Epistemic mistrust in babies:

A root to adult psychopathology

Peter Fonagy, OBE FMedSci FBA
Director, Integrated Mental Health Programme,
UCLPartners
Chief Executive, Anna Freud Centre
Slides from: P.Fonagy@ucl.ac.uk

Mentalization:
What is it?

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).

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Google Ngram of mentalization

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Mentalization: The Movie

(Inside Our an E-Motion Picture from Pixar

Attachments and
the development
of social
understanding

Measuring Mentalization (Baron-Cohen et

al., 2001) Reading the Mind in the Eyes Test
Friendly - A

Surprised - C

Sad - B

Worried - D

Measuring Mentalization (Baron-Cohen et

al., 2001) Reading the Mind in the Eyes Test
Surprised-A

Joking-C

Sure about something-B

Happy-D

Measuring Mentalization (Baron-Cohen et

al., 2001) Reading the Mind in the Eyes Test
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

Disappointed

Angry

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 for
Self 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 us
The parents capacity to mirror effectively her childs
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 childs anxiety aggravates
anxiety rather than soothe)
The same applies to child with inadequate sense of
independent self within therapeutic relationship

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

Attachment Disorganisation in Disrupted

Early Relationships
DISTRESS/FEAR

Exposure
to threat
Adverse
Emotional
Experience

Activation of attachment

Proximity seeking

The hyperactivation of the attachment system

High congruent & marked mirroring

Mirroring must not be too accurate, it

must be marked (systematically
distorted) so child knows he is not
observing caregivers dispositional state

Unmarked mirroring

Marked mirroring

Affect & Self Regulation Through

Representation
Mirroring
Psychological
Self:
2nd Order
Representations

of self-state:
Internalization
of objects image

Expression
symbolic organisation
of internal state

Physical Self:
Primary
Representations

Constitutional self
in state of arousal

Infant

Fonagy, Gergely, Jurist & Target (2002)

With apologies to Gergely & Watson (1996)

Reflection
Resonance

CAREGIVER

Theory: Birth of the Agentive Self

Attachment figure discovers infants mind (subjectivity)
Internalization
Representation of
infants mental
state

Core of
psychological
self

Attachment figure

Inference

Infant

Infant internalizes caregivers representation to form psychological self

Safe, playful interaction with the caregiver leads to the integration of primitive
modes of experiencing internal reality mentalization

Brain development 6-18 months

Babies start directing others attention by pointing from around 9-12 months
Little is known about neural basis of joint attention in infants
Adult research show the involvement the dorsal part of the
Joint attention
medial prefrontal cortex

and

posterior superior temporal

sulcus,

important areas of the

Mentalizing network

Tomaselo et al., 2007; Frith & Frith, 2006; Redkay, 2012

Social-cognitive development 6-18 months

Widening of discrimination of emotional displays
at 7 months infants show relatively enhanced visual and attention-sensitive ERPs, and
enhanced cardiac orientation response and increased attention-dwell time, to fearful
compared with neutral and happy expressions

Social Referencing
By 12 months, infants can use an adults emotional reaction to a novel object to inform
their own response
e.g. avoiding an object to which their mother expresses fear

However, understanding of emotions as an internal state that helps predict future

intentional actions is achieved later.

Happ & Frith, 2014; Vaish & Striano, 2004; Leppanen, 2011; Leppanen & Nelson, 2009; Camras & Shutter, 2010; Gergely, Egyed & Kiraly, 2007

Brain development 6-18 months

Attachment:
At 7-9 months, infants start showing stranger
wariness and distress at separation from carers
With increasing mobility at 12 months, exploratory
and safe haven behaviors become apparent
Strange Situation Procedure is widely used for
research at this age

Both mothers and babies show enhanced activation

of the anterior orbitofrontal cortex when seeing
each others faces versus strangers faces.

Zeanah, Berlin & Boris, 2011; Minagawa-Kawai et al., 2009;

Prediction from attachment class before

the childs birth to childs behavior
21%

27%
Secure
Insecure

79%

Secure Mums

73%

Insecure Mums

Prediction from attachment class before

the childs birth to childs behavior
18%

44%
Secure
Insecure

82%

Secure Dads

56%

Insecure Dads

Attachment, temperament & sensitivity:

genes & environment (N=188)

Mat. Sensitivity

Attachment security

C
E
52% 48%

Temperament

E
27%

A genes

A
73%

E non-shared

Source: Fearon, et al. (2006) Developmental Psychology

C
63%

C shared

E
37%

Mother's Reflective Function Predicts Infant-Mother

Strange Situation Classification at 12 months

% SSTs Classified

100%

80%
60%
40%
20%
0%
2

p <.0001

Reflective function ratings

Attachment classification at 12 months

Fonagy, Steele, Steele (1991) Inf. Ment

Health J.

Avoidant

Resistant

Secure

ADULT ATTACHMENT PREDICTS MATERNAL

BRAIN AND OXYTOCIN RESPONSE TO INFANT CUES
3rd trimester visit:
Pregnancy

7 month visit:
Videotaping

3rd trimester

7 mths

Study
Timeline

10 mths

14 mths

Bayley Scales
of Infant
Development

BIRTH
20 min

Mother-infant
separation 1

Data
Collected

10 month visit Visit 4:

Scanning
Follow-Up

5 min

6 min

Free play
interaction

Mirror-based
interaction

20 min

Mother-infant
separation 2

AAI

PANAS (1)

Blood draws

PANAS (2)

WTAR

Demographics

Demographics

Oxytocin change

IBQ

PDQ

ATQ

Cortisol

PSI

Breastfeeding
duration

BDI

Infant face
images

Adrenaline

Hours separated
per week

Noradrenaline

Adult Attachment Interview (AAI)

Type B: (Secure): values attachment, coherent balanced account of experiences
Type A: (Insecure): deny experiences (cant remember), devalue (denigrate)
Strathearn, Fonagy, Amico & Montague (2009) Adult attachment predicts maternal brain and oxytocin response
to infant cues. Neuropsychopharmacology;34(13):2655-66; Strathearn et al., 2013; Strathearn et al., 20134

2 sec

2 sec

26 sec random
inter-stimulus
interval

2 sec

2 sec

Own:
Happy
(OH)

2 sec

Unknown:
Happy
(UH)

2 sec

Unknown:
Sad
(US)
IDENTITY
STIMULUS
TYPES
A
F
F
E
C
T

Own
Infant

Unknown
Infant

Happy

OH

UH

Neutral

ON

UN

Sad

OS

US

Own:
Neutral
(ON)
Unknown:
Neutral
(UN)
Own:
Sad
(OS)

Security, oxytocin change and hypothalamic activation

OWN

UNKNOWN

>
Hypothalamus
Midbrain

Pons
Pituitary
region

(-3,2,-16)

Own vs. Unknown contrast

Maternal security and hemodynamic change

mPFC
VS

y=11
x=-6

Anterior
Insula
VS

y=6

y=16

Correlation of right ventral striatum activation to own infant

and change in serum oxytocin with mother-infant interaction

r=0.057, p=0.002

A provisional model of the

developmental roots of mentalization
Secure maternal attachment
Increased maternal OXT while with infant
More mentalizing (marked contingent) maternal
response to infant distress
Infant generates 2nd order representation of self state

Improved affect regulation enhances interpersonal

interactions robust mentalization

Facilitative impact of social interaction on

development of improved mentalization resilience

A provisional model of roots of

disorganized mentalization
Insecure disorganized maternal attachment
Reduced maternal OXT while with infant
Non-mentalizing (unmarked non-contingent)
response to infant distress undermines natural
process for the maturation of mentalization
Infant fails to internalize representation of self state
Mentalizing goes awry (more frequently) particularly
under conditions of high arousal and attachment
activation: mental states are enacted
Destructive impact on social interactions undermines
further opportunities for social development of
mentalizing vulnerability to trauma

More OT more
affectional contact

More OT more
response to parent

More OT more
social gaze more
parental affectionate
touch
Apter-Levi, Y., Zagoory-Sharon, O., & Feldman, R. (2014). Oxytocin and Vasopressin Support Distinct
Configurations of Social Synchrony. Brain Research(

Maternal Oxytocin Response Predicts Mother-toInfant Gaze (Kim, Fonagy, Michaels & Strathearn, 2014)
After (still face)
separation
the higher the
OT the more
likely M to turn
toward infant

Brain Res, 1580, 133-142

After (still face) separation

the lower the OT the more
likely M to turn away from
the infant

Antenatally secure mothers

show more marked mirroring
in recovery from still-face
situation (Kim, Fonagy &
Strathearn, 2014)

No more facial imitation

No more vocal imitation

Far more intention imitation

Brain development 6-18 months

Numerous studies reveal the development of important group of
social capacities related to
Reciprocity and
sharing of mental states

Joint attention
Social referencing
Attachment
Implicit mental state
attribution

Self-awareness and
identification

Towards the end of this period

Mirror recognition
Social position awareness
In-/out-group distinctions

Walle & Campos, 2012; Mandel et al., 1995; Tacikowski et al., 2013; Kampe et al., 2003

Mentalization of parental trauma moderates

outcome of CA&N on disorganised attachment
Implications for intergenerational transmission of attachment

Abuse and High RF-T

Abuse and Low RF-T

33%

37%
63%

67%

Organised infant
attachment
Disorganised
infant attachment

Prediction of infant attachment disorganisation is twice as powerful (22% vs 41%

of variance explained) when maternal RF-T is added to a model containing
maternal unresolved trauma as only predictor.
Unresolved trauma: =2.54**; RF-T: =-1.50*
Maternal RF-G is not a significant predictor of infants disorganised attachment
Berthelot, Ensink, Bernazzani, Normandin, Luyten & Fonagy, 2015

Mothers unresolved
trauma blunts amygdala
response to infant distress
(Kim, Fonagy, Allen &
Strathearn, 2014)

Measuring parental RF using the Squiggle

Initially developed by Winnicott (1971)
Adapted by Ensink, Normandin & Fonagy (2000)

Mother needs to direct the creation of 6 sequenced

drawings to produce a story
Mother is free to comment and ask questions to the child
It poses challenged faced by mothers in everyday interaction
with their children:
Provide structure
Consider the childs interests and reactions
Allows for a playful interaction

Measuring parental RF using the Squiggle

Those subscales loaded onto 3 distinct factors:

Reflective
orientation (=.87)
Interest in the
subjective
experience of the
child
Affective
communication
Capacity to play

Affectionate
support of agency
(=.85)
Support of
investment/
agency of the
child
Expression of
affection

Negativity (=.74)
Aggressive
control
Hostility

* The items Withdrawal/Disengagement did not load on any factor

Measuring parental RF using the Squiggle

Relationships with child sexual abuse and psychopathology
N= 158 mother infant dyads
88 girls
70 boys
89 children experienced sexual abuse
54 girls
35 boys

Correlations with PDI

Reflective orientation .45***
Affectionate support of agency .30**
Negativity -.40**

Mothers of sexually abused children in comparison with not abused:

Showed less reflective orientation (t156 = 2.826, p = 0.005)

Less affectionate support of agency (t156 = 2.668, p = 0.009)

No differences regarding negativity (t156 = -0.622, p = 0.535)

Reflective orientation

Externalising problems (r= -.18*)

Delinquency (r= -.14)
Aggression (r= -.16*)
Dissociation (r= -.14)
Teacher reported (TR) internalising (r= -.29*)
TR externalising (r=-.36*)
TR social problems (r= -.39**)
TR attention problems (r= -.35**)
TR delinquency (r= -.39**)
TR aggression (r= -.39**)

Affectionate support of agency

Internalising (r= -.15)

Externalising (r= -.19*)
Attention problems (r= -.16*)
Delinquency (r= -.17*)
Aggression (r= -.19*)
Dissociation (r= -.19*)

Negativity
Externalising (r= .15)
TR delinquency (r= .23)

* p<.05
** p<.01
p<.08

Brain development 6-18 months

Implicit Theory of mind and Mentalizing
Research has shown some ability to track false beliefs as young as 7 months:
Faced with scenarios that violate their expectations infants display anticipatory gazes
and prolonged gazes
Gaze tests of theory of mind at age 1 correlate with behavioural tests at age 4

Studies suggests an early differentiation of Empathy and Mentalizing

networks, each associated with different aspects of social reciprocity:

Greater left frontal activation during rest
EEG was associated with comforting
behaviour (ten months later)

Greater right temporal activation was associated with

instrumental helping behaviour (4 months later).

Baillargeon, Scott and He, 2010; Yamaguchi, Kuhlmeier, Wynn and vanMarle, 2009; Paulus, Ku hn-Popp, Licata, Sodian, Meinhardt, 2012

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.

Sensitivity to others state of mind

False belief for baby

True belief for Smurf
True belief for baby
False belief for Smurf
M Kovcs et al. Science
2011;330:1830-1834

Sensitivity to others state of mind

Ball Not There
False belief for baby

Ball Not There

True belief for baby
False belief for Smurf

The infant but not the

Smurf believes that
the ball should be there

Infant knows ball is not there

But Smurf does not believes
it should be there

Neither infant nor

the smurf believe
that ball is there

Neither infant nor

the Smurf believe that
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

Infants from first year pay attention to what people

around them know whose knowledge can be trusted

Published by AAAS

The concept of
epistemic trust
and epistemic
hypervigilance:
the common
ground of PD?

The theory of natural pedagogy and

epistemic trust (Gergely & Csibra, 2008; Fonagy & Allison, 2014)

New form of evolution (late Pleistocene)

based on learning and the
transmission of cultural knowledge

As soon as you need to create tools to make tools

the process of tool-making becomes, distanced
from its ultimate function, opaque in its
intent and necessitates communication

The theory of natural pedagogy and

epistemic trust (Gergely & Csibra, 2008; Fonagy & Allison, 2014)
New form of evolution (late Pleistocene)
based on learning and the
transmission of cultural knowledge
The challenge of discerning of epistemic
trustworthiness and the need for
ET=
Epistemic
EPISTEMIC VIGILANCE!
Trust

The theory of natural pedagogy and

epistemic trust (Gergely & Csibra, 2008; Fonagy & Allison, 2014)
New form of evolution (late Pleistocene)
based on learning and the
transmission of cultural knowledge
The challenge of discerning of epistemic
trustworthiness and the need for
ET=
Epistemic
EPISTEMIC VIGILANCE!
Trust

The pedagogic stance is triggered by

ostensive communicative cues (E.G. turntaking contingent reactivity, eye contact)
Ostensive cues have in common
Person recognized as a self
Paid special attention to (noticed as an agent)

Innate Sensitivity to Contingency

The theory of epistemic trust

New form of evolution (late Pleistocene)
based on learning and the
transmission of cultural knowledge
The challenge of discerning of epistemic
trustworthiness and the need for
EPISTEMIC VIGILANCE!

The pedagogic stance is triggered by

ostensive communicative cues (E.G. BEING
CALLED BY NAME)
Ostensive cues have in common
Person recognized as a self
Paid special attention to (noticed as an agent)

Triggering the Pedagogical Stance

Ostensive cues function to trigger epistemic

trust:
Opening channel to receive knowledge about social
and personally relevant world (CULTURE)
Going beyond the specific experience and acquire
knowledge relevant in many settings
Triggers opening of an evolutionarily protected
epistemic channel for knowledge acquisition

Mimicry may be protected by human evolution

because it generates epistemic trust
Social smile (recognition of self) increases imitation
because smile generates epistemic trust and opens
channel to receive knowledge

Contingent responding at 8 m. & epistemic trust

Deligianni, Senju, Gergely et al., 2011

8-month-old can feel addressed

Babies detect contingent activity of such objects
and follow them with their gaze.

Infants ability to detect

contingency is not dependent on
the presence of any other social
cues, like faces or human voices.
It is suggested that infants may
have interpreted the non-human
object as an agent with
communicative and referential
intention towards them.

Deligianni, Senju, Gergely et al., 2014

Experimental illustration of ostensive cues

Gergely, Egyed et al. (2013)

Subjects : 4 groups of 18-montholds Stimuli: Two unfamiliar

objects

1: Baseline control group

No object-directed attitude demonstration

Simple Object
Request by
Experimenter A

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

Ostensive Communicative Demonstration

Requester: 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

Social Cues that Create Epistemic Trust

Attachment to person who responded sensitively in

early development is special condition for
generating epistemic trust cognitive advantage of
security including neural development (Van Ijzendoorn et al.)
Generally any communication marked by
recognition of the listener as intentional agent will
increase epistemic trust and likelihood of
communication being coded as
Relevant
Generalizable
To be retained in memory as relevant

OSTENSIVE CUES TRIGGER EPISTEMIC TRUST

WHICH TRIGGERS A SPECIAL KIND OF
ATTENTION TO KNOWLEDGE RELEVANT TO ME

Social Cues that Create Epistemic Trust

Attachment to person who responded sensitively in
early development is special condition for
generating epistemic trust cognitive advantage of
security
Generally any communication marked by
recognition of the listener as intentional agent will
increase epistemic trust and likelihood of
communication being coded as
Relevant
Generalizable
To be retained in memory as relevant

OSTENSIVE CUES TRIGGER EPISTEMIC TRUST

WHICH TRIGGERS A SPECIAL KIND OF
ATTENTION TO KNOWLEDGE RELEVANT TO ME

Young Childrens Trust in Their Mothers Claims

(Corriveau, Harris, Meins et al., 2009)

Longitudinal study of attachment,

147 children assessed for attachment in infancy
Tested twice for epistemic trust aged 50 and 61
months
Mother and a stranger make conflicting claims
Task 1: name a novel object
Task 2: name a hybrid animal made up 50% each of two
animals
Task 3: name a hybrid animal made up of 75% one animal
and 25% of another

Question:
Who does the child spontaneously turn to?
Who does the child believe?

Corriveau et al.s Studies of Epistemic Trust

Mummy said its a snegg and
Joan (stanger) said its a yoon.
What do you think its called, a
snegg or a yoon?

Mummy said its a yiff and

Joan said its a zazz. What do
you think its called, a yiff or a
zazz?
Mummy said its a crut and
Joan said its a larp. What do
you think its called, a crut or a
larp?

A 50:50 animal from Corriveau et al.

50% pig : 50% bear

If Mother names hybrid as pig

then stranger always names it
bear

A 50:50 animal from Corriveau et al.

50% cow : 50% horse

If Mother names hybrid as
horse then stranger always
names it cow

A 75:25 animal from Corriveau et al.

75% rabbit : 25% squirrel

Mother always names hybrid as squirrel
and stranger always names it rabbit

A 75:25 animal from Corriveau et al.

75% bird : 25% fish

Mother always names hybrid as fish
and stranger always names it as bird

Proportion of Trials on Which Children Chose Their Mother for

Information by Attachment Group and by task
Novel Object

Percent Mothers Chosen

N=146

***

80

50-50 Hybrid

***

75-25 Hybrid

*** ***
*
60

***
40

***

20

Avoidant
Corriveau, Harris, Meins et al.,
Child Dev,, 80, 750-761.

Secure

Resistant

Disorganised

Attachment Classification at 18 months

Individual Differences in Creating

Epistemic Trust
Influential communicators
use ostensive cues to maximum
create illusion of recognizing agentiveness of
listener

Looking at audience
Addressing current concern
Communicating that they see problem from agents perspective
Seeing and recognizing individual struggle in understanding

Massive difference in ability of individuals to

influence (teachers, politicians, managers, therapist)
explicable in terms of varying capacity to generate
epistemic trust

Meta-analytic studies of teacher

effectiveness

John Hattie is Professor of Education at the University of

Auckland, New Zealand.
15 years research and synthesizes over 800 meta-analytic
studies relating to the influences on achievement in schoolaged students.
Builds a story about the power of teachers and of feedback,
and constructs a model of learning and understanding.
Is there a set of predictors to good teaching outcomes
based on:

The child?
The home?
The school?
The curricula?
The teacher?

With grateful thanks to Dr Peter Fuggle

Meta-analytic studies of teacher

effectiveness
What makes a teacher the most effective?
It is teachers seeing learning through the
eyes of students
The key ingredients are:
Awareness of the learning intentions
Knowing when a student is successful
Having sufficient understanding of the students
understanding
Know enough about the content to provide meaningful
and challenging experiences

Passion that reflects the thrills as well as awareness

of the frustrations of learning.
With grateful thanks to Dr Peter Fuggle

Odds of a clinical episode in MBT by

therapist

Being mentalized in the context

of an attachment relationship
EPISTEMIC
TRUST

Ability to form and

learn from social
connections

EPISTEMIC
TRUST

Ability to reappraise via mentalizing where necessary to repair, preserve,

develop and increase these connections throughout life

Implications for
understanding
and treating PD

The nature of psychopathology in PD

Social adversity (most deeply trauma following
neglect) is the destruction of trust in social
knowledge of all kinds rigidity, being hard to
reach
Cannot change because cannot accept new
information as relevant (to generalize) to other
social contexts
Personality disorder is not disorder of personality
but inaccessibility to cultural communication
relevant to self from social context
Partner
Therapist
Teacher

Epistemic Mistrust

Judgment bias for approachability and

trustworthiness of faces.
P<.001

Nicol et al., 2013 Plos One

BPD
Control

P<.001

NS
NS

Approachable as
Unapproachable

Unapproachable as
Approachable

Trustworthy as
Untrustworthy

Untrustworthy as
Trustworthy

Epistemic mistrust not believing what one is told

It is the consequence of high levels of epistemic vigilance
(the over-interpretation of motives and a possible
consequence of hyper-mentalization, Sharp et al., 2011)
The recipient of a communication assumes that the
communicators intentions are other than those
declared and therefore not treating the communication
deferentially
Mostly it consists of misattribution of intention and
seeing the reasons for someones actions as malevolent
and to be treated with epistemic hyper vigilance
Most important consequence is that the regular process
of modifying stable beliefs about the world (oneself in
relation to others) remains closed

Implications: The nature of psychopathology

Epistemic mistrust which can follow

perceived experiences of maltreatment or
abuse leads to epistemic hunger combined
with mistrust
Therapists ignore this knowledge at their peril
Personality disorder is a failure of
communication

It is not a failure of the individual but a failure of learning

relationships (patient is hard to reach)
It is associated with an unbearable sense of isolation in
the patient generated by epistemic mistrust
Our inability to communicate with patient causes
frustration in us and a tendency to blame the victim
We feel they are not listening but actually it is that they find
it hard to trust the truth of what they hear

Openness to the (social) environment is usually adaptive

Openness to the (social) environment is usually adaptive

Openness to the (social) environment is usually adaptive

but so is hypervigilance under certain circumstances

Building a social network in childhood and

adolescence

When the capacity to form bonds of trust is

shaky and tends to break down

we lose our safety net

Reconceptualising BPD: understanding not

in terms of disease mechanisms

but as an absence of expected resilience

or lack of epistemic trust

which may once have been adaptive