. It consists of 36 items that are scored on a 5 point Likert scale, ranging from 1 ( ‘almost never (0-10%)’ ) to 5 ( ‘almost always (91-100%)’ ). A higher total score indicates greater emotion dysregulation. The highest possible total score is 180. The measure has demonstrated adequate construct and predictive validity and good test-retest reliability in undergraduate students59, and was recently validated in a community sample of adolescents71. The DERS has been used previously in inpatient adolescent samples72, 73. In the present sample, internal consistency of this measure was good with a Cronbach’s alpha of .86.

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